Nursing Assessment & Health Assessment of Human Function
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| Discuss the purpose of a physical examination. | show 🗑
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| Discuss the communication skills necessary to promote physical and psychological comfort during an exam. | show 🗑
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| show | privacy
adequate lighting
quite backround noise
equipment works/proper equipment (warm stethoscope)
room temp comfortable
place equip in order of use
perform hand hygeine
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| show | 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
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| Describe evidence based practice r/t the palpation phase of a physical examination. | show 🗑
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| show | 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
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| show | listening to body sounds
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| show | Sweet heavy thick odor = infection
Hallitoisis= poor dental care, gingevitus, aspiration, strep
Sweet fruity breath = diabetic acidois, keytone bodies
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| show | Collecting subjective and objective data from the primary and secondary sources. And being considerate of cultural differences
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| What is subjective & objective data? | show 🗑
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| discuss methods to complete an organized physical examination using the head to toe method. | show 🗑
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| show | General health state
vital signs and weight
nutritional status
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| show | observe posture
assess gait & balance
evaluate mobility
ADL's
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| show | 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
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| How would you assess Skin, Hair, Nails in head to toe? | show 🗑
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| How would you assess Chest in head to toe? | show 🗑
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| How would you assess the Abdomen in head to toe? | show 🗑
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| How would you assess the genitalia in head to toe? | show 🗑
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| How would you assess the extremities in head to toe? | show 🗑
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| show | at the conclusion of the assessment you need to summarize your findings and concerns. this validates and clarifies any misunderstandings.
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| discuss the roles of the various interdisciplinary health care team members for completeing the health history and physical examination | show 🗑
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| show | 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
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| What is light palpation depth? What is it used for? | show 🗑
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| What is deep palpation depth? What is it used for? | show 🗑
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| show | fingertips
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| What part of your hand is used to detect a patients temperature? | show 🗑
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| What part of your hand is used to detect vibration? (fremitus) | show 🗑
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| show | Flat, extreme dullness
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| show | Tympanic, musical
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| What type of sound would you hear if percussing a lung? | show 🗑
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| show | Dull, thud like sound
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| What is the diaphram best used for hearing? | show 🗑
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| show | low pitched sounds
abnormal heart sounds, murmurs, bruits
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| General survey | show 🗑
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| Neurological assessment is what? | show 🗑
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| What is the GCS (Glascow Coma Scale)? | show 🗑
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| show | difficulty understanding & follow simple command/directions
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| What is expressive aphasia? | show 🗑
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| What is the difference in remote & recent memory? | show 🗑
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| show | swooshing sound when an artery is partially obstructed and prevents blood flow moving thru vessel
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| show | Point of maximal impulse-apical area of the heart
5th intercostal space, left midclavicular line
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| In what order do you auscultate the heart sounds? | show 🗑
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| Name all the peripheral pulse locations | show 🗑
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