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health assessment
foundations exam 2
| Question | Answer |
|---|---|
| Health assessment | collecting, validating, and analyzing data |
| subjective | based on patient experiences and perceptions |
| objective | measurable and directly observable |
| two components of health assessment | health history and physical assessment |
| health history | collection of subjective information about the patient's health status |
| physical assessment | collection of objective data about changes in the patient's body systems |
| characteristics of nursing assessments | purposeful, prioritized, complete, systematic, factual and accurate, relevant, recorded in a standard manner |
| What does the nursing assessment focus on? | the patients response to the health problem |
| What is the primary source of information? | the patient |
| Types of health assessments | initial/comprehensive, ongoing partial, focused, emergency |
| initial/ comprehensive health assessment | conducted upon admission to health care facility |
| ongoing partial health assessment | conducted at regular intervals |
| focused health assessment | conducted to assess a specific problem |
| emergency health assessment | conducted to determine life-threatening or unstable conditions |
| When is the initial assessment performed? | shortly after admittance to a health care facility |
| What is the initial assessment performed to establish? | a complete database for problem identification and care planning |
| Who is the initial assessment performed by? | the nurse to collect data on all aspects of patient's health |
| What is the on-going/partial assessment performed to compare? | a patient's current status to baseline data obtained earlier |
| What is the on-going/partial assessment performed to reassess? | health status and make necessary revisions in care plan |
| Who is the on-going/partial assessment performed by? | the nurse to collect data about current health status of patient |
| When may the focused assessment be performed? | during the initial assessment or as routine ongoing data collection |
| What is the focused assessment performed to gather? | data about a specific problem already identified, or to identify new or overlooked problems |
| Who is the focused assessment performed by? | the nurse to collect data about the specific problem |
| Emergency priority assessments | short, focused, prioritized assessments completed to gain the most important information needed first |
| What can emergency priority assessments flag? | existing problems and risks |
| Which of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer? A. Initial Assessment B. Focused Assessment C. Emergency Assessment D. On-going/partial assessment | A. initial assessment |
| Components of a health history | Biographical data, reason for seeking health care, history of present health concern, past health history, family health history, functional health assessment, psychosocial and lifestyle factors, review of systems |
| problems related to data collection | inappropriate organization of database, omission of pertinent data, inclusion of irrelevant data, misinterpreted data, failure to establish partnership, recording an interpretation of data rather than observed behavior, failure to update database |
| Validating inferences | performing physical exam. using proper equipment and procedure, using clarifying statements, sharing inferences with team members, checking findings with research reports, comparing cues to knowledge base of normal function, checking consistency of cues |
| When to verify data | when there is a discrepancy between what the person is saying and what the nurse is observing, when the data lacks objectivity |
| What to do whenever a critical change in the patient's health status is assessed? | immediately give verbal reporting of data |
| What do do when patient is admitted? | enter initial database into computer or record in ink on designated forms |
| Summarize objective and subjective data in... | concise, comprehensive, and easily retrievable manner |
| What to do when documenting data | use good grammar and standard medical abbreviations, use patients own words when possible, avoid nonspecific terms subject to individual interpretation or definition |
| One of the nurses' primary ethical responsibilities is... | safeguarding the privacy of patients |
| Preparing the patient for physical assessment | consider the physiologic/psychological needs of patient; explain process to the patient, that physical assessments should not be painful, each procedure in detail as it is conducted, that privacy will be maintained using drapes, answer patient questions |
| Considerations when performing health assessment | lifespan considerations, cultural considerations and sensitivity, patient preparation, environmental preparations |
| body system general constitutional symptoms | fever, chills, night sweats, malaise, fatigability, recent weight loss or gain |
| skin symptoms | rash, itching, change in pigmentation or texture, sweating, hair growth and distribution, condition of nails, skin care habits, protection from sun |
| skeletal symptoms | problems of joints, muscles, or bones including pain, stiffness, deformity, restriction of motion, swelling, redness, heat, cramping |
| head symptoms | headaches, dizziness, syncope, head injuries |
| eye symptoms | vision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, glaucoma, cataracts, glasses or contact lenses worn, date of last eye appointment |
| ear symptoms | hearing acuity, earache, discharge, tinnitus, vertigo, history of tubes or infection |
| nose symptoms | sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain or therapy, use of nose drops and sprays |
| teeth symptoms | pain, bleeding, swollen, or receding gums, recent abscesses, extractions, dentures, dental hygiene practices, last dental examination |
| mouth and tongue symptoms | soreness of tongue or buccal mucosa, ulcers, swelling |
| throat symptoms | sore throat, tonsillitis, hoarseness, dysphagia |
| neck symptoms | pain, stiffness, swelling, enlarged glands or lymph nodes |
| endocrine symptoms | goiter, thyroid tenderness, tolerance to heat and cold, changes in skin pigmentation, libido, polyuria, polydipsia, polyphagia, hormone therapy, unexplained weight change |
| respiratory symptoms | pain in the chest with breathing, dyspnea, wheezing, cough, sputum, hemoptysis, risk factors, and testing for tuberculosis |
| cardiovascular symptoms | chest pain, palpitations, dyspnea, orthopnea, history of heart murmur, edema, cyanosis, claudication, varicose veins, exercise tolerance, blood pressure, history of blood clots |
| hematologic symptoms | anemia, tendency to bruise or bleed, any known abnormalities of blood cells |
| lymph node symptoms | enlargement, tenderness, drainage |
| gastrointestinal symptoms | apetite, food intolerance, belching, heartburn, nausea, vomiting, hematemesis, bowel habits, flatulence, stool characteristics, hemorrhoids, jaundice, laxatives or antacids, history of ulcers or other conditions, previous diagnostic tests |
| urinary symptoms | dysuria, pain, urgency, frequency, hematuria, nocturia, oliguria, hesitancy, dribbling, decrease in size or force of stream, passage of stones, incontinence |
| reproductive symptoms | puberty onset, sexual activity, use and type of contraception, libido, sexual dysfunction, history of sexually transmitted infections, menstrual cycle, pregnancies |
| breast symptoms | pain, tenderness, discharge, lumps, mammograms, breast self-examination |
| neurologic symptoms | loss of consciousness, seizures, confusion, memory, cognitive function, incoordination, weakness, numbness, paresthesia, tremors |
| psychiatric symptoms | how patient views self, mood, sadness, depression, anxiety, irritability, obsessive thoughts, compulsions, suicidal or homicidal thoughts, hallucinations |
| nurses role in diagnostic procedures | assist, complete, witness, schedule, prepare, provide, dispose, transport |
| assist | assist before, during, and after diagnostic tests |
| complete | complete testing as prescribed |
| witness | witness the patients consent |
| schedule | schedule the test |
| prepare | prepare the patient physically and emotionally |
| provide | provide care and teaching after the test |
| dispose | dispose of used equipment |
| transport | transport specimens |
| equipment used during a physical examination | thermometer and sphygomomanometer, scale, flashlight or penlight, stethoscope, metric tape measurer and ruler, eye chart, watch with a second hand |
| positions used during physical assessment | standing, supine, sims position, lithotomy, sitting, dorsal recumbent, prone, knee-chest |
| standing position | patient stands erect, should not be used for patients who are weak, dizzy, or prone to fall, used to assess posture, balance and gait |
| supine | patient lies flat on back, facilitates abdominal muscle relaxation and is used to assess vital signs and the head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses |
| sims position | patient lies on either side with the lower arm belw the body and the upper arm flexed at the shoulder and elbow, both knees are flexed, with the upper leg more acutely flexed, used to assess rectum or vagina |
| lithotomy | patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the heels in stirrups, used to assess female genitalia and rectum |
| sitting | pt sit in chair, side of bed or remain in bed w/ head elevated, allows visualization of upper body, facilitates full lung expansion, used to assess vital signs and head, neck, anterior, and posterior thorax, lungs, heart, breasts, and upper extremities |
| dorsal recumbent | pt lies on back w/ legs separated, knees flexed, and soles of feet on the bed, used to assess head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses, not used for abdominal assessment bc it causes contraction of the muscles |
| prone | pt lies flat on abdomen with head turned to one side, used to assess the hip joint and the posterior thorax |
| knee-chest | pt kneels with body at 90 degree angle to hips, back straight, arms above head, used to assess anus and rectum |
| physical assessment | collection of objective data that provide information about changes in the patient's body systems |
| data in a physical assessment is obtained through | inspection, palpation, percussion, auscultation |
| inspection | performing deliberate, purposeful observations in a systematic manner |
| palpation | using the sense of touch to assess skin temperature, turgor, texture, and moisture, as well as vibrations and shape or structures within the body |
| percussion | striking one object against another to produce sound to assess the location, shape, size, and density of tissues |
| auscultation | listening with a stethoscope to sounds produced in the body |
| What does inspection begin with? | the initial patient contact and continues through the entire assessment |
| What is essential for distinguishing the color, texture, and moisture of body surfaces? | adequate natural or artificial lighting |
| Inspect each area of the body for... | size, color, shape, position, movement, and symmetry, noting normal findings and any deviations from normal |
| Inspection is usually followed by... | palpation during the assessment of each body part |
| assessments made using palpation | temperature, turgor, texture, moisture, vibrations, shape and masses, organs |
| assessments made using percussion | location of organs, shape of organs, size of organs, density of other underlying structures or tissues |
| assessments of sounds determined by auscultation | blood pressure, heart, lung and bowel sounds |
| characteristics of sounds determined by auscultation | pitch: high to low, loudness: soft to loud, quality: gurgling or swishing, duration: short, medium, long |
| bell side | picks up high pitch |
| diaphragm side | picks up low pitch |
| elements of a head-to-toe physical assessment | general survey, height and weight, vital signs, head and neck, chest and back, upper and lower extremities, abdomen, genitalia, anus and rectum |
| components of the general survey | observing the patient's overall appearance and behavior, taking vital signs, measuring height, weight, and waist circumference, calculating BMI |
| BMI 18.5 | underweight |
| BMI 18.5-25 | healthy weight |
| BMI 25-30 | overweight |
| BMI 30 or greater | obesity |
| Integument assessment | identify risk factors, inspection and palpation |
| identify integument risk factors | history of rashes, lesions, bruising, allergies, exposures to sun, chemicals, piercings or tattoos, degree of mobility, nutritional status |
| erythema | redness |
| eccyhmosis | collection of blood in subcutaneous tissue |
| petechiae | hemorrhagic spots/capillary bleeding |
| cyanosis | bluish or grayish color |
| jaundice | yellow color |
| pallor | paleness |
| diaphoresis | excessive perspiration |
| turgor | elasticity |
| edema | excess fluid |
| assessing the head and neck | identify risk factors, inspection and palpation, visual acuity, extraocular movements, peripheral vision, hearing and sound conduction, thyroid gland and lymph nodes |
| identify risk factors head and neck | changes in vision or hearing, history of allergies, chronic illnesses, exposure to harmful substances or smoking, history of infection or trauma |
| assessing the thorax and lungs | identify risk factors, inspection, palpation, auscultation, and percussion, posterior thorax excursion/chest expansion |
| identify risk factors thorax and lungs | history of trauma or lung surgery, number of pillows used when sleeping, cough, chest pain, allergies, exposure to chemicals or smoke |
| lung sounds | bronchial or tubular, bronchovesicular, vesicular, adventitious, wheeze, rhonchi, crackles, stridor, friction rub |
| assessing cardiovascular and peripheral vascular systems | identify risk factors, inspection, palpation, and auscultation, carotid arteries, heart sounds, peripheral pulses, neurovascular status |
| identify risk factors cardiovascular and peripheral systems | history of chest pain, palpitations, dizziness, swelling in ankles or feet, medications, personal or family history, type and amount of exercise |
| common cardiovascular and peripheral vascular variations in older adults | difficult to palpate apical pulse and/or distal arteries, dilated proximal arteries, more prominent and tortuous blood vessels, varicosities common, increased blood pressure, widening pulse pressure |
| abdominal assessment | identify risk factors, inspection, auscultation, percussion, palpation |
| identify risk factors abdominal assessment | abdominal pain, indigestion, nausea, changes in bowel habits, appetite, alcohol ingestion, menstrual history |
| Do you inspect or auscultate first? | inspect |
| right upper quadrant | plyorous, duodenum, liver, right kidney and adrenal gland, hepatic flexure of colon, head of pancreas |
| left upper quadrant | stomach, spleen, left kidney and adrenal gland, splenic flexure of colon, body of pancreas |
| right lower quadrant | cecum, appendix, right ovary and fallopian tube, right ureter and lower kidney pole, right spermatic cord |
| left lower quadrant | sigmoid colon, left ovary and fallopian tube, left ureter and lower kidney pole, left spermatic cord |
| assessing the musculoskeletal system | identify risk factors, inspection, palpation |
| identify risk factors musculoskeletal system | trauma, arthritis, neurologic disorders, history of pain or swelling in muscles or joints, frequency and type of exercise, dietary intake of calcium, smoking, excercise, and diet history |
| assessing the neurologic system | identify risk factors, health history interview, mental status, memory, emotional status, cognitive abilites and behavior, cerebellar function- motor skills, coordination, and balance; cranial nerve function, motor and sensory function; reflexes |
| identify risk factors assessing the neurologic system | hx of numbness, tingling, seizures, trembling; headaches or dizziness, trauma to head or spine, history of htn or stroke, changes in vision, hearing, taste, or smell, hx of diabetes or cardiovascular disease, alcohol and medications |
| assessing mental status | loc: awake and alert, lethargic, stuporous, comatose; level of awareness: time, place, person; memory (STM, LTM); language |
| ending the history and assessment | is there anything else you would like to tell me? What additional concerns do you have? |
Created by:
camrynfoster