Chapter 30 Health Assessment

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almondmilktea
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65143
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Chapter 30 Health Assessment
Updated:
2011-02-08 22:41:57
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Nursing
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Nursing
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  1. Assessment include: (in order)
    • inspection
    • palpation
    • percussion
    • auscultation
  2. Inspection uses the senses of __
    deliberate, purposeful, and systematic visual examination

    vision and smell

    moisture, color, texture of body surfaces

    shape, body, position, size, symmetry of the body
  3. Palpation uses the sense of ____
    touch. warm hands before touching client.

    Identify tender areas and palpalte them LAST.

    Start with light palpation to detect surface characteristics, then perform deeper palpation.

    assess texture, temp., and moisture of teh skin, as well as organ location and size.

    Assess for swelling, vibration or pulsation, rigidity, or spasticity, and crepitation.

    Assess for the presence of lumps or masses, as well as presence of tenderness or pain.
  4. Percussion involves _____
    tapping the client's skin.

    provides info related to presence of air, fluid, or solid masses as well as organ size, shape and position.
  5. Auscultation involves___
    listening to sounds produced by the body, such as heart, lung or bowel sounds.

    • direct: use of unaided ear
    • indirect: use of stethoscope
  6. cyanosis
    mottled bluish coloration
  7. erythema
    redness
  8. pallor
    pale, whitish coloration
  9. jaundice
    yellow coloration
  10. 4 types of health assessment:
    • comprehensive
    • ongoing/ partial
    • focused
    • emergency
  11. 3 types of physical assessment
    • complete assessment
    • examination of a body system
    • examination of a body area
  12. Purpose of the physical examination:
    to obtain baseline data

    to supplement, confirm, or refute data obtained in nursing history

    to obtain data that will help establish nursing diagnoses and plan of care

    to evaluate the progress of a clients health problem

    to make clinical judgements about client's health status

    to identify areas for health promotion and disease prevention
  13. during preparation:
    instruct the client that all information gathered and documented during the assessment is kept confidentioal in accordance with the HIPPA. this means that only those health care providers who have a legitimate need to know the client's information will have access to it.
  14. be sure to prepare the:
    • patient
    • environment
    • be sensitive to culture!
  15. A health history and physical examination provides a means of detecting any existing problems.
  16. a physical assessment helps the nurse establish
    nursing diagnoses

    plan the client's care

    evaluate the outcomes of nursing care
  17. Steps in examination procedure
    planning

    obtain appropriate equipment

    prepare the client

    implementation of procedures

    evaluation of findings
  18. Sequence for physical exam
    General survey

    vital signs

    head to toe
  19. Assessment of the head:
    •Hair, scalp, cranium, face

    •Eyes and vision

    •Ears and hearing

    •Nose and sinuses

    •Mouth and oropharynx

    •Cranial nerves
  20. Assessment of the Neck
    •Muscles

    •Lymph nodes

    •Trachea

    •Thyroid gland

    •Carotid arteries

    Neck veins
  21. Assessment of Upper extremities
    •Skin and nails

    •Muscle strength and tone

    •Range of motion

    •Brachial and radial pulses

    •Biceps and triceps reflexes

    •Sensation
  22. Assessment of Chest and Back
    •Skin

    •Chest shape and size

    •Lungs

    •Heart

    •Spinal column

    •Breasts and axilla
  23. Abdomen
    skin

    abdominal sounds

    specific organs

    femoral pulses

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