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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
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?
- –Table, bed
- –HOB up
- –Keep warm
- –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?
- •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)
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?
- •Recently smoked?
- •Developmental stages
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)
S/S: pallor, mottling, clamminess, confusion, dizziness, chest pain, inc HR, dec UOP
nicotine can increase BP ?
immeadiately and up to 15mins
caffine can affect BP for how long?
up to 3 hrs
what is most common alteration with BP?
what are causes of orthostactic BP/
anemia, dehydration, prolonged BR, blood loss, anti HTN meds
what is pulse pressure?
difference between systolic and diastolic pressure
low pulse pressure (<25) means
severe blood loss
BP is 70/50. PP is 20, this is a sing of ?
BP is 200/80. PP is 120, this is a sign of ?
head trauma or illness
pulse pressure is an indicator of
ICP (intracranial pressure)
increased PP with bradycardia means?
exercise or stiffening arteries can do what to PP?
what part of your hand do you use when assessing for temp
dorsal part (back)
when assessing the itegumentary system, you want to check for?
color, moisture, temp, texture, turgor, vascular changes, edema, lesions
what kind of changes does the integumentary system reveal?
O2, circ, nutrition, and hydration
when assessing integumentary system, use fingers to assess
texture (smooth, rough, thin, thick, tight) and moisture (moist/dry)
really white almost grey, can indicate low BP, severe anemia, found in face, buccal mucosa (mouth), conjunctiva, nail beds
blue colored (not enough O2, decreased blood flow)
yellow (liver or gall bladder), the yellow color can be in the skin, tears, eyes
checks elastictisity of the skin. normal is less than or equal to 3 sec, you check it over clavicle or other bony area
if skin turgor is greater than 3 seconds, it indicates?
how do you check for edema?
press skin firmly for 5 seconds and release
with edema, 1+ is ?
with edema, 2+ is?
edema is usually found in pts with ?
CHF, exception can be pregnancy
when discussing vascularity, pin-point red or purple spots caused by small hemorrages are called ?
Petechiae or purpura suggest
serious blood clotting disorders, drug reactions, liver dz, infections, or meningitis
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)
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
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
what is clubbed nails an indicator of?
when doing a physical exam of the nails, what do you look for?
color, shape, texture, nail abnormalities
how long should cap refill take? what does it indicate?
less than or equal to 3 secs
indicates adequate arterial blood flow
if cap refill is greater than 3 secs, it can indicate ?
anemia or lack of blood flow
what does HEENT stand for?
head, eyes, ears, nose, throat
when checking vision, what does 20/20 mean?
1st # is me (i see 20')/ 2nd # is normal person (they see 20')
what does 20/200 mean with vision?
person being examined sees 20'/ the normal person sees 200'
what does perrla mean?
pupils equal round reactive to light accomidations
pinpoint pupils are common with?
Dilated or constricted can be
neurological or medication
what central nerve is is responsible for pupil reaction?
what is epitaxis
how do you treat a nose bleed?
lean forward, pressure to nose, cold to bridge, neo-synephrine
what do you want to look for when checking nose and sinuses
Spongy gums that bleed easily indicate
peridontal dz or vitamin C deficiency
when looking at mouth what do you want to check for?
•Color•Hydration•Texture•Lesions•Edema•Defects•Ability to chew•Dental hygiene- caries
difficulty breathing, must be upright to breathe
breathlessness, on exertion or at rest, poor activity tolerance, can be a cardiac problem, exposure to work, possible smoker
what is hunch-back
what is sway-back
curvature of the spine
what are some types of respiratory patterns
what is eupnea
regular respiratory patterns in depth and rate (normal)
what is tachypnea
faster respiratory rate
what is bradypnea
slower respiratory rate
what is apnea
absence of respiration
what are S/S of respiratory distress
retractions, nasal flaring, wheezing, stridor, tripod breathing, cyanosis, etc
an abnormal respiratory pattern that gradully becomes faster and deeper than normal then slower alternating with periods of apnea
anbnormal repiratory pattern that has faster and deeper respirations with pauses- usually labored, occurs in diabetic acidosis
what breath sound is course low-pitched, may clear with cough
breath sound that is whistling, high-pitched bronchus
breath sounds that are course, loud, heard with consolidation, heard over trachea with expiration longer than inspiration. it should be loud, high-pitched, hollow
breath sound that is scratchy, high-pitched
fine crackling, high pitched
breath sounds that are near the mainstream bronchus, between scapula, medium pitched, blowing sounds
breath sounds that are heard on lungs peripheral parts, inspiration longer than expiration, soft, breezy, lower-pitched than bronchialvesicular
if you differentiate abnormal breath sounds, what term do you use
estimation of heart size by noted diameter (apical impulse)
PMI (point of maximum impulse)
•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
closure of mitral valve (left atrium and ventricle)
closure of aortic valve
the contraction phase of the heart
the relaxation phase of the heart
caused by turbulent blood flow produced by valvular pathology
what is the best position to assess JVD
how do you palpate carotid arteries
low and seperate
what do you check when checking for tissue perfusion
skin should be warm, pink, and check cap refill
bulging of nail tissue in nail base- insufficient oxygenation at the periphery reulting from CHD or chronic resp dz
when checking for venous insufficency, what do you look for
mormal pulse, cyanotic or normal color, normal temp, possible edema
what are signs of arterial insufficiency
pale skin, cool temp, decreased pulse, thin shiny skin, thick nails, decreased hair distribution
pain in calf on dosiflection, sign of thrombophlebitis
positive homan's sign
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
what quadrant should you start with and has more pronouced sounds and is easiest heard when assessing abdomen
right lower quadranr
how must you listen for bowell sounds before determing no sounds
when assessing mental and emotional status, what do you look at
behavior, appearance, language, sheech, facial symmetry
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)
when discussing (LOC) lethargic means
•sleeps often, arouses easily, responds appropriately to stimuli
when discussing (LOC) obtunded means
arouses by shaking or shouting, responds appropriately then returns to sleep
when discussing (LOC) stuporus means
responds only to painful stimuli, purposeful movement then withdraws finger or pushes your hand away
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)
when discussing (LOC) comatose means
shows no response or reflexes, flaccid muscle tone in arms and legs
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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