Health Assessment Techniques in Nursing Practice

What is the nursing process essential for?

Providing holistic, patient-centered care.

What are the five steps of the nursing process?

1. Assessment 2. Diagnosis 3. Planning/Outcomes 4. Implementation 5. Evaluation.

What is the priority nursing role in the nursing process?

Assessment.

What is the purpose of bedside assessment in nursing?

To ensure patient safety and check for immediate health concerns.

What does the ABC stand for in nursing situational assessment?

Airway, Breathing, Circulation.

What should a nurse assess regarding the patient's environment?

Bed position, call bell accessibility, clutter, hazards, and emergency equipment.

What are some elements to assess in a nursing situational assessment?

1. Level of Consciousness 2. Oxygen flow 3. IV access 4. Medical devices 5. Patient's personal items.

What should be included in the review of systems for skin assessment?

Rashes, lesions, itching, redness, changes in moles, and self-skin exams.

What questions should be asked during a respiratory assessment?

Cough, chest pain, dyspnea, sputum production, hemoptysis, wheezing, and recent chest x-ray.

What should be assessed regarding breast health?

Lumps, nipple discharge, breast pain, prosthetics, and frequency of mammograms.

What are key components of the ear assessment in nursing?

Hearing checks, hearing aids, tinnitus, earwax, and pain.

What should be evaluated during a mouth/throat assessment?

Dentist checkups, bleeding gums, dysphagia, and xerostomia.

What neck issues should be assessed in a nursing evaluation?

Lumps, limited range of motion, and history of neck injury.

What cardiovascular symptoms should be assessed?

Chest pain, palpitations, dyspnea on exertion, and history of EKG.

What hematological issues should be reviewed?

Bleeding, bruising, petechiae, and history of blood transfusions.

What gastrointestinal symptoms should be assessed?

Nausea, vomiting, diarrhea, constipation, and abdominal pain.

What urinary symptoms should be evaluated?

Frequency, urgency, incontinence, and changes in urine color.

What is the role of handwashing and PPE in nursing assessments?

To prevent infection and ensure safety for both the patient and the nurse.

What is the importance of introducing oneself to the patient?

To establish rapport and trust before beginning the assessment.

What should be checked regarding assistive devices during a nursing assessment?

Presence and functionality of devices for eye, ear, and mobility assistance.

What is the significance of ensuring an orderly room in patient care?

An orderly room is a safe room, reducing hazards for both patients and staff.

What is the purpose of assessing 'Nature Calls' in nursing?

To ensure the patient has access to necessary toileting aids like commodes or bedpans.

What are some urinary symptoms to inquire about during a review of systems?

Frequency, urgency, dysuria (pain with urination), nocturia (increased urination at night), change in urine color, hematuria (blood in urine), malodorous urine, incontinence.

What gastrointestinal symptoms should be assessed?

Appetite changes, nausea, vomiting, hematemesis (vomiting blood), heartburn, abdominal pain, change in bowel patterns, constipation, diarrhea, change in size (diameter) of stool, melena (blood in stool), rectal bleeding, hemorrhoids.

What specific questions should be asked regarding a patient's colonoscopy and endoscopy history?

When were they performed and by whom?

What are Kegel exercises and who are they relevant for?

Kegel exercises are pelvic floor exercises relevant for women.

What musculoskeletal symptoms should be evaluated?

Myalgias (muscle pain), arthralgias (joint pain), pain in bones, range of motion limitation in extremities, muscle weakness, muscle tremors.

What neurological symptoms should be assessed?

Seizures (type and date), fainting spells, memory changes, tingling, burning, numbness in extremities, loss of coordination, loss of balance, shaking tremors, muscle spasms.

What vascular symptoms should be inquired about?

Varicose veins, swelling and edema in extremities, pain in legs with walking.

What women's health history should be gathered?

Mammogram (when, where), Pap smear (when, by whom), menarche (first menses), menstrual cycle frequency and duration, menopause age and symptoms, STIs, perineal lesions, discharge, itching.

What men's health history should be gathered?

Penis lesions or discharge, erectile dysfunction, testis swelling or pain, libido changes, hernias, prostate exam (when, by whom).

What is the purpose of assessing level of consciousness (LOC)?

To evaluate the patient's arousability and ability to respond to questions.

What questions can be asked to assess a patient's orientation?

What is your name? Where are you now? What year is it? What season is it? What month is it? What day of the week is it?

What is the significance of assessing changes in libido?

It can indicate hormonal changes, psychological issues, or relationship problems.

What should be asked regarding a patient's menstrual history?

Frequency of menstruation, length of menstrual cycle, any problems, and symptoms of menopause.

What are the components of a fall assessment tool?

Assessment of falls, including where falls occurred and any related injuries.

What is the relevance of asking about assistive walking devices?

To understand mobility challenges and the need for support.

What are some signs of potential neurological issues?

Tingling, burning, numbness in extremities, loss of coordination, and shaking tremors.

What should be noted about a patient's bowel habits?

Changes in bowel patterns, constipation, diarrhea, and any rectal bleeding.

What is the importance of documenting a patient's OB history?

To assess reproductive health and any complications related to pregnancies.

What symptoms may indicate a need for further evaluation in the urinary system?

Difficulty starting a urine stream, hesitancy, and incontinence.

What lifestyle factors can affect gastrointestinal health?

Dietary habits, exercise, and stress levels.

What are the potential implications of erectile dysfunction in men?

It may indicate underlying cardiovascular issues or psychological factors.

What should be assessed regarding a patient's pain during walking?

Pain that goes away with rest may indicate claudication or vascular issues.

What are the normal findings for orientation in a patient?

An alert and oriented person to person, place, time, and situation.

What cognitive impairments can cause disorientation or confusion?

Neurological disease, stroke, dementia, psychological problems, or medication side effects.

What is lethargy in a patient?

Difficulty maintaining or sluggish mentation; the patient is arousable and able to answer questions.

What does it mean if a patient is obtunded?

The patient can only be kept awake by verbal or tactile stimuli and is confused when awake.

Describe the state of a patient in stupor.

The patient is unresponsive to verbal stimuli with decreased responsiveness to painful stimuli and may open their eyes nonverbally.

What characterizes a comatose patient?

No response to any stimuli, which may indicate a medical emergency.

What is the purpose of inspecting and palpating the head and face?

To assess for normal size and shape of the head, facial appearance, and symmetry.

What equipment is needed for inspecting and palpating the head?

Gloves.

What are the normal findings when palpating the head?

No tenderness, masses, or depressions; symmetric, midline, round; normocephalic; head is straight and still.

What should be inspected when assessing the head?

Size, shape, configuration, and movement.

What lighting is used for inspecting the face?

Tangential lighting.

What facial expressions should be assessed during inspection?

Eye contact, flat affect, happy or sad affect.

What are the normal findings for facial symmetry?

Bilaterally symmetrical facial structures, equal nasolabial folds and palpebral fissures, relaxed expression, and no involuntary muscle movement.

What should be inspected regarding the condition and texture of the skin on the face?

Appearance/symmetry of the face, edema, and smooth, clear skin.

How should the temporomandibular joint (TMJ) be assessed?

Palpate with fingertips in front of each ear at the zygomatic.

What should be palpated on the face?

Tenderness and swelling, ensuring no facial tenderness and non-tender temporal arteries.

What are the normal findings for the TMJ?

No clicking sounds or limited range of motion.

What is the significance of assessing nasolabial folds and palpebral fissures?

To evaluate facial symmetry and cranial nerve function (CN VII).

What does a bloated or disfigured appearance of the face indicate?

Possible underlying health issues or abnormalities.

What is the expected finding for the skin during facial inspection?

Skin should be smooth, clear, and without edema.

What does a flat affect in facial expression suggest?

Possible emotional or psychological issues.

What is the average mouth opening in inches?

1.4 - 2 inches

Where are the temporal arteries located?

In front of the earlobes and corners of the eyes.

What should be assessed when a patient opens and closes their mouth regarding the temporal arteries?

Look for clicking sounds or decreased range of motion.

What are some abnormal findings of the head and face?

Pain, tenderness, a mass, depression in the skull, involuntary movements, macrocephaly.

What is macrocephaly?

An abnormally large head size.

What is Bell's Palsy?

Facial paralysis on one side of the face, possibly due to a viral infection affecting cranial nerve VII.

What are the symptoms of Grave's Disease?

Exophthalmos, lid lag, edema, and corneal ulceration due to excessive thyroid hormone.

What condition is characterized by increased androgen secretion in women?

Hirsutism, leading to hair growth on the upper lip.

What hormonal change occurs during menopause?

Estrogen deficiency, resulting in peach fuzz facial hair and dry skin with increased wrinkles.

What is myxedema?

A decrease in thyroid hormone causing hypothermia, facial pallor and swelling, and periorbital swelling.

What are the characteristics of Parkinson's Disease?

Mask-like facial appearance, slurred and soft speech.

What is rosacea?

A condition with a red flush on the face, appearing sunburned with visible small blood vessels.

What causes acromegaly?

Excess growth hormone produced by the pituitary gland, leading to enlarged bones of the face.

What is temporal arteritis?

Inflammation of the temporal arteries causing jaw pain and unilateral headaches.

What is TMJ disorder?

Clicking or popping of the jaw associated with jaw, tooth, or ear pain, and poor range of motion.

What is the purpose of inspecting and palpating the nose?

To assess for tenderness, inflammation, deviation, or occlusion.

What are normal findings when inspecting the nose?

Nose symmetrical, septum straight, skin color matches face color, no lesions or swelling, no drainage.

What are abnormal findings when inspecting the nose?

Asymmetry, deviated septum, redness, bruising, lesions, tenderness, swelling, nasal drainage.

What is the first priority when managing a nosebleed?

Control bleeding.

What position should a patient with a nosebleed be in?

Upright position with the head above heart level.

What is the purpose of palpating the maxillary and frontal sinuses?

To assess for tenderness or pain.

What indicates a sinus infection when palpating the sinuses?

Tenderness or pain.

What is the purpose of assessing Cranial Nerve I (Olfactory)?

To assess the sense of smell.

What is the purpose of assessing Cranial Nerve II (Optic)?

To assess for visual acuity.

What is the procedure for assessing the sense of smell in a patient?

Hold an available scent (like coffee beans) under one nostril, have the patient identify it, then use a different scent for the other nostril.

What are the steps to test visual acuity using a Snellen chart?

Place the Snellen chart at an appropriate height, have the patient stand 20 feet away, cover one eye and read from top to bottom, then repeat with the other eye and both eyes uncovered.

What are the medical abbreviations for the eyes?

OS (left eye), OD (right eye), OU (both eyes).

What is considered normal distant visual acuity?

20/20.

What are the abnormal findings related to the sense of smell?

Inability to smell or identify the correct scent indicates loss of olfactory nerve function.

What is myopia?

Nearsightedness where distant objects appear blurred.

What is hyperopia?

Farsightedness where nearby objects appear blurred.

What is presbyopia?

The inability to focus on near objects due to aging.

What defines legal blindness?

Visual acuity of 20/200, meaning a patient can see at 20 feet what a person with normal vision can see at 200 feet.

What equipment is needed for inspecting and palpating the eyes?

A tangential light source and gloves.

What are normal findings when inspecting the eyelids?

Eyelids should open and close completely, with no redness, drainage, or drooping.