Nursing Assessment & Health Assessment of Human Function
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Describe evidence based practice r/t the ascultation phase of a physical examination. | listening to body sounds
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| 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
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| 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
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| 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.
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| 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
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| How would you assess General Health in head to toe? | General health state
vital signs and weight
nutritional status
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| How would you assess Mobility & Self Care in head to toe? | observe posture
assess gait & balance
evaluate mobility
ADL's
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| 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
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| How would you assess Skin, Hair, Nails in head to toe? | inspect scalp & hair
evaluate skin turgor
observe skin lesions
assess wounds
inspect nails
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| How would you assess Chest in head to toe? | Inspect & palpate breasts
inspect & ausculate lungs
ausculate heart
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| How would you assess the Abdomen in head to toe? | Inspect, Ausculate, palpate four quadrants
palpate & percuss liver, stomach, bladder
bowel elimination
urinary elimination
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| How would you assess the genitalia in head to toe? | inspect female client
inspect male client
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| 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
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| differentiate between normal & abnormal findings of the physical examination and health history. |
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| 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.
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| 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
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| 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
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| What is light palpation depth? What is it used for? | 1/2-1 inch deep
checkin pulses, edema, tenderness, superficial pain
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| 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
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| What part of your hand is used to detect the texture of a patients skin? | fingertips
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| What part of your hand is used to detect a patients temperature? | back of hand (dorsum)
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| What part of your hand is used to detect vibration? (fremitus) | palm of the hand
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| What type of sound would you hear if percussing the sternum? | Flat, extreme dullness
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| What type of sound would you hear if percussing an air filled stomach? | Tympanic, musical
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| What type of sound would you hear if percussing a lung? | Resonant, hollow sound
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| What type of sound would you hear if percussing a liver? | Dull, thud like sound
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| 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
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| What is the bell best used for hearing? | low pitched sounds
abnormal heart sounds, murmurs, bruits
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| General survey | inital assessment beginning with first contact w/ pt. Allows nurse to note physcial, mental, overall health status
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| Neurological assessment is what? | assessment of mental, intellectual, emotional status
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| 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)
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| What is receptive aphasia? | difficulty understanding & follow simple command/directions
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| What is expressive aphasia? | cannot speak; understands but unable to effectively communicate verbally
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| What is the difference in remote & recent memory? | remote-anniversary dates/birthdays
recent-what you had for breakfast
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| Bruits | swooshing sound when an artery is partially obstructed and prevents blood flow moving thru vessel
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| PMI | 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? | (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
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| Name all the peripheral pulse locations | carotid
brachial
radial
femoral
popliteal
dorsalis pedis
posterior tibialis
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