Physical assessments Flashcards
(99 cards)
What two assessments do you do when you are doing a health assessment of the ear?
The whisper test and Romberg Test
What do you do when performing the whisper test?
Ask patient to cover right/left ear - whisper on the left/right ear 1-2 ft away - patient repeat what you said.
What do you do during the Romberg test?
For balance.
Ask patient to stand with feet together and arms on the side. Eyes open, then closed; stand close to patient to prevent fall.
What are the 5 types of Physical assessments?
Brief/General 10 min assessment (Head to Toe)
Ongoing/Follow up Assessment
Focused Assessment
Comprehensive Assessment
Emergency Assessment
Explain what a Brief/General 10 min assessment is.
Concise and timely assessment from head to toe.
Explain what a Ongoing/Follow- up assessment is.
Assessment done at regular intervals. Usually concentrates on identified health problems and attempts to monitor positive or negative changes to evaluate effectiveness of treatment and to detect new problems. could be hourly, weekly, monthly, yearly depending on problem.
Explain what a Focused assessment is.
An in-depth assessment of a specific health issues. Can involve 1 + body systems.
It is used to address the immediate concerns/
Explain what a Comprehensive assessment is.
Provides a holistic information, an overall information of body systems
and functional abilities; emotional status; cultural and spiritual beliefs;
psychosocial situation; family and community dynamics
Done during admission (initial) assessment & when transferring units from ER to inpatient.
Explain what an Emergency assessment is.
It focuses on the ABC’s
Performed in acute settings such as the ER, ICU, NICU. Assesses life threatening/unstable situations.
What is subjective date that is collected during a health assessment?
Subjective data are based on patient experiences and perceptions, are known only by the patient (e.g., pain and nausea), and are reported by the patient (the patient’s own words; sensations, symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information).
What is objective date that is collected during an health assessment?
Objective data are measurable and are directly observed or elicited through general observation and physical examination (physical characteristics, body functions, and measurements [blood pressure, height, respiratory rate], appearance, behavior, laboratory results). Objective data may also be obtained through the patient’s health record and observations reported by the patient’s family, significant others, or care givers about the patient.
What is the purpose of performing a health assessment?
Nursing health assessment involves gathering information about the health status of the patient. The nurse then evaluates and synthesizes the information (data). The nurse plans appropriate nursing interventions based on this data and evaluates patient care outcomes to deliver the best possible care for each patient. A health assessment includes a health history and a physical assessment.
What is a health history?
A collection of subjective information that provides information about the patient’s health status.
What is a Physical assessment?
Physical assessment is a collection of objective data that provides information about changes in the patient’s body systems.
What must nurses do to do adapt the assessment on each patient?
Clinical judgement.
How does a nursing health assessment differ from other types of health assessments?
Tt is a holistic collection of information about factors that affect or are affected by one’s level of health. Nurses focus on how a person’s health status is affecting activity levels and abilities to perform tasks, as well as how patients are coping with their health issues and any related loss of function or change in ability to function.
What are nursing health assessments used for?
The information from the nursing health assessment is used to formulate diagnoses or patient problems that require nursing care. Assessments are used to plan, implement, and evaluate teaching and care to promote an optimal level of health through interventions to prevent illness, restore health, and facilitate coping with disabilities or death.
It is also used to identify health problems that require interdisciplinary care or immediate referral to other health care providers.
What is triage?
Prioritizing patients problems.
How do we as nurses prepare our patients for a physical assessment?
We provide privacy such as draping around their bed, providing them with hospital gowns. Only the part being assessed should be exposed.
We ensure the room temperature is comfortable and give them warm blankets if needed.
How do we as nurses prepare the environment to help ourselves to better perform our assessments?
We try to do it in a soundproof room with adequate lighting. Using an easy to maneuver examination table and arrange our equipment for easy use.
If you were doing a brief general physical assessment for ‘safety’ what are some things that you would assess?
Bed position.
Call bell location.
Appropriate emergency equipment.
Assistive health devices.
Fall risks/hazards.
If you were doing a brief general physical assessment for ‘vital signs’ what are some things that you would assess?
Temperature
Pulse
REspirations
BP
O2 sats.
Pain assessment.
If you were doing a brief general physical assessment for ‘mental status’ what are some things that you would assess?
Level of consciousness
Orientation to person, place, and time.
Speech
If you were doing a brief general ‘psychosocial assessment’ what are some things that you would assess?
Behavior and affect.
