Health History Flashcards
1
Q
purpose
A
- gather baseline data about the client’s health
- supplement, confirm, or refute previous data
- confirm and identify nursing diagnosis
- make clinical judgements r/t changes in data
- evaluate physiological outcomes of care
2
Q
considerations for physical assessment
A
- cultural sensitivity
- infection control: cleaning hands and stethoscope
- environment: private
- equipment: bring it all, don’t forget something
3
Q
types of data
A
- subjective: based on patient’s verbal descriptions, pain rating
- objective: fact, measurable observation, behavior that we observe, everything else in vital signs
4
Q
sources of data
A
- primary: from patient
- secondary: from medical record, friends, family, healthcare professionals, can be skewed bc not from patient themselves
5
Q
diagnostic tests
A
- laboratory: ABG’s, CBC, sputum
- radiologic studies: chest x-ray, CT, V/Q scan, PET scan
- skin tests
- pulmonary function tests
- endoscopy examinations
6
Q
methods of data collection
A
- interview:
– orientation phase: introduction, explaining what going to be doing and why
– working phase: determining plan of care
– termination phase: end of care - nursing health history: past medical history, surgery, hospitalizations, diagnosis, everything even though it isn’t related to why they are there (chief complaint = why they are there)
- physical examination
- diagnostic and laboratory results
7
Q
types of physical assessment
A
- comprehensive: interview
- focused: only one focus like if they have cold, only check respirations, listen to lungs and look at throat
- system specific
- ongoing: assessing same thing day after day to see if changes
- all assessments are considered head to toe: full blown head to toe
8
Q
elements of assessment
A
- history: baseline history (normal, when healthy), problem-based history
- examination: vital signs, inspection, auscultation, palpation
9
Q
process and the physical
A
- assessment: interview and physical assessment
- nursing diagnosis: ex: skin breakdown
- planning: based on assessment data, bring in others like dietary, make a turning schedule, keep sheets clean and bump free
- evaluation: establishes nursing accountability, looking back at it all and having someone else ensure you do what you planned to do
10
Q
what part of the process establishes nursing accountability?
A
evaluation
11
Q
techniques for assessment
A
- inspection
- palpation
- percussion
- auscultation
- olfaction
includes all sense except taste
12
Q
inspection (visual)
A
- good lighting
- expose all of part to be examined; drape or cover parts not being examined for privacy
- use additional lighting/devices for some areas of body; eyes, ears, throat (penlight)
- observing for: color, shape/symmetry, movement, position (making sure that everything is where it is supposed to be)
13
Q
palpation (tactile)
A
- bimanual/manual technique
- dorsum of hand (outside of hand to assess temp bc inside of hand is warmer): assess shape and texture
- palm or ulnar surface of hand
- palmar surface of finger/finger pads
light palpation: 1 cm or .5 depth
deep palpation: 4 cm or 2 in depth - palpate to assess: texture, resistance, resilience, mobility, temperature, thickness, shape (ex: knot in breast exam) and moisture
14
Q
auscultation (auditory) characteristics of sound
A
- frequency: # of oscillations per second generated by a vibrating object
- loudness: amplitude of a sound wave (ex: abdominal assessment before and after lunch, lots of noises)
- quality: descriptive
- duration: length of time that sounds last
15
Q
auscultation use of stethoscope
A
always directly place on skin
- bell best for low pitched sounds (vascular and some heart sounds)
- diaphragm best for high pitched sounds (bowel and some abnormal lung sounds)
