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health assessment exam 1 > introduction to physical assessment > Flashcards

introduction to physical assessment Flashcards

1
Q

assessment is….

A

A collection of data about an individuals health care

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2
Q

Subjective Data

A

What the patient TELLS YOU. what you observe

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3
Q

Objective Data

A

What is ON the patient

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4
Q

Data Base

A

The chart and everything else we have going on.

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5
Q

An organized assessment is the starting point of every approach to….

A

Clinical reasoning…learning and experience

bedside, vital signs, an idea of what is going on.

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6
Q

WHY do we do assessments?

A
  1. make clinical judgement or diagnosis
  2. assess a person’s RISK or actual health problems and life processes
  3. Diagnose higher levels of wellness
  4. starting point of all models of clinical reasoning
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7
Q

Baseline

A

first set of data we collect about a patient

we then know if something has changed

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8
Q

First level priority

A

Emergent, life threatening, and immediate

ex. CODING airway problems, circulation problems

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9
Q

Second Level priority

A

Next in urgency, requiring attention so as to avoid further deterioration.
ex. mental status changes, acute urinary elimination problems, diabetic who hasn’t had insulin, abnormal lab values, risk of infections,

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10
Q

Third level priority

A

Important to the patients health but can be addressed after more urgent problems are addressed
ex. lack of knowledge, activity, rest

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11
Q

The assessment process

A

Nurse
Professional attitude
Established rapport..no trust= no information

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12
Q

Reflection

A

Repeat what you have heard to encourage more details

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13
Q

Empathy

A

Show understanding

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14
Q

Facilitation

A

Encourage patients to say more

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15
Q

Sympathetic approach

A

Do something in the same order
spend more time listening than talking
use silence to encourage the patient to continue talking

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16
Q

Effective communication: Seeking connection

A

At the start open- ended questions: this gives the patient free range to tell us what is wrong.
“ What brings you to the office?”
“ Have there been any changes since the last office visit:

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17
Q

Direct Questions

A

This is after open ended questions. we need to be more specific
“ How long have you had symptoms?”
Where does it hurt?

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18
Q

Leading questions

A

MOST RISKY

“ That is a horrible tasting medicine isn’t it?”

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19
Q

Verbal Responses: Empathy

A

Recognizes a feeling and puts it into words

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20
Q

Verbal Responses: Clarfication

A

Use when person’s words are ambiguous or confusing

ex. “ when you said…what did you mean?”

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21
Q

Verbal Responses: Confrontation

A

May focus on discrepancy or inconsistency in person’s narrative
ex. someone who says they are depressed but they do not act or look depressed ( SMILING)

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22
Q

Verbal Responses: Interpretation

A

It links events, makes associations, implies cause, ascribes feelings

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23
Q

Verbal Responses: Explanation

A

These statements inform the patient

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24
Q

Verbal Responses: Summary

A

Final review of what person has said, it condenses facts and presents your view of health problems

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25
Q

ten traps of interviewing

A
  1. providing false assurance or reassurance
    ex. everything will be ok
  2. giving unwanted advice
    ex. pregnant etc.
  3. using authority
    ex. do this because I said so
  4. using avoidance language
  5. engaging in distancing
  6. using professional jargon
    ex. teach the patient the language
  7. using leading or biased questions
  8. talking too much
  9. interrupting
  10. using “ WHY” questions
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26
Q

Types of ASSESSMENTS: complete

A

Includes complete health history and full physical examination

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27
Q

Types of ASSESSMENTS: focused or problem centered

A

only one thing wrong

for limited or short term problems

28
Q

types of ASSESSMENTS: follow up

A

Evaluate problems at regular intervals

ex. high blood pressure give medicine- come back in 2 weeks..

29
Q

Types of ASSESSMENTS: emergency

A

Rapid collection of data with concurrently lifesaving measures
ex. coding or heart attack

30
Q

Cultural Competence: Culturally sensitive

A

Possessing basic knowledge of and constructive attitudes toward diverse cultural populations

31
Q

Culturally appropriate care

A

ex. johavah’s witness

applying underlying background knowledge necessary to provide the best possible health care

32
Q

Culturally competent

A 
Understanding and attending to total context of patients situation including the following: 
1. immigration status
2. stress and social factors
3. cultural similarities and differences
" all that is going on"
33
Q

SYMPTOMS

A

Subjective information

ex. spoken information

34
Q

SIGN

A

Objective information
physical examination or in lab reports
“ find out -objective

35
Q

Source of Information

A

State who is giving the history
- usually there is a person although source may be relative or friend
“ Who gives the information
Is the source RELIABLE?
A reliable person ALWAYS gives the same answers when questions are rephrased later in the interview

36
Q

Parts of Health History: Biographical data

A
  1. name
  2. address
  3. phone number
  4. age
  5. birth date
  6. race
  7. ethnic origin
  8. occupation
  9. marital status
  10. gender
    this is first
37
Q

Chief Complaint ( CC)

A

A brief statement in the person’s own words that describe the reason for the visits
ex. “ I have a sore throat
NOT INTERPRETATION of what they said-it IS what they said

38
Q

History of present Illness

A 
Use OLDCARTS
Onset ( when did this start?)
Location/radiation ( upper arm)
Duration ( come/go)
Characteristics ( burn vs stab)
Aggravating factors ( worse or better) 
Relieving factors ( medication- what makes it better)
Treatment ( medication)
Severity ( rate the pain)
39
Q

Past Medical History

A
  1. childhood illness
  2. accidents
  3. serious chronic illnesses ( diabetes/cancer)
  4. Hospitalizations
  5. surgical history
  6. obstetrics history ( children
  7. immunizations
  8. allergies
  9. current medications ( dosage, route,)
40
Q

Family History

A

HUGE PART IN KNOWING
age and health or cause of death of relatives
genogram

41
Q

R.O.S. review of systems

A
  1. evaluate past and present health state of each body systems
  2. double check to see if anything was omitted in the HPI ( history of present complaint)
  3. evaluate health promotion practices
  4. order of systems is roughly head to toe
42
Q

Obtaining a health history

A

review of systems every week

  • medications and treatments
  • health promotion
  • same partner each week
43
Q

Basic Equipment

A 
Thermometer
stethoscope
sphygmomanometer
scale
visual acuity charts
penlight
measuring tape
44
Q

Advanced equipment

A

ophthalmoscope ( red reflex this semester
otoscope on model ear
tuning fork
reflex hammer

45
Q

Assessment techniques

A 
IPPA
inspection
palpation
percussion 
aucultation
46
Q

Inspection

A
  1. ” concentrated watching”
  2. done first with assessment of each body system and is ongoing
  3. compare right and left side of body for SYMMETRY
  4. requires good lighting and adequate exposure
    Categories:
    indirect: assisted by equipment
    direct: sight, hearing, smell
47
Q

Palpation

A 
TOUCH
use calm gentle approach
warm hands first
Assess: 
texture
temperature
moisture
organ location and size
swelling ( EDEMA)
Spasticity
crepitation
vibration
pulsation
presence of lumps or masses
presence of pain or tenderness
48
Q

Palpation: Fingertips

A

tactile discrmimination
texture, swelling, pulsations, determine presence of lumps
finger and thumb “ Pinching”
detects POSITION, SHAPE, and CONSISTENCY of an organ or mass ( the shape or presence)
Dorsa ( back of hand)
used for determining temperature
Skin on hands are thinner than palms
bad of fingers ( metacarpophalangeal joints) or ulnar surface of the hand detects vibration

49
Q

Types of Palpation

A 
start with light palpation to detect surfac
 characteristics
1. pulse
2. skin temp
3. texture
4. consistency
5. warmth
6. mobility
7. tenderness
50
Q

deep palpation

A

for organ size
shape
rebound tenderness
abnormalities; tumors or masses

51
Q

Percussion

A

” to strike”

  1. assess underlying structures
  2. assess location, size, and density of the organ
  3. detect tenderness ( sinus)
  4. Eliciting deep tendon reflex using percussion hammer
52
Q

Methods or percussion: direct or immediate

A

hand or fingertips directly on the surface

nothing in between

53
Q

indirect percussion

A 
Mediate
used more often
uses both hands
striking hands contact the stationary hand fixed on the person's skin
yields a sound and subtle vibration
54
Q

blunt percussion

A

ulnar surface of the fist

reflex hammer

55
Q

Percussion notes characteristics: resonance

A

Lungs

clear hollow low pitched sounds

56
Q

Hyperresonance

A

lungs

low booming longer sound than resonance

57
Q

Tympany

A

Abdomen

Loud high pitched musical or drum like

58
Q

dullness

A

dense organs

soft high pitched muffled

59
Q

flatness

A

muscles, bones, solid mass

very soft high pitched dead stop of sound

60
Q

Auscultation

A

Listen to sounds produced through the stethoscope
warm quiet room
avoid artifact
warm stethoscope end piece
rub in palm
NEVER LISTEN THROUGH A GOWN OR OVER CLOThING

61
Q

Diaphragm

A

high pitched sounds
breath sounds
bowel sounds
and normal heart sounds

62
Q

bell

A

low pitched sounds

extra hear sounds and murmurs

63
Q

Auscultation determines…

A

Intesity
pitch
duration
recurring sounds

64
Q

Order of Physical Assessment

A

Inspection, palpation, percussion, auscultation

65
Q

abdomen physical assessment

A

Inspection
auscultation
percussion
palpation

66
Q

infant physical assessment

A

inspection
auscultation
palpation
percussion

67
Q

When Charting…..

A
  1. start at the beginning of the page with date and time
  2. immediately afterwards start documenting your findings
  3. end the paragraph with your first initial and last name and NSUA
  4. chart in pen only
  5. if error is made….then date and initial. some facilities require mistake entry or error
    * ** follow protocol for wherever you work***

health assessment exam 1 (1 decks)

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