INTRODUCTION Flashcards
explain what is health assessment
An evaluation of the health status of an individual by performing a physical examination after obtaining a health history.
give the components of health history
- BIOGRAPHICAL DATA
- REASON FOR SEEKING CARE:
CHIEF COMPLAINTS - CURRENT HEALTH STATUS
- PAST HEALTH HISTORY
- FAMILY HISTORY
- PSYCHOSOCIAL PROFILE
TYPES of Health history
complete health history and focused health history
3 TYPES of PHYSICAL EXAMINATION:
Complete assessment
examination of the body
examination of a body area
the two aspects of health assessment are?
the physical examination and the Nursing health history
what are the four basic types of assessment?
Initial comprehensive assessment
Ongoing or partial assessment
Focused or problem-oriented health assessment
Emergency assessment
identify the four(4) assessment processes.
Collecting data
Organizing data
Validating data
Documenting data
It is a comprehensive orderly manner of examining a client.
physical assessment
PRINCIPAL METHODS USED TO COLLECT DATA
observing and interviewing
what is the purpose of performing a physical examination?
Gather baseline data about the client’s health.
Supplement, confirm or refute data obtained in the nursing history
Confirm and identify nursing diagnoses
Make clinical judgments about a client’s changing health status and management.
Identify area of health promotion and disease prevention.
Evaluate physiologic outcomes of health care.
PREPARATION GUIDELINES IN PHYSICAL ASSESSMENT
Preparing Physical Setting or Environment
Preparing Oneself
Preparing Equipment
Approaching and preparing the client
Comfortable room temperature
Door /curtain should be closed: free of interruptions
Preparing Physical Setting or Environment
Quiet area: free of distractions
Preparing Physical Setting or Environment
Adequate Lighting
Firm and adjustable examination table
Bedside table tray
Preparing Physical Setting or Environment
Assess your own feelings and anxieties
Wash hands before and after examination
Wear mask or gloves if necessary
Preparing oneself
List equipments necessary for each part of the exam.
Equip yourself on how to use each equipment.
Gather necessary equipment
preparing equipment
Approaching and preparing the client
Psychological Preparation
Physical Preparation
Positioning
Psychological Preparation
Physical Preparation
Positioning
Approaching and preparing the client
what are the different physical assessment techniques?
IPPA(inspection, palpation, percussion, auscultation)
IAPP(inspection, auscultation, palpation, percussion)
4 types of palpation
Light palpation
Moderate palpation
Deep palpation
Bi manual palpation
palpations that are usef for vibratios, thrills, and fremitus
Ulnar/palmar :
palpation to check the temperature
dorsal
Involves tapping the body parts.
Assess underlying structures
percussion
three types of percussion
direct percussion
indirect percussion
blunt percussion
the types of POSITIONING A PATIENT FOR EXAMINATION OR TREATMENT
a. Horizontal Recumbent Position.
b. Fowler’s Position.
c. Dorsal Recumbent Position.
d. Dorsal lithotomy Position.
e. lithotomy Position.
f. Prone Position.
g. Knee-Chest Position.
h. Sim’s Position.
Why should the patient should be draped?
a. To provide comfort and privacy during examination.
b. To prevent unnecessary exposure of the patient’s body.
c. To help the patient relax—a patient who is embarrassed will be tense and less cooperative.
d. To prevent chilling — the drapes will provide warmth.
What are the important things to remember when draping?
Draping vary with :
patient’s condition,
the position of client,
the examination and
temperature.
Draping should be loose
what does coldspa stands for?
character
onset
location
duration
severity
pattern
associated factors
how does it feel, look, sound, smell?
character
when did it begin?
onset
where is it? Does it radiate?
Location
how long does it last? Does it recur?
duration
how bad is it?
severity
what makes it better? What makes it worse?
pattern
what other symptoms that occur with it?
associated factors
what is the meaning of PQRST
Precipitating / Palliative Factors
Quality/ Quantity
Region/ Radiation/ Related Symptoms
Severity
Timing
palpation using the fingerpads
Strength of pulses,
texture,
size,
shape
Crepitus
It requires the use of stethoscope to:
Listen to heart sounds
Movement of blood
Movement of bowel
Movement of air
auscultation
Assess for the :
Intensity
Pitch
Duration
Quality
auscultation
Involves senses to detect abnormal findings
inspection
Starts from the time you meet the client and continues through out the examination.
inspection
Proper exposure of body part inspected
inspection
