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NUR 104-chpt 10 & 25

Nursing Assessment & Health Assessment of Human Function

QuestionAnswer
Discuss the purpose of a physical examination. to establish a baseline or any risk factors validate & support data obtained on assessment/during health history creating a prob statement (nursing dx) aids in evaluating the outcome aids in making clinical judgement about pts change in health status
Discuss the communication skills necessary to promote physical and psychological comfort during an exam. have pt use restroom dressed & draped appropriately proper positioning (supine for heart/abdominal explain why/what you are doing use understandable words be professional no unnecessary body parts exposed
Identify the components that are important in peparing a physical examination. privacy adequate lighting quite backround noise equipment works/proper equipment (warm stethoscope) room temp comfortable place equip in order of use perform hand hygeine
Describe evidence based practice r/t the inspection phase of a physical examination. the visual examination of a pt done methodically. any abnormalities are identified, with factors such as color, shape, symmetry, movement, pulsations, texture of involved body part
Describe evidence based practice r/t the palpation phase of a physical examination. speciallized use of touch, using fingertips and palms to determine size, shape & configuration of underlying body structures. pulses of bloodvessels, outlines of organs, or size shape or mobility of masses, temp, tenderness
Describe evidence based practice r/t the percussion phase of a physical examination. one or both hands used to strike body surface to produce sounds of underlying organs. discovers location and level of organs, consistency of body structures, presence of tenderness, to identify tumors or masses
Describe evidence based practice r/t the ascultation phase of a physical examination. listening to body sounds
Describe evidence based practice r/t the olfaction phase of a physical examination. Sweet heavy thick odor = infection Hallitoisis= poor dental care, gingevitus, aspiration, strep Sweet fruity breath = diabetic acidois, keytone bodies
Identify between the different components of the nursing health history. Collecting subjective and objective data from the primary and secondary sources. And being considerate of cultural differences
What is subjective & objective data? subjective is what is told to you by the patient. pain is subjective because it is unmeasurable. objective is directly observed or measured. vital signs or apperance are objective.
discuss methods to complete an organized physical examination using the head to toe method. General Mobility & Self Care Head Face Neck Chest Abdomen Genitalia Extremeties
How would you assess General Health in head to toe? General health state vital signs and weight nutritional status
How would you assess Mobility & Self Care in head to toe? observe posture assess gait & balance evaluate mobility ADL's
How would you assess Head, Face, Neck in head to toe? Evaluate cognition level of consciousness orientation mood lang & memory sensory fx inspect/examine eyes test vision test hearing cranial nerves inspect oral cavity/teeth inspect lymph nodes inspect neck veins
How would you assess Skin, Hair, Nails in head to toe? inspect scalp & hair evaluate skin turgor observe skin lesions assess wounds inspect nails
How would you assess Chest in head to toe? Inspect & palpate breasts inspect & ausculate lungs ausculate heart
How would you assess the Abdomen in head to toe? Inspect, Ausculate, palpate four quadrants palpate & percuss liver, stomach, bladder bowel elimination urinary elimination
How would you assess the genitalia in head to toe? inspect female client inspect male client
How would you assess the extremities in head to toe? palpate arterial pulses observe capillary refill evaluate edema assess joint mobility measure strength assess sensory fx assess circulation, movmt,sensation deep tendon reflexes inspect skin & nails
differentiate between normal & abnormal findings of the physical examination and health history.
identify proper communication of data collected during the physical examination and health assessment at the conclusion of the assessment you need to summarize your findings and concerns. this validates and clarifies any misunderstandings.
discuss the roles of the various interdisciplinary health care team members for completeing the health history and physical examination all team members involved should be consistent in documentation and info pertaining to a specific pt. communication should be clear among team members
discuss how the health history and the physical examination contribute to the nursing process. provides an adequate database to aid in formulating a conclusion or problem statement (nursing dx) by comparing data the nurse can determine whether supportive data to meet dx has been obtained, whether further data should be collected, or another dx
What is light palpation depth? What is it used for? 1/2-1 inch deep checkin pulses, edema, tenderness, superficial pain
What is deep palpation depth? What is it used for? 11/2-2 inches deep palpate organs, masses : liver, spleen, impaction helps in assessing size
What part of your hand is used to detect the texture of a patients skin? fingertips
What part of your hand is used to detect a patients temperature? back of hand (dorsum)
What part of your hand is used to detect vibration? (fremitus) palm of the hand
What type of sound would you hear if percussing the sternum? Flat, extreme dullness
What type of sound would you hear if percussing an air filled stomach? Tympanic, musical
What type of sound would you hear if percussing a lung? Resonant, hollow sound
What type of sound would you hear if percussing a liver? Dull, thud like sound
What is the diaphram best used for hearing? high pitched sounds, breath sounds, normal heart sounds, bowel sounds, *if body hair is present, you can wet it to reduce friction sounds
What is the bell best used for hearing? low pitched sounds abnormal heart sounds, murmurs, bruits
General survey inital assessment beginning with first contact w/ pt. Allows nurse to note physcial, mental, overall health status
Neurological assessment is what? assessment of mental, intellectual, emotional status
What is the GCS (Glascow Coma Scale)? evaluates pts best eye response, best motor & verbal response on a scale of 3-15 (15 being awake/alert) (3 being pt doesnt respond to stimuli)
What is receptive aphasia? difficulty understanding & follow simple command/directions
What is expressive aphasia? cannot speak; understands but unable to effectively communicate verbally
What is the difference in remote & recent memory? remote-anniversary dates/birthdays recent-what you had for breakfast
Bruits swooshing sound when an artery is partially obstructed and prevents blood flow moving thru vessel
PMI Point of maximal impulse-apical area of the heart 5th intercostal space, left midclavicular line
In what order do you auscultate the heart sounds? (all patients take meds) aortic- right,2nd intercostal space@ sternal border pulmonic- left, 2nd intercostal space@ sternal border tricuspid-left, 5th intercostal space@ lower sternal border mitral-left, 5th intercostal space @ lower sternal border
Name all the peripheral pulse locations carotid brachial radial femoral popliteal dorsalis pedis posterior tibialis
Created by: jessicaspring