Health Assessment

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  1. Types of Assessments:
    Comprehensive, Ongoing, Focused, Emergency
    • Comprehensive: everything
    • Ongoing: beginning of shift
    • Focused: only assess for specific problem
    • Emergency: ABCs
  2. Purpose of Assessment
    • gather baseline data
    • Holistic Foundation of Nursing Process
    • data confirmation: affirm data is correct
    • guides the nursing process
    • clinical judgements
    • evaluate
    • identify risk factors for alterations in health
    • screen for risk factors/warning signs of cancer
  3. Guideline for Health Hx
    • 1. Biographical Data
    • 2. Reason for Seeking HC: focuses rest of assmt, open-ended q's, document in pt's own words
    • 3. Hx of Present Health Condition: explore thoroughly
    • 4. Medical Hx: may give insight to present symptoms, ID risk factors (past illnesses), chronic heal probs/treatment
    • 5. Family Hx: consider disorders w/genetic links, risk factors
    • 6. Lifestyle: contributes to overal health and well-being
  4. Prepare the Patient:
    • sensitive to psychological and physiological needs
    • Explain: first will be question, second will be physical exam (not painful)
    • Use general terms
    • Explain in more detail during procedure
    • Direct & Honest
    • Modesty
    • Empty bladder?
  5. Prepare the Environment
    • adequat lighting
    • exam table
    • gown and drape
    • instruments/supplies
    • warm enough?
    • curtain/screen if needed
    • infxn control
  6. Systematic Manner of Assessment
    • Systematic and Consistent Examination
    • Head to Toe or Body Systems
    • know what you need to check, know every time
    • check for symmetry
    • regulate/pace the assmnt appropriate to pt situation
    • minimize movents of person (organized order, logial flow)
    • use correct terminology in chart but general terms w/pt
  7. Skin/Older Adult:
    Senile Keratosis
    raised dark areas
  8. Senile Lentigines
    flat brown age spots
  9. Cherry Angioma
    small round red spots
  10. Skin/Infant-Child:
  11. Lanugo
    fine, downy hair in first two weeks of infancy
  12. Adventitious Breath Sounds
    not normally head in lungs but can be heard when aucultated with normal sounds
  13. Auscultation
    listen w/stethoscope to sounds produced within the body
  14. Bronchial Sounds
    • hear over trachea
    • high-pitched
    • expiration > inspiration
  15. Bronchovesicular Sounds
    • heard over mainstem bronchus
    • "blowing" sounds
    • inspiration = expiration
  16. Bruits
    • abnormal "swoosh" sounds similar to murmur
    • made over major blood vessels
    • partially blocked artery
  17. Comprehensive Assessment
    • when patient first enters setting
    • history and physical
    • provides a baseline
  18. Crackles
    • fine to coarse crackling noise
    • made as air moves through wet secretions
    • on inspiration
  19. Cyanosis
    bluish/grayish color in response to inadequate oxygenation
  20. Arcus Senilis
    white ring around cornea
  21. Diaphoresis
    excessive perspiration
  22. Eccymosis
    • Bruise
    • collection of blood in subQ
    • purpleish-bluish color
  23. Ectropion
    outward turn of lower eyelid
  24. Entropion
    inward turn of lower eyelid
  25. Edema
    excess fluid in tissues
  26. Emergency Assessment
    • rapid focused assessment to determine potentially fatal situations
    • (ABCs of CPR)
  27. Erosion
    • loss of superficial epidermis
    • moist, nonbleeding
  28. Erythema
    redness of skin (face, neck)
  29. Excoriation
    scratch of the epidermis
  30. Fissure
    • deep linear crack
    • extends into dermis
  31. Focused Assessment
    • assess a specific problem
    • question related factors
    • physically assess vitals and specific area
  32. Friction Rub
    • grating sound
    • inflamed pleura against chest wall
  33. Gynecomastia
    enlargement of one or both breasts in pubescent boys
  34. Glasgow Coma Scale
    • assess level of consciousness
    • eye opening, motor response, verbal response
    • 7 or less: defines coma
    • 15: maximum score
    • Get a ballpark, then find deficit
  35. Inspection
    process of performing deliberate, purposeful observation in a systematic manner
  36. Hirsuitism
    excessive hair on face/body
  37. Jaundice
    • yellow skin r/t liver/gallbladder disease
    • some anemia or hemolysis
  38. Oncholysis
    separation of nail from nailbed
  39. Ongoing Partial Assessment
    • conducted at regular intervals during care
    • concentrates on indentified problems
    • monitors positive/negative changes
    • evaluate effectiveness of interventions
  40. Pallor
    paleness: inadequate circulation, inadequate oxygenation of tissues
  41. Ptosis
    drooped upper eyelids
  42. Pseudostrabismus
    pupils at inner folds
  43. Presbycusis
    hearing loss
  44. Palpation
    use sense of touch to assess temp, turgor, texture, moisture, vibrations, shape
  45. Percussion
    striking one object against another to produce sound
  46. Petechiae
    • small hemorrhagic spots cause by capillary bleeding
    • assess color, size, location
  47. Precordium
    • APETMA
    • Aortic
    • Pulmonic
    • Erb's Point
    • Tricuspid
    • Mitral/Apical
  48. Stertorous
    noisy, strenuous respirations
  49. Turgor
    • skin fullness/elasticity
    • usually assessed on sternum or over clavicle
  50. Vesicular Breath Sounds
    • soft-low pitched
    • over base of lungs on inspiration
    • expiration < inspiration
  51. Wheeze
    • continuous sounds originate in small air passages narrowed by secretion, swelling, tumor
    • Sibilant: musical
    • Sonorous: course
  52. Equipment
    • Stethoscope
    • Opthalmoscope
    • Otoscope
    • Snellen Chart: vision screen test
    • Nasal Speculum
    • Tuning Fork
    • Percussion Hammer
Card Set
Health Assessment
Test 3
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