Physical assessments Flashcards
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.
If you were doing a brief general physical assessment of the head, eyes, ears and nose, what are some things that you would assess?
Eyes
Pupils
Mouth
Carotid arteries
Swallowing
throat
neck
facial color
moisture
lesions
wounds
glasses
hearing aid
ability to hear and see
If you were doing a brief general physical assessment of the chest what are some things that you would assess?
Chest color,
Moisture,
Lesions,
Wounds,
Quality of respirations,
Heart sounds,
Lung sounds,
Cough,
Sputum.
If you were doing a brief general physical assessment of the abdomen what are some things that you would assess?
Abdomen color,
Moisture,
lesions,
wounds,
bowel sounds,
tenderness,
distension,
pain/discomfort,
ability to eat,
urine elimination pattern & urine characteristics,
bowel elimination pattern & stool characteristics.
If you were doing a brief general physical assessment of the upper and lower extremities, what are some things that you would assess?
skin,
color,
pulses,
temperature,
tenderness,
edema,
capillary refill,
strength,
sensation,
range of motion,
lesions,
wounds
If you were doing a brief general physical assessment of the patients activity, what are some things that you would assess?
Movement and ambulation
Ability to move in bed
Ability to get out of bed
Ability to walk and the distance they can walk
Gait
If you were doing a brief general physical assessment of the patients therapeutic devices, what are some things that you would assess?
Peripheral and central venous access devices
Supplemental oxygen setting
Pacemaker
Cardiac monitor
Urinary catheters
Gastric tubes
Chest tubes
Dressings
Braces
Slings
What are the components of a patients health history?
Biographic data.
The reason for the patient seeking healthcare.
Present health or history of present health concern.
Past health history.
Functional health.
Review of systems.
What is biographical data?
patient’s name.
address & billing & insurance information.
biologic sex.
sexual orientation.
gender identity.
age and birth date.
marital status.
occupation.
race & ethnic origin.
religious preference.
presence of an advance directive/living will, and the patient’s primary health care provider.
What are we assessing when a patient is in a standing position and with what patients should this position not be used?
Used to assess posture, balance, and gait.
Should not be used with patient who are weak, dizzy or prone to fall.
What is supine position and what are we examining for when a patient is in this position?
Patient is laying flat on the back with legs extended and knees slightly flexed. Facilitates abdominal muscle relaxation and used to assess vital signs, head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities and peripheral pulses.
What is sims position and what are we examining for when a patient is in this position?
The patient lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed. It is used to assess the rectum or vagina.
What is lithotomy position and what are we examining for when a patient is in this position?
The patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the heels in stirrups. It is used to assess female genitalia and rectum.
What is sitting position and what are we examining for when a patient is in this position?
The patient may sit in a chair or on the side of the bed or examining table, or remain in bed with the head elevated. It allows visualization of the upper body, facilitates full lung expansion, and is used to assess vital signs and the head, neck, anterior and posterior thorax, lungs, heart, breasts, and upper extremities.
What is dorsal Recumbent position and what are we examining for when a patient is in this position and when should it not be used?
The patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. It should not be used for abdominal assessment because it causes contraction of the abdominal muscles.
What is prone position and what are we examining for when a patient is in this position?
The patient lies flat on the abdomen with the head turned to one side. It is used to assess the hip joint and the posterior thorax.
