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
what are the 3 parts of a health assessment?
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.
what kind of info does yhe health history give you?
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
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
what kind of info do you get during your physical exam?
objective info about pt status
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
why is important to be accurate during your health assessment?
accuracy of assessment will help mold the plan of care and determine interventions
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
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
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 )
what is the first thing you do before doing your physical assessment
what is the first thing you always do before giving a physical assessment?
always introduce yourself and tell them what you are doing
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)
what are principles of inspection?
position and expose body parts (only parts being assessed)
inspect for size, shape,color, symmetry, position, abnormalities
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)
how does a nurse palpate an area?
light palpation, 1/2" with fingertips of one hand (looking for tenderness/pain)
•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?
•Listening to sounds created in body organs to detect variations from normal
•Listen for wheezing and speech before putting stethoscope on
what is this?
what are some characteristic oders you find with olfaction
•feces/urine (ammonia smell)
•sweet/fruity-ketones in diabetic
•Sweet, heavy, thick odor indicative of infection (usually bedsores, amputated limbs, car wreck sores)
what are ways that you prepare the environment for as exam or assessment?
–Beaware of pt. reluctance to talk or share if afraid others will hear
- Prevent interruptions, limit noise
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
what kind of psychological preperations do you need to make for an assessment?
•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)
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)
–Do not judge parents or children
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
what are things check when doing a general survey?
General Appearance and Behavior
-–Gender and Race
–Signs of Distress
–Body type (slim, average, over weight)
–Posture (slumped normal)
–Gait (normal, walker, cane)
–Body Movements (shaking, Parkinson disease)
•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
what determines when, where, how, and by whom VS are measured?
the pts condition
a nursing assistant can take VS, but who is ultimately responsible even if the task is deligated?
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?
what is normal temp for adult
98.6 F or 36-38 C
what is normal pulse rate for an adult
60 – 100
what is normal respirations for an adult
12 – 20
narcotics can lower RR, you do not give narcotics if RR is below
when taking a pts temp, which ways are most accurate and why?
orally and rectal- because body core temp is most accurate
what is normal blood pressure for adult?
what is considered high for BP and needs to be treated?
140/90 three times
what is ideal for pulse oximetry?
what is magic # for pulse ox
what are 4 ways to measure temp?
what are some things to look for when taking temp that could affect temp
•Recent hot or cold drinks?
what do the words febrile, afebrile, and pyrexia mean
febrile - fever
afebrile - no fever
pyrexia - heat
where is the temp control center (hypothalamus) located?
what are some things that can affect the hypothalamus
head injuries, stroke
what type of heat loss is •2 obj near each other but not physically touching with heat transferring from warmer to cooler obj (environment)
what type of heat loss is •transfer between
2 obj in direct contact (cool cloths, holding)
what type of heat loss is •heat loss through air movement (circulating fans)
what type of heat loss happens when •liquid changes to gas (sweating/diaphoresis)—600-900 mL of H2O lost/d adult
who is most at risk for hypothermia?
new borns and elderly
what happens to VS when a pt has hypothermia?
they go down
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
brain gets overheated (uncontrolled Temp elevation caused by anesthesia or trauma to hypothalmus), this is called what?
•(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?
what of test can you expect to have done if a pt has fever?
cultures (bld, urine, LP, sputum, wound)
do not give antbiotics to pts with fever until ?
after cultures are done
antipyretics are usually ordered for Temp > ?
102F/38.5 - 39C
•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
increasing or decreasing temp to quickly can cause?
brain swelling and seizures
what is considered low BP?
BP taken lying, sitting, standing. can not be deligated! BP decreases when pt stands to fast, severe cases can cause loss of concious
spasms of the hand when BP cuff is pumped up?
what does trousseau's sign indicate?
Sometimes normal for patient, sometimes life-threatening, Usually illness, arterial dilation, decreased peripheral venous return, decreased circulating volume or CO (heart not pumping well)