health assessment

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jword2
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134068
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health assessment
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2012-02-17 01:16:39
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nursing
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  1. what is the purpose of doing a health assessment?
    provides a baseline of pts functions at first seen and data for future assessment comparison

    supplements, confirm, or refutes data

    confirms nursing diagnosis

    make clinical judgements about changing health status

    evaluate outcomes
  2. what are the 3 parts of a health assessment?
    health history

    behavioral exam

    physical exam
  3. during the health assessment, where do you get info and what does it tell you?
    comes from pt, charts, papers filled out by pt

    tells diseases or past diseases, meds, past surgeries, etc.
  4. what kind of info does yhe health history give you?
    subjective info
  5. during the health assessment, what does the behavioral exam tell you?
    what kind of behavior the pt has at that time. if they are wild, appropriate, depressed, anxios
  6. during the health assessment, what is the physical exam?
    hands on examination, S/S, what are their complaints, what are you gonna do about it
  7. what kind of info do you get during your physical exam?
    objective info about pt status
  8. why is a good nursing history important during the health assessment important?
    a good history helps focus your assessment on systems that affected or abnormal
  9. why is important to be accurate during your health assessment?
    accuracy of assessment will help mold the plan of care and determine interventions
  10. what is the baseline of a health assessment?
    your findings of problems or what the pt is doing at the particular time you assess the pt. Its not necessarily what normal range is but what pt has at that time, ussed to compare as you treat pt
  11. what are some things you need to know about cultural sensitivity?
    when doing your assessment be culturally aware of behaviors such as eye contact and touch, avoid stereotyping, learn disorders of common ethnic populations
  12. what are skills a nurse needs to do a physical assessment?
    inspection (these are visual signs you get from looking and talking the pt)

    palpation (the nurse does light palpations, looks for mass, lumps, swelling, etc.)

    percussion (usually done by advanced practicioners)

    auscultation ( listening to breath sounds and HR)

    olfaction (smell )
  13. what is the first thing you do before doing your physical assessment
  14. what is the first thing you always do before giving a physical assessment?
    always introduce yourself and tell them what you are doing
  15. when are some good times to intergrate your health assessment with nursing care
    giving baths (good time to visually inspect the pt)

    use all care as oppertunities for pt teaching (teaching and DC planning starts with admission)
  16. what are principles of inspection?
    adequate lighting

    position and expose body parts (only parts being assessed)

    inspect for size, shape,color, symmetry, position, abnormalities
  17. what are things you need to do during an inspection
    compare ares on opposite sides of the body

    use additional light for body cavities (mouth, nostrils, pupils, inserting caths)

    do not hurry

    pay attention to detail (what you see and hear)
  18. how does a nurse palpate an area?
    light palpation, 1/2" with fingertips of one hand (looking for tenderness/pain)
  19. •Tapping the body with the fingertips to produce a vibration
    •Mostly done by advanced practitioners
    •Sounds can tell location, size, and density (mass, fluid in organ or cavity)

    this is called what? who usually does this?
    percussion

    advanced practitioners
  20. •Listening to sounds created in body organs to detect variations from normal
    •Listen for wheezing and speech before putting stethoscope on


    what is this?
    auscultation
  21. what are some characteristic oders you find with olfaction
    • •alcohol
    • •feces/urine (ammonia smell)
    • •sweet/fruity-ketones in diabetic
    • •Sweet, heavy, thick odor indicative of infection (usually bedsores, amputated limbs, car wreck sores)
  22. what are ways that you prepare the environment for as exam or assessment?
    • –Privacy
    • –Lighting
    • –Table, bed
    • –HOB up
    • –Keep warm
    • –Beaware of pt. reluctance to talk or share if afraid others will hear
    • - Prevent interruptions, limit noise
  23. what kind of preperations do you need to do with equipment when getting ready for exam or assessment?
    •Forms•Gloves•Ruler•BP cuff•Stethoscope•Thermometer•Watch•Penlight•Wash handsSet up equipment in organized manor to ease transition
  24. what kind of psychological preperations do you need to make for an assessment?
    • •Explain procedure
    • •Professional/relaxed demeanor (stiff/formal decreases communication, too laid back decreases pt. confidence in your ability)
    • •Witness (male nurse may want witnesswhen doing procedures like caths)
    • •Watch their expression (make sure pt. is comfortable)
  25. what are some different appraoches you need to use when assessing different age groups?
    • –Obtain history from parents when assessing a child (never call parents by first name, call children by first name)
    • –Non threatening environment
    • –Treat adolescents as adults (may need parents out of room for teens to be open and honest)
    • –Confidentiality
    • –Do not judge parents or children
  26. what are things you need to remember when assessing elderly pts.
    • •Provide rest periods
    • Elderly client sets the pace for the exam.
    • Illness can be seen as threat to independence and step toward institutionalization
    • Watch for S/S of tiring (grouchy, grimacing, droopy eyelids)
    • Discuss ADLs that are fundamental to independent living assess mental status
    • •Painful procedures last
  27. what are things check when doing a general survey?
    • General Appearance and Behavior
    • -–Gender and Race
    • –Age
    • –Signs of Distress
    • –Body type (slim, average, over weight)
    • –Posture (slumped normal)
    • –Gait (normal, walker, cane)
    • –Body Movements (shaking, Parkinson disease)
  28. •Hygiene and grooming •Dress•Body Odor•Affect (expressions, smiling , frowning)•Mood (happy, depressed)•Speech (clear, slurred)•Client abuse (bruises, scars, if suspect spousal abuse try to get spouse out of room)

    these are things you look for when?
    when doing a general survey
  29. what determines when, where, how, and by whom VS are measured?
    the pts condition
  30. a nursing assistant can take VS, but who is ultimately responsible even if the task is deligated?
    the RN
  31. as a nurse, yo can take VS as often as you deem necessary, but what is the longest amount of time you can wait between measuring VS?
    4 hrs
  32. what is normal temp for adult
    98.6 F or 36-38 C
  33. what is normal pulse rate for an adult
    60 – 100
  34. what is normal respirations for an adult
    12 – 20
  35. narcotics can lower RR, you do not give narcotics if RR is below
    8-10
  36. when taking a pts temp, which ways are most accurate and why?
    orally and rectal- because body core temp is most accurate
  37. what is normal blood pressure for adult?
    120/80
  38. what is considered high for BP and needs to be treated?
    140/90 three times
  39. what is ideal for pulse oximetry?
    98%-100%
  40. what is magic # for pulse ox
    93%
  41. what are 4 ways to measure temp?
    orally

    auxillary

    rectal

    tempanic
  42. what are some things to look for when taking temp that could affect temp
    • •Recent hot or cold drinks?
    • •Recently smoked?
    • •LOC
    • •Developmental stages
  43. what do the words febrile, afebrile, and pyrexia mean
    febrile - fever

    afebrile - no fever

    pyrexia - heat
  44. where is the temp control center (hypothalamus) located?
    the brain
  45. what are some things that can affect the hypothalamus
    head injuries, stroke
  46. what type of heat loss is •2 obj near each other but not physically touching with heat transferring from warmer to cooler obj (environment)
    radiation
  47. what type of heat loss is •transfer between
    2 obj in direct contact (cool cloths, holding)
    conduction
  48. what type of heat loss is •heat loss through air movement (circulating fans)
    convection
  49. what type of heat loss happens when •liquid changes to gas (sweating/diaphoresis)—600-900 mL of H2O lost/d adult
    evaporation
  50. who is most at risk for hypothermia?
    new borns and elderly
  51. what happens to VS when a pt has hypothermia?
    they go down
  52. what are some interventions the nurse can do for hypothermia?
    • cut off any wet clothing and warm pt.
    • do not warm to fast
    • give warm IV fluids, heating blankets, hot liquids, keep head covered
  53. brain gets overheated (uncontrolled Temp elevation caused by anesthesia or trauma to hypothalmus), this is called what?
    malignant hyperthermia
  54. •(S/S giddiness, confusion, delirium, excessive thirst, N/V, muscle cramps, visual changes, incontinence, hot, dry skin (most important)) these are S/S of what?
    heat stroke
  55. what of test can you expect to have done if a pt has fever?
    labwork

    cultures (bld, urine, LP, sputum, wound)
  56. do not give antbiotics to pts with fever until ?
    after cultures are done
  57. antipyretics are usually ordered for Temp > ?
    102F/38.5 - 39C
  58. •they interfere with the hypothalamic response and dec heat production. Mask S/S of infxn by suppressing immune system—not used to treat fever, but important to know their effect on suppression of ability to develop fever in response to pyrogens. may need to check WBC to see if elevated
    steroids
  59. increasing or decreasing temp to quickly can cause?
    brain swelling and seizures
  60. what is considered low BP?
    SBP <90
  61. BP taken lying, sitting, standing. can not be deligated! BP decreases when pt stands to fast, severe cases can cause loss of concious
    ortostatic hypotension
  62. spasms of the hand when BP cuff is pumped up?
    trousseau's sign
  63. what does trousseau's sign indicate?
    low calcium
  64. Sometimes normal for patient, sometimes life-threatening, Usually illness, arterial dilation, decreased peripheral venous return, decreased circulating volume or CO (heart not pumping well)
    low BP
  65. S/S: pallor, mottling, clamminess, confusion, dizziness, chest pain, inc HR, dec UOP
    low BP
  66. nicotine can increase BP ?
    immeadiately and up to 15mins
  67. caffine can affect BP for how long?
    up to 3 hrs
  68. what is most common alteration with BP?
    HTN
  69. what are causes of orthostactic BP/
    anemia, dehydration, prolonged BR, blood loss, anti HTN meds
  70. what is pulse pressure?
    difference between systolic and diastolic pressure
  71. low pulse pressure (<25) means
    severe blood loss
  72. BP is 70/50. PP is 20, this is a sing of ?
    shock
  73. BP is 200/80. PP is 120, this is a sign of ?
    head trauma or illness
  74. pulse pressure is an indicator of
    ICP (intracranial pressure)
  75. increased PP with bradycardia means?
    increased ICP
  76. exercise or stiffening arteries can do what to PP?
    increase it
  77. what part of your hand do you use when assessing for temp
    dorsal part (back)
  78. when assessing the itegumentary system, you want to check for?
    color, moisture, temp, texture, turgor, vascular changes, edema, lesions
  79. what kind of changes does the integumentary system reveal?
    O2, circ, nutrition, and hydration
  80. when assessing integumentary system, use fingers to assess
    texture (smooth, rough, thin, thick, tight) and moisture (moist/dry)
  81. really white almost grey, can indicate low BP, severe anemia, found in face, buccal mucosa (mouth), conjunctiva, nail beds
    pallor
  82. blue colored (not enough O2, decreased blood flow)
    cyanosis
  83. yellow (liver or gall bladder), the yellow color can be in the skin, tears, eyes
    jaundice
  84. checks elastictisity of the skin. normal is less than or equal to 3 sec, you check it over clavicle or other bony area
    skin turger
  85. if skin turgor is greater than 3 seconds, it indicates?
    dehydration
  86. how do you check for edema?
    press skin firmly for 5 seconds and release
  87. with edema, 1+ is ?
    2mm deep
  88. with edema, 2+ is?
    4mm deep
  89. edema is usually found in pts with ?
    CHF, exception can be pregnancy
  90. when discussing vascularity, pin-point red or purple spots caused by small hemorrages are called ?
    petechiae
  91. Petechiae or purpura suggest
    serious blood clotting disorders, drug reactions, liver dz, infections, or meningitis
  92. what are things you want to look at when assessing lesions and rashes
    •Location•Size•Shape•Type•Texture•Exudate•Color•Characteristics (painful, itchy) •Grouping (clustered or linear) •Distribution (localized or generalized)
  93. Who is at HR for skin breakdown?
    •Patients with…–Neuro deficits–Chronic illness–Orthopedic problems–Decreased mental capacity–Poor tissue oxygenation –Low cardiac output (CO)–Inadequate nutrition
  94. what are some things to look for when assessing hair?
    •Color changes•Quantity•Quality•Distribution•Patterns of hair loss•Alopecia-baldness•Scalp‑redness, scaling, crusting, lesions, lice
  95. what is clubbed nails an indicator of?
    pulmonary problems
  96. when doing a physical exam of the nails, what do you look for?
    color, shape, texture, nail abnormalities
  97. how long should cap refill take? what does it indicate?
    less than or equal to 3 secs

    indicates adequate arterial blood flow
  98. if cap refill is greater than 3 secs, it can indicate ?
    anemia or lack of blood flow
  99. what does HEENT stand for?
    head, eyes, ears, nose, throat
  100. when checking vision, what does 20/20 mean?
    1st # is me (i see 20')/ 2nd # is normal person (they see 20')
  101. what does 20/200 mean with vision?
    person being examined sees 20'/ the normal person sees 200'
  102. what does perrla mean?
    pupils equal round reactive to light accomidations
  103. pinpoint pupils are common with?
    opiod intoxication
  104. Dilated or constricted can be
    neurological or medication
  105. Diplopia
    double vision
  106. Photophobia
    light sensitive
  107. what central nerve is is responsible for pupil reaction?
    CN 111
  108. what is epitaxis
    nose bleeds
  109. how do you treat a nose bleed?
    lean forward, pressure to nose, cold to bridge, neo-synephrine
  110. what do you want to look for when checking nose and sinuses
    •Asymmetry•Inflammation•Deformity•Mucosa•Discharge•Bleeding•Septum•Palpate sinuses
  111. Spongy gums that bleed easily indicate
    peridontal dz or vitamin C deficiency
  112. when looking at mouth what do you want to check for?
    •Color•Hydration•Texture•Lesions•Edema•Defects•Ability to chew•Dental hygiene- caries
  113. difficulty breathing, must be upright to breathe
    orthopnea
  114. breathlessness, on exertion or at rest, poor activity tolerance, can be a cardiac problem, exposure to work, possible smoker
    dyspnea
  115. what is hunch-back
    kyphosis
  116. what is sway-back
    lordosis
  117. curvature of the spine
    scoliosis
  118. what are some types of respiratory patterns
    eupnea

    tachypnae

    bradypnea

    apnea

    S/S distress
  119. what is eupnea
    regular respiratory patterns in depth and rate (normal)
  120. what is tachypnea
    faster respiratory rate
  121. what is bradypnea
    slower respiratory rate
  122. what is apnea
    absence of respiration
  123. what are S/S of respiratory distress
    retractions, nasal flaring, wheezing, stridor, tripod breathing, cyanosis, etc
  124. an abnormal respiratory pattern that gradully becomes faster and deeper than normal then slower alternating with periods of apnea
    cheyne-stokes
  125. anbnormal repiratory pattern that has faster and deeper respirations with pauses- usually labored, occurs in diabetic acidosis
    kussmauls
  126. what breath sound is course low-pitched, may clear with cough
    rhonchi
  127. breath sound that is whistling, high-pitched bronchus
    wheeze
  128. breath sounds that are course, loud, heard with consolidation, heard over trachea with expiration longer than inspiration. it should be loud, high-pitched, hollow
    bronchial
  129. breath sound that is scratchy, high-pitched
    rub
  130. fine crackling, high pitched
    crackles
  131. breath sounds that are near the mainstream bronchus, between scapula, medium pitched, blowing sounds
    bronchovesicular
  132. breath sounds that are heard on lungs peripheral parts, inspiration longer than expiration, soft, breezy, lower-pitched than bronchialvesicular
    vesicular
  133. if you differentiate abnormal breath sounds, what term do you use
    adventitious
  134. estimation of heart size by noted diameter (apical impulse)
    PMI (point of maximum impulse)
  135. •Pulse deficit = different radial and apical rates
    •Must check at same time to state deficit—may need a partner to check
    •Apical must be checked for 1 full
    minute—note if regular or irregular
    apical-radial pulse
  136. closure of mitral valve (left atrium and ventricle)
    S1
  137. closure of aortic valve
    S2
  138. the contraction phase of the heart
    systole
  139. the relaxation phase of the heart
    diastole
  140. caused by turbulent blood flow produced by valvular pathology
    murmurs
  141. what is the best position to assess JVD
    sitting position
  142. how do you palpate carotid arteries
    low and seperate
  143. what do you check when checking for tissue perfusion
    skin should be warm, pink, and check cap refill
  144. bulging of nail tissue in nail base- insufficient oxygenation at the periphery reulting from CHD or chronic resp dz
    finger clubbing
  145. when checking for venous insufficency, what do you look for
    mormal pulse, cyanotic or normal color, normal temp, possible edema
  146. what are signs of arterial insufficiency
    pale skin, cool temp, decreased pulse, thin shiny skin, thick nails, decreased hair distribution
  147. pain in calf on dosiflection, sign of thrombophlebitis
    positive homan's sign
  148. when assessing the abdomen, what do you do first and what do you do last
    ausultate first, palpations last because it may stimulate activity and cause misleading bowel sounds
  149. what quadrant should you start with and has more pronouced sounds and is easiest heard when assessing abdomen
    right lower quadranr
  150. how must you listen for bowell sounds before determing no sounds
    5 minutes
  151. when assessing mental and emotional status, what do you look at
    behavior, appearance, language, sheech, facial symmetry
  152. when discussing (LOC) what is alert : AAOx3
    •awake, responds appropriately to verbal, auditory, tactile and visual stimuli-oriented X3; full name (person) where are you? (place) Time of day/month/year (time)
  153. when discussing (LOC) lethargic means
    •sleeps often, arouses easily, responds appropriately to stimuli
  154. when discussing (LOC) obtunded means
    arouses by shaking or shouting, responds appropriately then returns to sleep
  155. when discussing (LOC) stuporus means
    responds only to painful stimuli, purposeful movement then withdraws finger or pushes your hand away
  156. when discussing (LOC) semi-comatose means
    • responds only to painful stimuli (pressure over nailbeds or
    • sternum-Do not use nipple squeezing or other cruel methods)
  157. when discussing (LOC) comatose means
    shows no response or reflexes, flaccid muscle tone in arms and legs
  158. when discussing (LOC) what is the MMSE
    (mini-mental state examination)—orientation and cognitive function—max score 30, 21 or less are considered cognitively impaired and need further evaluation

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