Lecture: Assessment Flashcards
What are the two components of an assessment and how are they obtained? State whether each is objective or subjective.
A health history is obtained using interviewing skills and is subjective because the patient is telling you based on their perspective. The physical assessment is obtained through a head to toe assessment and is objective because you are gaining factual information.
What are the six factors to include in a health history?
Biographical/demographical info, c/o, history of present illness (HPI), past medical info (PMI), family history (FH), lifestyle
Examples of biographical data for health history
Name, DOB, gender, religion, occupation, PCP
Examples of lifestyle in health history
Smoking, drinking, drugs, diet, sleep exercise, resources for assistance
Who is the primary source of data for a patient’s health history?
The patient
What are the three types of assessment?
Complete physical assessment, acute care med-surg assessment and ongoing partial assessment
When is an assessment done?
At the start of a shift or during the first home health visit.
What are the main pressure points that should be checked for pressure ulcers?
Pinna, shoulder blades, elbows, sacrum, coccyx, knees, heels, toes
What is Jugular Vein Distention (JVD)?
A sign that the heart is not pumping effectively–blood begins to back up in the jugular vein
How is peripheral vascular pulse measured?
On a scale of 0-4+ and symmetry
What are the four classifications of bowel sounds?
hyperactive, normal, hypoactive, and total absence
How long do you need to listen for to determine there is a total absence of bowel sounds?
5 minutes
What does the acronym PERLA stand for?
Pupils equal and reactive to light and accomodation
What are petechiae and what do they indicate?
Small red dots on the skin that indicate low platelets
What does WNL stand for?
Within normal limits
