151 Test 2

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Author:
bosma67
ID:
259752
Filename:
151 Test 2
Updated:
2014-02-03 00:30:53
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test
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Description:
Health Assessment
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  1. Health Assessment Data Collection
  2. Sources of Data
  3. Communication techniques
  4. Methods:
    Interviewing
    • planned communication or a conversations with a prupose
    • directive-highly structured and elicits specific information; nurse establishes and controls
    • nondirective/indirective/informal-rapport building; client controls
  5. Methods:
    Observing
    conscious, deliberate skill that is devolped through effort and with an organized approach; noticing data; selecting, organizing, and interpreting data using senses
  6. Methods:
    Examining
    physical examinations or assessment is a systematic data-collection method that uses observations to detect health problems; organized (head to toe; body systems)
  7. Organizing data
  8. Validating data
  9. Documenting data
  10. Holistic considerations
  11. Holistic Health Assessment
  12. General Components/General Survey
  13. Mental Status
  14. Nutritional Status
  15. Holistic Considerations
  16. Documentation
  17. Methods of Examination
  18. General Approach
  19. Techniques
  20. Holistic Considerations
  21. Documentation
  22. Integumentary System
    Skin, Hair, Nails
  23. Assessment skills/process
    • Color
    • Moisture
    • Texture
    • Lesions
    • Edema
    • Sensation
  24. Normal Range of Findings
  25. Skin
    • Inspection(in natural light)
    • color-relatively consistant/uniform
  26. Hair
    • Inspection
    • separate hair to see scalp-assess color, dryness, scaliness, lumps, lesions, lice
    • Palpate
    • check for lumps/masses; note locations, size, tenderness, and mobility
  27. Nails
    • Inspection
    • nail plate shape(colorness, convex curve)
    • 160* angle
    • texture-smooth
    • nail bed color(caucasion pink, blaches w/pressure, capillary refil <3 secs)
    • Palpation
    • nail base(firm, nontender)
  28. Holistic Considerations
  29. Documentation
  30. Head and Neck
    Nose, Mouth, Eyes, Ears
    skull, face, eyes, ears, nose and sinuses, mouth and pharynx, trachea, thyroid gland, and lymph nodes
  31. Assessment Skills/Process
  32. Head
    • Inspect-size, shape, and symmetry
    • Palpate-nodules, masses, or depressions
  33. Neck
    • inspection-enlargement?, looking/swollowing
    • palpation-size, masses, smoothness
    • ascultation-bruit indicates +blood flow to area, hypothyroidism??
  34. Nose
  35. Face
    • Inspect
    • face strength & sensation-trigeminal nerve(V)
    • face symmetrical movement-facial(VII)
    • head and shoulders-spinal accessory(XI)
  36. Eyes
    • Inspect
    • visual acuity-distance vision, snellen and rosenbaum charts, eye cover, ishihara test for color blindness
    • EOM's-penlight/opthalmoscope light, eye cover
    • visual fields-eye cover
    • external structurs-penlight/opthalmoscope, gloves
    • interna structures-opthalmoscope
  37. Ears
    • Inspection-size, shape, lesions
    • Palpation-
  38. Assessment Skills/Process
    • Head-inspect and palpate
    • Face-inspect
    • Eyes-inspect
    • penlight, ophthalmoscope, eye cart
  39. Normal Range of Findings
  40. Head
    proportionate, symmetric; skull generally gently curved w/promineces @ grontal & parietal bones
  41. Face
    color, symmetry, distribution of facial hair
  42. Ears
    Symmetric and proportionate to head
  43. Holistic Considerations
  44. Documentation
  45. Thorax/Lungs
  46. Assessment Skills/Process
  47. Normal Range of Findings
  48. Holistic Considerations
  49. Documentation
  50. Cardiovascular/Peripheral Vascular Systems
  51. Assessment Skills/ Process
  52. Normal Range of Findings
  53. Holistic Considerations
  54. Documentation
  55. Abdomen/Anus
  56. Assessment Skills/Process
  57. Normal Range of Findings
  58. Holistic Considerations
  59. Documentation
  60. Musculoskeletal System
  61. Assessment Skills/Process
  62. Normal Range of Findings
  63. Holistic Considerations
  64. Documentation
  65. Neurologic System
  66. Assessment Skills/Process
  67. Normal Range of Findings
  68. Holistic Considerations
  69. Documentation

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