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Potter Perry Ch. 30
Health Assessment & Physical Examination
| Question | Answer |
|---|---|
| What are the first steps toward providing safe and competent nursing care? | The health assessment and the physical examination |
| What will the nurse be able to do by performing health assessment's and physical examination's? | You will identify health patterns and evaluate each patient's responses to treatments and therapies |
| How do nurses gather assessment data about patient's past and current health conditions? | Using a comprehensive or focused approach depending on the patient situation |
| Where are assessments usually performed? | Health fairs, screening clinics, health providers office, acute care agencies or in patients homes |
| Depending on the outcome of an assessment the nurse should | Consider evidence-based recommendations for care based on a patients values, the health provider's clinical expertise or own personal experience |
| What does a complete nursing assessment involve? | A nursing history and behavioral and physical examination. |
| Through the health history interview you | Gather subjective data about a patient's condition |
| When should the nurse obtain objective data? | While observing a patient's behavior and overall presentation. |
| How do you identify additional objective data? | By doing a head to toe body system review during the physical examination |
| Hat are the nurses clinical judgments based on what? | On all the gathered data you would create a plan of care for each situation |
| With accurate data the nurse can create what? | A patient centered care plan, identifying the nursing diagnoses, desired patient outcomes and nursing interventions. |
| How is the continuity in healthcare improved? | It is improved when you evaluate a patient by making ongoing, objective, and comprehensive assessments. |
| When is a physical examination conducted? | It is conducted as an initial evaluation in triage for emergency care; for routine screening to promote wellness behaviors and preventive health care measures; to determine eligibility for health insurance, military service, or a new job; or to admit a p |
| What should the nurse do after considering the patients current condition? | The nurse then selects a focused physical examination on a specific system or area. (Ex - when a patient is having a severe asthma episode, the nurse first focuses on the pulmonary and cardiovascular systems so treatment can begin immediately. |
| What does the nurse integrate for patients who are hospitalized? | The collection of physical assessment data during routine patient care, validating findings with what is known about the patients health history. (Ex-On entering a patient's room a nurse may notice behavioral patient cues that indicate comfort , anxiety |
| When should you use physical examination? | Gather baseline data about the patients health history, support or refute subjective data obtained in the nursing history, identify and confirm nursing diagnoses, make clinical decisions about a patient's changing health status and management, evaluate th |
| What factors affect your approach as well as the type of findings you might expect in dealing with how cultural differences influence patient behaviors? | Consider the patients health beliefs, use of alternative therapies nutritional habits, relationships with family, comfort with physical closeness during the examination and history |
| What do you do by recognizing cultural diversity? | You show respect for each patient's uniqueness, leading to higher quality care and improved clinical outcomes |
| Physical Examination is a routine part of a nurses what? | Patient assessment |
| When do you perform a reassessment? | When a patient's condition changes as it improves or worsens |
| In some home health visits a focused physical examination is preferred. This includes | Proper preparation of the environment, equipment, and patient ensures a smooth physical examination with few interruptions. |
| What does a disorganized approach cause? | Errors and incomplete fi findings |
| What is the main priority for confused patients? | Safety |
| Should you ever leave a confused or combative patient alone during an examination? | No |
| What type of precautions should you use throughout an examination? | Standard precautions |
| Why do you use standard precautions during an examination? | Some patient's present with open skin lesions, infected wounds, or other communicable diseases. |
| Why should you wear gloves with an open sore or microorganisms are present? | To reduce contact with contaminants. |
| What other equipment should you wear besides gloves if a patient has excessive drainage or there is a risk of splattering from a wound? | Additional personal protective equipment such as an isolation gown or eye shield should be used. |
| What are the two types of allergic responses that appear with (NRL) natural rubber latex? | Immunological reaction type 1 and the allergic contact dermatitis type 4 response. |
| What is the most immediate allergic response? | The immunological reaction type 1 response |
| What happens with the immunological reaction type 1 response? | The body develops antibodies known as immunoglobulin E that can lead to an anaphylactic response. |
| When does atopy occur? | When there is an increased tendency for the body to form antibodies as a result of the immune response |
| Allergic contact dermatitis type 4 response | Causes a delayed reaction that appears 12 to 48 hours after exposure |
| Equipment and supplies for physical assessment | Cervical brush or broom devices (if needed), cotton applicators, disposable pad/paper towels, drapes/cover, eye chart (Snellen chart), flashlight and spotlight, forms (physical, laboratory), nonlatex gloves(clean), gown for patient, opthalmoscope, otoscop |
| Equipment and supplies for physical assessment | Papanicolaou (pap) liquid preparation (if needed), percussion (reflex) hammer, pulse oximeter, ruler, scale with height measurement rod, specimen containers, slides, wooden or plastic spatula, and chronological fixation (if needed), sphygomanometer and cu |
| Equipment and supplies for physical assessment | Sterile swaps, stethoscope, tape measure, thermometer, tissues, tongue depressions, tuning fork, vaginal speculum (if Needed), water soluble lubricant, watch with second hand or digital display |
| Medicine equipment containing latex | Disposable gloves, blood pressure cuffs, stethoscope tubing, intravenous injection parts, touriquets, syringes, adhesive tape, oral and nasal airways, endotracheal tubes, catheters, eye goggles, anesthesia masks, respirators, rubber aprons, wound drains, |
| Household items containing latex | Rubber bands, erasers, motercycles and bicycle handrails, carpeting, swimming goggles, shoe soles, expandable fabric (wristbands), dishwashing gloves, condoms, diaphragm, balloons, pacifiers and baby bottle nipples |
| Medical equipment containing nonlatex substitutes | Vinyl, nitride, or neoprene gloves, covered cuffs, covered tubing, needless system, stopcocks, covered latex ports, latex free or cloth covered touriquets, glass syringes, nonlatex tapes, nonlatex tubes, hard plastic tubes, silicone catheters, silicone ey |
| Household items containing nonlatex substitutes | String; latex free bands, silicone erasers, handgrips removed or covered, other types of flooring, silicone construction, leather shoes, fabric removed or covered, vinyl gloves, nonlatex condoms, synthetic rubber diaphragms, maylor balloons, silicone, pla |
| What does physical preparation involve? | Making certain that patient privacy is maintained with proper dress and draping. |
| What position would you use to assess the head and neck, posterior thorax and lungs, anterior thorax and lungs, breasts, axillae, heart, vital signs, and upper extremities | sitting |
| what position would you use to assess the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, pulses | supine |
| What position would you use to assess the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen | Dorsal recumbent |
| What position would you use to assess the female genitalia and genital tract | Lithotomy |
| What position would you use to assess the rectum and vagina | Sims |
| What position would you use to assess the musculoskeletal system | Prone |
| What position would you use to assess the heart | Lateral recumbent |
| What position would you use to assess the rectum | Knee-chest |
| what does a routine pediatric examination focus on | health promotion, illness prevention, growth and development, sensory screening, dental examination, and behavioral assessment |
| A comprehensive health assessment and examination of older adults include | physical data, developmental stage, family relationships, religious and occupational pursuits, and a review of the patient's cognitive, affective, and social level |
| What is an important aspect to assess with the older adults | the patient's ability to perform basic activities of daily living bathing, grooming) and complex instrumental activities of daily living (making a phone call) |
| how often should you perform a complete examination and when | twice. Once on admission and once a day. |
| Where does an assessment begin for an adult examination | begins with an assessment of the head and neck and progresses methodically down the body to incorporate all body systems |
| what are the 4 techniques used in a physical examination | inspection, palpation, percussion, and auscultation |
| Inspection occurs when | interacting with a patient, watching for nonverbal expressions of emotional and mental status. |
| olfaction helps to | detect abnormalities that cannot be recognized by any other means. |
| What can be used concurrently with inspection, or it may follow in a more deliberate fashion | Palpation |
| Palpation involves | Using the sense of touch to gather information |
| why do you palpate the skin | For temperature, moisture, texture, turgor, tenderness, and thickness and the abdomen for tenderness, distention, or masses. |
| why do we use different parts of the hand | to detect different characteristics |
| The palmar surface of the hand and finger pad should be used to | determine position, texture, size, consistency, masses, fluid, and crepitus |
| We use the dorsal surface or the back of the hand for | assessing body temperature |
| The palmar surface of the hand the fingers is more sensitive to | vibration |
| By lightly grasping the body part with the fingertips we are measuring for | position, consistency, and turgor |
| The radial pulse is detected with | the pads of fingertips, the most sensitive part of the hand |
| Dorsum of the hand | detects temperature variations of the skin |
| The bony part of the palm at the base of the fingers detects | vibrations |
| Skin is grasped with the fingertips to assess | turgor |
| what are the 2 types of palpations used | light and deep |
| Light palpations is performed by | placing the hand on the body part being examined; it also involves pressing inward about 1 cm (1/2 inch) |
| Deep palpation is used to | examine the condition of organs such as those in the abdomen; depress the area under examination approximately 4 cm (2 inches), using one or both hands (bimanually) |
| When using bimanual palpation you should | relax one hand (sensing hand) and place it lightly over the patient's skin. The other hand (active hand) helps apply pressure to the sensing hand. |
| Which palpation should you have your clinical instructor observe for the first time | deep palpation |
| What does percussion involve | tapping the skin with the fingertips to vibrate underlying tissues and organs |
| When the vibration travels though the body tissues, and the character of the resulting sound reflects what | the density of the underlying tissue. |
| The denser the tissue the | quieter the sound |
| By knowing how various densities influence sound it is possible to | locate organs or masses, map their edges, and determine their size. |
| what does an abnormal sound suggest | a mass or substance such as air or fluid within an organ or body cavity. |
| Who uses the skill of percussion more often | advance practice nurses |
| Auscultation involves | listening to sounds the body makes to detect variations from normal |
| What is used to hear internal body sounds | stethoscope |
| Can you hear some sound such as speech and coughing without a stethoscope | yes |
| How are internal body sounds created | by blood, air, or gastric contents as they move against the body structures |
| What part of the stethoscope is best for hearing low-pitched sounds such as vascular and certain heart sounds | bell |
| What part of the stethoscope is best used for listening to high-pitched sounds such as bowel and lung sounds | diaphragm |
| Frequency indicates what | the number of sound wave cycles generated per second by a vibrating object. |
| The higher the frequency, | the higher the pitch of a sound and vice versa |
| Loudness refers to what | the amplitude of a sound wave. |
| Auscultated sounds range from | soft to loud |
| Quality refers to | sounds of similar frequency and loudness from different sources. |
| How can you describe the quality of sound | by using terms such as blowing or gurgling |
| Duration means | the length of time that sound vibrations last |
| The durations of sound is | short, medium, or long |
| Layers of soft tissue dampens the | duration of sounds from deep internal organs |
| For assessing appearance and behavior you should include | gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, signs of patient abuse, substance abuse, |
| recommended preventive screening for breast cancer age 20 -39 | Monthly breast self-examination Clinical breast examination by health care professional every 3 years |
| recommended preventive screening for breast cancer age 40 and up | monthly BSE Annual clinical breast examination by health care professional Annual mammograms (women at increased risk need to speak to health care provider regarding screening options) |
| recommended preventive screening for colon/rectal cancer age 50 and up | Men and woman need to have one of the following: fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually or flexible sigmoidoscopy (FSIG) every 5 years; the combination of FOBT or FIT annually and an FSIG every 5 years is preferred over |
| recommended preventive screening for ear disorders | all ages: periodic hearing checks as needed over age 65: regular hearing checks |
| recommended preventive screening for eye disorders | Age 40 and under: complete eye examination every 3 -5 years(more if positive history for eye disease. ex-diabetes) Ages 40 to 64: Complete eye examination every 2 years to screen for conditions that may go unnoticed. ex- glaucoma ages 65 and up: Complet |
| recommended preventive screening for heart/vascular disorders | men age 45 to 65/ women age 45 to 65: regular measurement of total blood cholesterol levels, lipids, and triglycerides, blood pressure screenings (if pt has risk factors for coronary artery disease (CAD), blood pressure screening needs to begin at age 20- |
| recommended preventive screening for obesity | all ages: periodic height and weight measurements |
| recommended preventive screening for oral cavity/pharyngeal disorders/cancer | all ages(children, adults, older adults) regular dental examinations every 6 months |
| recommended preventive screening for ovarian cancer | age 18 and up or on becoming sexually active: annual pelvic examinations by health care provider(this screening occasionally detects ovarian cancer in its advanced stage. Those as high risk need to have a though pelvic exam, a transvaginal ultrasound, and |
| recommended preventive screening for prostate cancer | ages 50 and up: men who have at least a 10 year life expectancy need to have a digital rectal exam (DRE) and prostate specific antigen (PSA) blood test annually. Men at high risk require earlier screening. |
| recommended preventive screening for skin cancer | ages 20 to 40: see specialist every 3 years over 40: annual skin checkups with biopsy of suspicious lesions |
| recommended preventive screening for testicular cancer | age 15 and up: monthly testicular self exam (TSE) |
| recommended preventive screening for uterine cancer | screening begins 3 years after having vaginal intercourse but not later than age 21: annual pelvic exam by health care provider plus annual papanicolaou (PAP) test |
| recommended preventive screening for cervical cancer | screening begins 3 years after vaginal intercourse but no later than age 21: annual pelvic exam by health care provider, plus an annual Pap test( at age 30 or after, those who have had three normal test consecutively may be screened every 2 to 3 years. If |
| recommended preventive screening for endometrial cancer | same as cervical cancer: endometrial biopsy at age 35 for high risk pats (those with or at risk for hereditary nonpolyposis colon cancer(HNPCC) (at menopause women at average and high risk need to be informed about signs and symptoms to report) |
| if 2 or more of the CAGE questions are positive then | be aware that substance abuse is likely and the patient needs guidance and encouragement to seek treatment. |
| Odor : Alcohol | site or source: oral cavity potential causes: ingestion of alcohol,diabetes |
| Odor : Ammonia | site or source: urine potential causes: urinary tract infection, renal failure |
| Odor : Body odor | site or source: skin, particularly in areas where body rubs together(underarms and breast)wound site, vomitus Potential causes: poor hygiene, excess perspiration(hyperhidrosis) foul smelling perspiration (bromhidrosis) |
| Odor : Feces | site or source: vomitus/oral cavity (fecal odor)rectal area potential causes: bowel obstruction, fecal incontinence |
| Odor ; foul smelling stools in infant | site or source: stool potential causes: malabsorption syndrome |
| Odor : Halitosis | site or source: oral cavity potential causes: poor dental and oral hygiene, gum disease |
| Odor: Sweet, fruity, ketones | site or source: oral cavity potential causes: diabetic acidosis |
| Odor: stale urine | site or source: skin potential causes: uremic acidosis |
| Odor: sweet, heavy, thick odor | site or source: draining wound potential causes: pseudomonas(bacterial) infection |
| Odor: musty odor | site or source: casted body part potential causes: infection inside case |
| Odor: fetid, sweet odor | site or source: tracheostomy or mucus secretions potential causes: infection or bronchial tree(pseudomonas bacteria) |
| Among older adults risk factors for development of alcohol related problems include | chronic medical disorders, sleep disorders, social isolation, loneliness, bereavement, and acute or chronic pain. |
| who appears to abuse alcohol more often | older women |
| when is measurement of vital signs more accurate | when completed before beginning positional changes or movements. |
| What are the vital signs | temperature, pulse, blood pressure, respirations, pain |
| Integumentary systems refers to | skin, hair, scalp, and nails |
| assessment of the skin reveals the patient's health status related to | oxygenation, circulation, nutrition, local tissue damage, and hydration |
| cyanosis | bluish discoloration |
| jaundice | yellow orange discoloration |
| erythema | red discoloration |
| skin finding: diaphoresis | Commonly associated drug: sedative hypnotic(including alchol) |
| skin finding: spider angiomas | commonly associated drug: alcohol, stimulants |
| skin finding: burns (especially fingers) | commonly associated drug: alcohol |
| skin finding: needle marks | commonly associated drug: opioids |
| skin finding: contusion, abrasions, cuts, scars | commonly associated drug: alcohol, other sedative hypnotics, intravenous(IV) opioids |
| skin finding: homemade tattoos | commonly associated drug: cocaine, iv opioids (prevents detection of injection sites) |
| skin finding: vasculitis | commonly associated drug: cocaine |
| skin finding: red, dry skin | commonly associated drug: phencyclidine(PCP) |
| indurated | hardened |
| turgor | refers to the elasticity of the skin |
| petechiae | nonblanching, pinpoint size red or purple spots on the skin caused by small hemorrhages in the skin layers |
| edema | area of the skin that is swollen from a build up of fluid in the tissues |
| two common causes of edema | direct trauma and impairment of venous return |
| how do you assess the degree of pitting edema | press the edematous area firmly with the thumb for several seconds and release. |
| when pressure from the examiners fingers leaves an indention in the edematous area it is called | pitting edema |
| What determines the degree of edema | the depth of pitting, which is recorded in millimeters |
| 1+ edema equals | a 2mm depth |
| 2+ edema equals | a 4mm depth |
| 3+ edema equals | a 6mm depth |
| 4+ edema equals | a 8mm depth |
| lesion | refers broadly to any unusual finding of the skin surface. |
| what do you use the ABCD mnemonic to assess the skin for | any type of carcinoma |
| ABCD: A= asymmetry | look for an uneven shape |
| ABCD: B= border irregularity | look for edges that are blurred, notched, or ragged |
| ABCD: C= color | look for pigmentation that is not uniform; variegated areas of blue, black, and brown areas of pink, white, gray, blue, or red are abnormal |
| ABCD: D= diameter | look for areas greater than the size of a typical pencil eraser. |
| two types of hair that cover the body | soft, fine, vellus hair which covers the body and coarse, long, thick terminal hair, which is easily visible on the scalp, axillae, and pubic areas and in the beard on men |
| alopecia | hair loss or thinning of the hair |
| a weight gain of 5 pounds (2.3kg)in 1 day indicates | fluid retention problems |
| a weight loss is considered significant if the patient has | lost more than 5% of body weight in a month or 10% in 6 months |
Created by:
slclark1975