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NUR151-HealthAsses1
Health Assessment Part 1
| Question | Answer |
|---|---|
| Subjective data | Obtained from the client – primary source – if can’t communicate, ask secondary source of family members/people nearest them - Not measurable or observable, but what the patient tells us. |
| Example of subjective data | “I’m short of breath”, “My pain is 10/10”, “I feel sick to my stomach”, “His skin doesn’t look so red today”. |
| Objective data | Measurable & observable – we gather it as healthcare workers - other than client – facts, figures, etc. |
| Example of objective data | ”The patient walked 5 feet without assistance”, “He vomited X amount of emesis.” |
| Subjective or Objective – Feelings, perceptions, and self-report of symptoms? | subjective |
| Subjective or Objective – Blood pressure measurement? | objective |
| What is in medical record? | Medical history, labs, test results, current physical findings, and primary health care provider’s treatment plan. |
| Purpose of client interview? | Gather and provide information, ID problems & concerns, “chief complaint”, Why here? subjective data gathering and build rapport. |
| During assessment, where would you most likely gather the most subjective data? | Client interview/health history. |
| PMH | Past Medical Heath |
| ROS | Review of systems – a systematic method for collecting data on all body parts. |
| 5 Techniques for assessment | Inspection, palpation, auscultations, olfaction, and percussion |
| You typically hear the first heart sound best when auscultated where? | left 5th ICS along midclavicular line. |
| What do we palpate the skin for? | temperature, moisture, texture, turgor, tenderness, and thickness. |
| What do we palpate the abdomen for? | tenderness, distention, or masses |
| light palpation | 1 cm in depth |
| deep palpation | 4 cm in depth |
| The most sensitive area are palpitated | last |
| Percussion involves tapping the body with | the fingertips to produce a vibration that travels through body tissues. |
| Tympani sound is | drum-like, high pitch – ex: gastric bubble |
| Resonance sound is | hollow, low pitch – ex: healthy Lungs |
| Hyperresonance sound is | booming, very low pitched ex: Emphysemic lung tissue |
| Flatness sound is | very dull, high pitch – ex: muscle, bone |
| Dullness sound is | thud-like, medium pitch – ex: Liver, spleen, heart |
| Frequency | the number of sound wave cycles generated per second by a vibrating object. |
| Loudness | the amplitude of a sound wave. Auscultated sounds are loud or soft. |
| Quality | sounds of similar frequency and loudness from different sources - blowing or gurgling |
| Duration | the length of time that sound vibrations last |
| Go for the place of most concern first | focus assessment |
| The physical examination is made up of | individual assessments for each body system. |
| Sitting | head, neck, thorax – full expansion of lungs – symmetry of upper body parts - disadvantage: hard for client with weakness. |
| Supine | flat on back – to auscultate abdomen, femoral pulse, heart, abdomen - disadvantage: hard to breathe |
| Dorsal recumbent | on back with knees bent and together - abdominal area – relaxes ab muscles |
| Lithotomy | female genital and tract-embarrasing |
| Sims | lying on side with one leg flexed – exposes rectal and vaginal area – good for rectal exam or vaginal exam. Inflection of the hip and knee needed, so hard for hip patients. Used for enema. |
| Prone | flat on abdomen – musculoskeletal system – they can flex knees and hips – not good for respiratory patients. |
| Lateral recumbent | lying on their side with both knees slightly bent – on “left-lateral recombant” side for heart – good for murmurs |
| Knee-chest | rectum – embarrassing |
| Semi-fowler | 30 – 45degree angle while lying on back |
| Fowler | 90 degree angle while lying on back |
| What are some of the things to assess in a general survey? | age, gender, distress, posture, gait, hygiene, speech, affect. |
| First part of physical assessment is? | vitals |
| Assessment of the skin reveals changes in | oxygenation, circulation, nutrition, local tissue damage, and hydration. |
| Skin produces which Vitamin | D production |
| Melanoma | an aggressive form of skin cancer |
| Normal brown skin appears to be yellow-brown and normal black skin appears to be ashen gray when? | When patient is cyanotic. |
| If pallor is present, the mucous membranes will be | ashen gray |
| Assessment of cyanosis in dark-skinned client requires observation of | areas where pigmentation occurs the least (conjunctiva, sclera, buccal mucosa, tongue, lips, nail beds, and palms and soles) |
| Localized skin changes, such as pallor or erythema (red discoloration), indicate | circulatory changes |
| A | Asymmetry – same on each side or different? |
| B | Border – ragged edges, border irregularity |
| C | Color – Solid? Multi-colored? Brusing? |
| D | Diameter – How big? |
| E | Elevation – bigger than smaller? |
| Indurated | hardened |
| A decrease in turgor predisposes the client to | skin breakdown |
| Petechiae | dots that show broken blood vessels especially when they are thrombocytopenic – hemorrhages in the skin layer. |
| Spider angionomas | big nose with lots of spider veins |
| Macule | freckle or Petechia – flat area less than 1 cm in size that is discolored. |
| Patch | large amount of macules grouped together – larger than 1 centimeter. – birthmarks or Mongolian spots. |
| A birthmark would what kind of skin lesion? | A patch |
| A Mongolian spot would be what kind of skin lesion? | Patch - Look like bruises and occur a lot in infants and can be mistaken for child abuse. |
| Papule | something solid, elevated, and less than a centimeter- or a mole. |
| A nevus would be what kind of skin lesion? | Nevus = mole – a papule |
| Nodule | solid, elevated, and greater than a centimeter – can be hard or soft. – wart would be one. |
| What kind of skin lesion would a wart be? | A nodule |
| Tumor | 1-2 cm - Could describe as dime-size, quarter-size, etc. Usually centimeters is used. |
| Wheal | an elevated red area. Usually has fluid inside of the tissue. Mosquito bite or hives |
| A mosquito bite would be what kind of skin lesion? | wheal |
| Hives would be what kind of skin lesion? | Wheal because they are fluid filled |
| Cyst | fluid filled cavity in the subcutaneous area. Usually soft |
| Vesicle | an elevated cavity containing free serous fluid – less than a centimeter - Chickenpox, herpes. |
| Chickenpox would be what kind of skin lesion? | Vesicle |
| Pustule | pus filled, elevated cavity. Pimple |
| A pimple would be what kind of skin lesion? | Pustule |
| Ulcer | Deep loss of skin surface that extends into dermis and bleeds/scars – venous stasis ulcer. |
| Bulla | Blister – larger than 1 cm. Superficial in the epidermis. |
| Atrophy | Thinning of skin w/loss of normal skin furrow – skin is shiny and translucent |
| senile keratosis | thickening of skin |
| cherry angiomas | (ruby red papules |
| Primary Lesions | Occurring as initial spontaneous manifestations of a pathological process such as an insect bite. |
| Secondary Lesion | Resulting from later formation or trauma to a primary lesion such as a pressure ulcer. |
| When you detect a lesion, inspect it for | color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized. |
| Name some primary lesions | macules and nodules - come from some stimulus to the skin |
| Name a secondary lesions | ulcer - occur as alterations in primary lesions |
| Basal cell carcinoma | almost never spreads to other parts of the body |
| Squamous cell carcinoma | more serious than basal cell and develops on the outer layers of sun-exposed skin - may travel to lymph nodes |
| 4 Levels of edema | Mild-1, moderate-2, deep-3, very deep-4 |
| Anasarca | severe generalized edema |
| Normocephalic | Head round and symmetric and appropriate for size of body. |
| Microcephalic | small sized skull |
| Macrocephalic | large head bones |
| Hydrocephalus | infants - large head results from congenital anomaly or the buildup of cerebrospinal fluid in the ventricles. |
| Enlarged jaws and facial bones resulting from ___, a disorder caused by excessive secretion of growth hormone. | acromegaly |
| Puffy around eye could indicate ___. | heart failure |
| Trachea should be | mid-line, no lumps, thyroid gland normal |
| Listen to the thyroid for | bruits |
Created by:
Ladystorm