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HEALTH ASSESSMENT
chapter 8-10
| Question | Answer |
|---|---|
| CHAPTER 8- Assessment Techniques and Safety in the Clinical Setting | |
| Physical Assessment | |
| Inspection ALWAYS FIRST | concentrated watching NEED: good lighting.•adequate exposure.• use of instruments to enlarge your view such as otoscope, ophthalmoscope, penlight, nasal, and vaginal specula. |
| Palpation- GATHER MORE INFO ABOUT THINGS THAT YOU CANNOT SEE WELL-BACK UP INSPECTATION | TOUCH TO ASSESS: Texture, temperature and moisture •Organ location and size•Swelling, vibration, pulsation or crepitation•Rigidity or spasticity•Presence of lumps or masses•Presence of tenderness or pain |
| Palpation | Should be performed slow and systematic FROM HEAD TO TOE Start with light and proceed to deep. •Bimanual palpation is used for certain body parts or organs. |
| Palpation Techniques | Fingertips:best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps •Fingers and thumb:detection of position, shape, and consistency of an organ or mass |
| Palpation Techniques | Dorsa of hands and fingers:best for determining temperature because skin here is thinner than on palms•Base of fingers or ulnar surface of hand:best for vibration |
| Percussion (NOW XRAY-CT SCAN ETC...) | Tapping person’s skin with short, sharp strokes to assess underlying structures Mapping location and size of organs•Signaling density of a structure by a characteristic note•Detecting a superficial abnormal mass |
| Percussion (NOW XRAY-CT SCAN ETC...) | Eliciting pain if underlying structure is inflamed•Eliciting deep tendon reflex using percussion hammer |
| Percussion Methods-DON'T PERCUSE OVER BONE NOT A GOOD TECHNIQUE FOR DEEPER ORGAN | Direct, sometimes called immediate, the striking hand directly contacts body wall-HOMEOPATHY •Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on person’s skin USE DOMINANT 2 FINGERS-The Stationary striking hand |
| Production of Sounds | Characteristics of sounds•Amplitude (intensity)—loud or soft sound•Pitch (frequency)—number of vibrations per second•Quality (timbre)—subjective difference •Duration—length of time sound lingers |
| Production of Sounds | Basic principles •Structure with more air produces louder, deeper sound compared with denser structure.•Variations occur in clinical practice based on individual anatomical differences. |
| Auscultation | USE A STEHOSCOPE TO LISTEN TO SOUND KNOW WHEN TO USE A DIAPHRAGM-flat edge, high pitched sounds I.E BP-LUNG-BOWEL SOUND BELL- deep, hollow cuplike shape, soft pitched sounds I.E HEART-BP |
| Auscultation: Basic Principles | Eliminate extra noise. •Keep environment warm and warm your stethoscope. •Avoid listening over hairy body areas. •Never listen through a patient’s gown or clothing. •Avoid your own artifact. |
| Standard Equipment | vital signs platform scale (with height attachment), stethoscope, sphygmomanometer, and thermometer. Pulse oximetry |
| Standard Equipment | Otoscope, ophthalmoscope, penlight, and pocket vision screener•Skinfold calipers, skin marking pen, and tuning fork •Nasal speculum, tongue depressor, and cotton balls |
| Standard Equipment | Flexible tape measure and ruler, sharp object (split tongue valve), reflex hammer •Bivalve vaginal speculum, materials for cytology, lubricant, and fecal occult blood materials |
| Standard Precautions | Hand hygiene•Key factor in decreasing spread of infection •Perform before and after patient care •Use of protective equipment•Gloves, gown, mask, eye protection, or face shield •Respiratory hygiene/cough etiquette |
| The Clinical Setting: Hands On Provide explanations. Perform hand hygiene. Measurement and vital signs | •Have patient change into examination gown.•Maintain privacy and respect.•Begin with person’s hands as point of initial contact.•Concentrate on one step at a time—avoid distractions.•Examination sequence—EDUCATION•Summarize findings for person. |
| Examination of the Person - Who Is Sick | Alter position during examination.•Adapt assessment to patient’s comfort level.•Examine body areas appropriate to problem, collecting a mini database.•You may return to finish a complete assessment after initial distress has been resolved. |
| Developmental Competence | USE EQUIPMENT AND TECHNIQUE BASED OF DEVELOPMENTAL STAGE |
| The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for the examination? | Inspection, auscultation, percusion, palpation, NORMAL IT IS- Inspection, palpation, percussion-auscultation, |
| The nurse is preparing to do a physical assessment on a patient who is end-stage HIV positive. What should the nurse do for self-protection? | Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary. |
| CHAPTER 9- General Survey Characteristics | Covers general health state and any obvious physical characteristics•Provides an overall impression•Includes areas of physical appearance, body structure, mobility, and behavior |
| Objective Data: Physical Appearance | Age:person appears as perstated age •Sex:sexual development appropriate for gender and age •Level of consciousness:alert, oriented, and responds appropriately |
| Objective Data: Physical Appearance | Skin color:color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion •Facial features:symmetric with movement •Overall appearance: provide general statement r/t presence or absence of distress |
| Body Structure •Posture:person stands comfortably erect as appropriate for age•Position:description of patient’s position during assessment | Stature:height appears within normal range for age, genetic heritage •Nutrition:weight appears within normal range for height and body build; body fat distribution even •Symmetry: body parts look equal bilaterally and are in relative proportion |
| Mobility | Gait:normally base is as wide as shoulder width •Accurate; walk smooth, even, and well-balanced •Range of motion: full mobility for each joint and movement is deliberate, accurate, smooth, and coordinated •No involuntary movement |
| Behavior | Facial expression: maintains eye contact, expressions appropriate to situation •Mood and affect: comfortable, cooperative, pleasant •Speech:articulation clear and understandable •Dress:appropriate to climate•Personal hygiene:appears clean and groomed |
| Measurements: Weight | Use a standardized balance or electronic scale. •Remove shoes and heavy outer clothing •When sequence is necessary, aim for approximately same time of day and same type of clothing worn each time. |
| Measurements: Weight | Record weight in kilograms and pounds per facility •Show person weight per weight chart. •Compare person’s current weight with previous visit. |
| Height | Height •Use wall-mounted device or measuring pole on scale. •Align extended headpiece with top of the head. •Person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface. |
| BMI | Body mass index •Body mass index is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition. UNDERWEIGHT- <18.5 healthy 19-24.9 OVERWEIGHT 25-29.9 OBESE 30> |
| Abnormalities in Body Weight and Proportion | Dwarfism •Hypopituitary dwarfism •Achondroplastic dwarfism •Gigantism versus acromegaly (hyperpituitarism) •Anorexia nervosa •Endogenous obesity—Cushing’s syndrome •Marfan syndrome |
| Waist Circumference | Assesses body fat distribution as indicator of health risk. •An independent risk factor for disease, over and above that of body mass index (BMI). •Waist circumference measured in inches at smallest circumference below rib cage and above iliac crest |
| Waist Circumference | Hip circumference measured in inches at largest circumference of buttocks •Note the measurement at end of normal expiration. |
| Developmental Competence General survey r/t infants and children | Interpret based on age and developmental ability•Behavior and parental bonding•Measurement—weight and length (height)•Physical growth based on CDC growth charts |
| Developmental Competence General survey r/t aging adults | Normal consequence of aging changes r/t posture and gait•Measurement—weight and height |
Created by:
Seka_nurse
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