STEPS of HEALTH ASSESSMENT Flashcards
What are the 3 Special Considerations During Interview?
- Gerontologic Variations in Communication
- Cultural Variations in Communication
- Emotional Variations
The ff shows ____________
- Speak clearly
- Use straightforward language
- Ask questions in simple terms
- Avoid medical jargon and modern slang
- Show respect
- Have significant other present during the interview to provide or clarify the data
Gerontologic Variations
The ff shows ___________
- Be sensitive
- Seek help from expert “culture broker”
- Seek an interpreter if difficulty in communicating or if there is misunderstanding
Cultural Variations
The ff shows _________
WHEN INTERACTING WITH:
- An anxious client
- Angry client
- Depressed client
- Manipulative client
- Seductive client
- Discussing sensitive issues
Emotional Variations
One of the ways in collecting objective data is to do ___________.
Physical Examination
Under Objective Data: The Physical Examination
What are the Basic Knowledge in 3 Areas?
- Types and operations of equipment needed
- Preparation of the setting, oneself, and the client
- Performance of the four assessment techniques
IN PREPARING THE PHYSICAL SETTING
- The room should be comfortable, ______ room temperature.
warm
IN PREPARING THE PHYSICAL SETTING
- Provide area free of ________ from others.
interruptions
IN PREPARING THE PHYSICAL SETTING
- Adequate _________.
lighting
IN PREPARING THE PHYSICAL SETTING
- Firm examination table or bed at a heights that prevents __________.
stooping
IN PREPARING THE PHYSICAL SETTING
- A bedside ___________ that hold the equipment needed.
tray or table
UNDER THE GENERAL PRINCIPLES
- Wash ________.
hands
UNDER THE GENERAL PRINCIPLES
- Always wear gloves if there is a chance to encounter ___________.
blood and fluids
UNDER THE GENERAL PRINCIPLES
- If a pin or other sharp object is used, ________ it immediately.
discard
UNDER THE GENERAL PRINCIPLES
- Wear a mask and protective goggle in cases which __________ can occur.
splashing
IN APPROACHING THE CLIENT
- Establish __________ (Interview)
Nurse-Patient Interaction (NPI)
Note:
- Build rapport and trust with the patient before starting the examination.
- Gather health history and assess any concerns.
- Use active listening and therapeutic communication.
IN APPROACHING THE CLIENT
- Inform the client that ________ is needed based on the information gathered.
further assessment
IN APPROACHING THE CLIENT
- Remove clothing and put on a gown. Leave the _________ until such time for vaginal examination.
underwear
IN APPROACHING THE CLIENT
- Leave the room and let the patient change, _____ before re-entering again.
knock
IN APPROACHING THE CLIENT
- Respect the client’s _______.
request
IN APPROACHING THE CLIENT
- Sign ______ before the Physical Examination (PE) if necessary.
consent
IN APPROACHING THE CLIENT
- Give a specimen cup for UA (Urinalysis), or if not tell the patient to ________ first before Physical Examination (PE).
void
FAMILIARIZE ONLY!
What are the Steps in Conducting a Physical Examination?
Begin with Less Intrusive Procedures
- Start with non-invasive assessments (e.g., general inspection, vital signs, auscultation).
- Helps the patient feel more comfortable before moving to more sensitive examinations.
Explain Each Procedure and Teach Health Promotion
- Describe what you are doing and why to reduce anxiety.
- Use this opportunity to educate the patient on health maintenance and disease prevention.
Approach the Client from the Right Side of the Examination Table
- Most physical assessments are performed using the right hand for convenience and accuracy.
- This is a standard practice in clinical settings to ensure consistency.
Ask the Client to Change Position When Necessary
- Some examinations require different positions (e.g., sitting, supine, lateral, or lithotomy position).
- Always inform and assist the patient when changing positions to maintain safety and comfort.
What are the 4 Assessment Technique in performing Physical Examination or Getting the Objective Data?
- Inspection
- Palpation
- Percussion
- Auscultation
REMEMBER THE ACRONYM “IPPA”
What Assessment Technique is this?
- Vision, smell, hearing
- Close and careful visualization of the person as a whole and of each body system.
- Ensure good lighting
- Perform at every encounter with your client.
INSPECTION
What is the good source of light?
SUN
FAMILIARIZE ONLY!
What are the Guidelines in doing Inspection?
- Comfortable room and temperature
- Use good lighting
- Look and observe before touching
- Completely expose the body parts you are inspecting, while draping the rest.
- Color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sounds.
- Compare the appearance of symmetric body parts (like eyes, ears, arms, hands) of both sides of any individual body part.
What Assessment Technique is this?
- Examination of the body using the sense of touch.
Palpation
The pads of the fingers are used in Palpation because the concentration of __________ makes them highly sensitive to tactile discrimination.
nerve endings
Note:
- Finger pads, ulnar/palmar surface & dorsal surface
FAMILIARIZE ONLY!
Palpation is used to determine the ff
- Texture – Determines whether a surface is smooth, rough, thin, or thick (e.g., hair texture or skin roughness).
- Temperature – Uses the dorsal side of the hand to check for warmth (fever/inflammation) or coolness (poor circulation, shock).
- Moisture – Assesses if the skin is dry, moist, or excessively sweaty (could indicate dehydration, fever, or hormonal imbalances).
- Mobility – Checks if a structure is fixed, movable, still, or vibrating (e.g., tumors or nodules).
- Consistency – Determines if a mass is soft, firm, hard, or fluid-filled, which helps in identifying cysts, tumors, or swelling.
- Strength of Pulses – Assesses blood circulation by checking if pulses are strong, weak, thready (barely palpable), or bounding (very strong pulse due to high blood flow).
- Size – Determines if an organ, mass, or lump is small, medium, or large compared to expected normal size.
- Shape – Identifies whether a structure is regular, well-defined, or irregular (useful in detecting abnormal growths or lumps).
- Degree of Tenderness – Evaluates pain response when pressure is applied (e.g., abdominal tenderness may indicate infection or inflammation).
What are the 4 Types of Palpation?
- Light palpation
- Moderate palpation
- Deep Palpation
- Bimanual palpation
What type of Palpation is less than 1 cm deep?
Light palpation
What type of Palpation is 1-2 cm deep?
Moderate palpation
What type of Palpation is 2.5 - 5 cm deep?
Deep palpation
What type of Palpation uses 2 hands?
Bimanual palpation
What Assessment Technique is this?
- Is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt.
Percussion
What are the 3 Types of Percussion?
- Direct Percussion
- Indirect Percussion
- Blunt Percussion
What type of Percussion is this?
- Tapping directly on the body surface using 1 or 2 fingers.
Direct Percussion
Note:
- Used to identify pain and in checking the sinuses.
What type of Percussion is this?
- One hand flat on the body. Use the fingers on the dominant hand. Tap the middle finger.
Indirect Percussion
Note:
- Used in lungs and abdomen to check high-pitched (air filled) and liquid.
What type of Percussion is this?
- Use the first of ulnar side of the hand to apply force over an area. Use to assess the kidney.
Blunt Percussion
Different Uses of Assessment Techniques in Physical Examination
- Eliciting Pain
- Determining location, size, and shape
- Detecting abnormal masses
- Eliciting reflexes
Identify the inflamed underlying structure.
A. Eliciting Pain
B. Determining location, size, and shape
C. Detecting abnormal masses
D. Eliciting reflexes
A. Eliciting Pain
Percussion note changes between the borders of an organ and its neighboring organ.
A. Eliciting Pain
B. Determining location, size, and shape
C. Detecting abnormal masses
D. Eliciting reflexes
B. Determining location, size, and shape
Superficial abnormal structures or masses.
A. Eliciting Pain
B. Determining location, size, and shape
C. Detecting abnormal masses
D. Eliciting reflexes
C. Detecting abnormal masses
Deep tendon reflex
A. Eliciting Pain
B. Determining location, size, and shape
C. Detecting abnormal masses
D. Eliciting reflexes
D. Eliciting reflexes
This is the process of listening to sounds produced within the body.
Auscultation
Auscultation may be ________ or _______.
Direct or indirect
A ___________ is used primarily to listen to sounds from within the body, such as bowel sounds, or valve sounds of the heart and blood pressure.
Stethoscope
What are the 4 Characteristics of Sound mentioned on the part of Auscultation?
- Intensity
- Pitch
- Duration
- Quality
Loud and soft
A. Intensity
B. Pitch
C. Duration
D. Quality
A. Intensity
High or low
A. Intensity
B. Pitch
C. Duration
D. Quality
B. Pitch
Length
A. Intensity
B. Pitch
C. Duration
D. Quality
C. Duration
Musical, crackling, raspy.
A. Intensity
B. Pitch
C. Duration
D. Quality
D. Quality
BOWEL SOUNDS
- Normal: Normoactive (5-30/minute)
- Too Fast: Hyperactive (diarrhea, early obstruction)
- Too Slow: Hypoactive (constipation, ileus)
- Very Loud and Prolonged: Borborygmi (hunger, gas)
FAMILIARIZE ONLY!
Do’s and Don’ts
- Warm the diaphragm or the bell before placing it on the client’s skin.
- Explain what you are listening for.
- Do not apply too much pressure.
- Avoid listening through clothing, may obscure or alter the sound.
FAMILIARIZE ONLY!
GUIDELINES
- Eliminate distracting sound from the environment
- Expose the body part your are going to auscultate
- Use the diaphragm of the stethoscope to listen for high sounds, breath sounds, and bowel sounds.
- Use the bell for low-pitched sounds (heart sound and bruits)
What are the parts of Stethoscope?
FAMILIARIZE ONLY! Practice on your stethoscope by pointing at the parts and determining what it is called.
- Earpieces
- Ear tube
- Headset
- Tubing
- Chest-piece
- Stem
- Bell
- Diaphragm
POSITIONING
FAMILIARIZE only!
- Supine
- Prone
- Right Lateral Recumbent
- Left Lateral Recumbent
- Fowler’s
- Trendelenburg
- Lithotomy Position
- Sims’ (posterior view)
- Dorsal recumbent
- Standing
- Knee-chest
- Sitting
- Squatting
For Checking the Abdominal Area, what is the right sequence to follow?
- Inspection
- Auscultation
- Percussion
- Palpation
