The Complete Health Assesment Flashcards
Subjective data-Health History
biographical data
reason for seeking care
history of present illness
past medical history
allergies
family history, social history
current meds
review of systems
functional assessment or activities of daily living
Functional assessment (ADL, IADL)
are you retired
stairs?
driving
food (prep, delivery, nutrition)
community of support (family, community care, Meals on Wheels)
Getting up from the chair, off the exam table
devices
Objective Exam for adults
general appearance
measurements
skin
head and face
eye
ear
nose
mouth and throat
neck
chest
upper extremities
breasts
heart
\neck vessels
abdomen
inguinal area
lower extremities
MSK
Neuro
genitalia
rectum
Seated-in gown, what do you assess
skin
vital signs
head and face
eye
ear
nose
mouth and throat
neck
chest
heart
upper extremities
breasts
Patient sits up-what do yuo assess
neuro and msk
Patient stands up, what do you assess?
lower extremities
msk
Supine (laying down), what do you assess
breasts, neck vessels, heart, abdomen, inguinal area, lower extremities
Objective data for newborns and infants
position-supine
reorder the sequence based on sleep and wakefulness
vital signs
measurement (weight, length and head circumference plotted on growth curves)
General appearance (body symmetry, strong cry)
chest and heart (apical rate, abdominal movement with respirations (retraction)
abdomen-umbilicus and skin turgor
Head and face-moulding of cranium, fontanels
eyes-pupillary, blink, corneal light reflexes
ears-startle reflex
nose/mouth/throat-nasal flaring, salivation, rooting and sucking reflexes
neck-head lag, tonic neck reflex
upper extremities-absence of scarf signs, palm creases, grasp reflex
lower extremities-ROM,syndactaly(fused fingers/toes), ortolani manoevre
Genitalia
Neuro-Doll’s eye reflex, stepping and placing reflexes
Spine/rectum-trunk incurvation reflex, symmetry of gluteal folds, patent anal opening
Final-auditory canals with otoscope
Objective Data for young children
Considerations-desire for independence, fear of new environment, fear of invasive procedures, dislike of restraint
health history
general appearance-NPDDS
Soocial interactions, speech
Measure height and weight
Chest and heart-apical pulls, thrills, tactile fremitius
Objective data for young children
genitals-palpate scrotum for testis
lower extremities-orolani manoevre
head and neck-fontanelles and cranium, head circumference
Documentation and critical thinking
record data as soon as possible after exam
consider legal responsibility in documentation
balance between recording too much and too little data
succinctness-short clear phrases
avoid redundent descriptions
use simple line drawings
The hospital setting
need for consistent, specialized, focused, examination at least every 8 hours
utility of measurement depends on consistency in procedure from nurse to nurse
documentation and communication (SOAP and SBAR
initial assessment vs ongoing frequent assessments
SOAP charting
fascilitates clinical reasoning
Subjective
Objective
Assesment
Plan
SBAR Technique
fascilitates communication
Situation
Background
Assessment
Recommendation
Subjective and objective data in the hospital
health hisotry-refer from pervious shift report and assess for pain
general appearance-personal hygiene
Measurement-vital signs, pulse oximetry, pain level rating at rest and with activity, following analgesia
Analgesia
inability to feel pain
Assist patient to bed
check general appearance
measurement
neuro
respiratory system
Subjective and objective neuro
eyes open to me
motor response is strong and equal
verbal response appropriate, clear speech
pupil response
muscle strength in upper and lower extremities
facial droop
sensation
ability to swallow
Subjective data and objective data-respiratory system
check 02 delivery method
note FiO2
respiratory effort
SOB on rest, exertion
asuculatet bresth sounds
check cough
spirometer use
Subjective and objective assessment-cardiac
rythym at apex, apical and radial pulse
heart sounds in all auscultory zones
capillary refill
palpate pedal pulses
use doppler if needed
skin-assess temperature, colour, turgor, integrity, condition of dressings, Brdaen Risk Assesment
Objective and subjective data of abdomen
bowel sounds, palpation in all four quadrants
nausea or vommiting
drainage tubes-placement, colour, consistency, and odour amount
stoma
tolerating diet
Objective and Subjective GI system
regular voiding-amount, colour
indwelling catherter in place
bladder scan as protocol if decreased urinary output
Critical Findings
systolic BP
Temp
Heart Rate
Respiratory rate
O2 saturation
Urine output
Postoperative nausea (not relieved by meds)
surgical pain not controlled with analgesia
bleeding
altered level of conscious, confusion
sudden, restlessness, anxiety
SBAR Framework
Situation, background, assesement, recommendation
tool to organize verbal communication
focuses on immediate problem and keeps message concise
Measurement
Height
Weight
BMI
Vital signs
radial pulse
respirations
blood pressure
temperature
oxygen saturation
pain assessment
Order of examination
Head to toe assessment
systems assessment
Head and face
inspect scalp, hair, and cranium
inspect face, expression, symmetry
Eyes
inspect external eye structures, conjunctivae, sclerae, corneae irides
test pupils size and response to light and accomodation
Ears
inspect extrnal ear position and alignment, skin condition and auditory meatus
move aurcile and push tragus for tenderness
using an otoscope, inspect the canal and tympanic membrane, colour, position, landmarks and integrity
Nose
symmetry and lesions
mouth and throat
buccal mucosa, teeth, gums, floor of mouth, palate, uvula
tonsils if present
uvula mobility and gag reflex
stcick tongue out
neck
symmetry, lumps and pulsations
neck vessels
jugular venous pulse
Upper extremities
inspect skin, symmetry, temp, pulses
ROM and muscle strength of hands-wrists, fingers, arms, shoulders and elicit the reflexes
chest and thoracic area
inspect and auscultate
anterior chest
respirations and skin and auscultate breath sounds
heart
inspect and palpate the precordium for pulsations and lift
auscultate with diaphragm
auscultate apical rate and rythym
auscultate with bell at locations
abdomen
inspect contour, symmetry, skin, characteristics, umbilicus, pulsations
auscultate bowel sounds
ausultate for vascular signs over the aorta and renal arteries
percuss all quadrants
plapate-in all quadrants
(IAPP)
Lower extremities
inspect the symmetry, skin characteristics, hair distribution, varicose veins
palpate pulses: popiteal, posterior tibial, dorsalis pedia
palpate for temp and edema
separate toe and inspect
test ROM and muscle strength (hips, knees, ankles, feet
Test reflexes
Standing MSK
GAit (tandem walking-toe to toe)
assess rombergs sign
Romberg’s signs
sense of balance-stand and close eyes
While standing-the back
Check spine as person touches their toes
asses range of motion of the spine as person hyperextends, rotates and bends laterally
assess the spinous process as the person bends forwards
Neurologic
test sensation
test rapid alternating movements-upper extremity function
test lower extremity function by asking each person to run each heel down the oppoiste shin
Neurologic
test sensation
test rapid alternating movements-upper extremity function
test lower extremity function by asking each person to run each heel down the opposite shin
