Health Assessment Lecture Exam 1 SG

What is the purpose of performing a health assessment?

A health assessment gives background about a person’s health history and gives the doctor solutions to provide care. A collection of data about an individual's health.

What is the difference between subjective and objective data?

Subjective data is the Chief complaint where you gather information from the patient and ask open-ended questions, building a relationship with the client. (What the patient tells me)

 

Objective data- is the signs you can monitor and see for yourself.

 

What are the 4 types of assessment data

Complete data (total database)

Episodic data or problem

Follow update

Emergency data

complete data (total database)

full history and physical examination

episodic or problem

focus or specific problem

Follow update­

1.    following up with the other doctor.

Emergency data

emergency “life or death info.”

Distinguish between open-ended and closed-ended questions. What do you hope to achieve with the use of open-ended questions and with the use of closed-ended questions?

Open-ended questions give the patient a path for open communication w whereas close-ended questions need a “yes” or “no” answer. This covers all bases for the nurse/doctor to have a complete, clear and concise patient assessment.

therapeutic communication

Facilitation

Silence

Reflection

Empathy

Clarification

Confrontation

Interpretation

Explanation

Summary

Facilitation

encouraging the patient to go on

Silence

don’t answer the patient

Reflection

echo the statement

Empathy

recognize the patient's feelings and put them into words

Clarification

clarify their statement

Confrontation

Focus on the patient’s attention on what you observed

Ex. Patient says no pain but you noticed them limping

Interpretation

connect the dots

Explanation

educating

summary

summarize

Ten traps of interviewing

1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
   10. Using “why” questions

intimate zone

0-1.5 ft

personal distance (physical assessment)

1.5 to 4ft

social distance (where the interview occurs)

4ft-12ft

public space

greater than 12ft

positive nonverbal behaviors

Professional appearance

Open posturing-be welcoming.

Facilitating gestures

Facial animation interest

Eye contact

The moderate tone of voice

Appropriate touch

Moderate rate of speech

Components of Health history

Biographic data 

Source of the history 

Reason for seeking care 

History present illness (HPI)

Past medical history (PMH)

Family History (FH)

Review of systems (ROS)

Functional assessment (FA)

Reasons for seeking care of chief compliant

Use patient's own words

Avoid medical terms

Ask about symptoms

Symptoms

the experiences that suggest disease or dysfunction described in the history

signs

found on exam; when abnormal structure or function suggests the presence of disease.

History of Present Illness (HPI)

Location

character or quality

severity or quantity

timing

setting

aggravating or relieving factors

associated factors

patients perception

What is OLDCARTS

Onset

Location

Duration

Characteristics

Aggravating Factors

Relieving Factors

Treatments

Severity

Past Medical History

Childhood illness

Accidents or injuries

Serious or chronic illnesses

Hospitalization

Operations

Obstetric History  

Immunizations

Most recent exam

Allergies

Current Medications

Last menstrual

Gravida

number of times pregnant

Para

number of live birth after 20 weeks

AB

abortions elective and spontaneous

Review of systems

Subjective data-said to the nurse by the patient

Evaluate the health of each body system

Make sure nothing is overlooked

Look for practices to better health

Functional Assessment

Social and self-care

ADLs-Activities of Daily Living

IADL’s­–Instrumental Activities of Daily Livings

Genogram symbols

Male is a square

Female is a circle

Family is connected by two horizontal lines

Is a health history subjective or objective data?

subjective

4 assessment techniques

inspection

palpation

percussion

auscultation

how do you alter the exam for infants/children

work fast

eyes

ears

throat last

pray for sleep

use the parents

how do you alter the exam for an elderly patient

adjust position and slow pace

General survey objective data physical appearance

age

sex

level of consciousness

skin color

facial features

General survey objective data body structure

stature

nutrition

symmetry

posture

position

body build

contour

What is the prep for examination of the skin

Good lighting

assemble equipment

take vital signs

inspect hands with touch

annular

Ciruclar

Ex: tinea or ringworm

confluent

Hives or allergic reaction

grouped

cluster of legions; poison ivy and contact dermatitis

gyrate

dancing twisted, spirals

(think of a snake, burrows or scabies infection)

discrete

remain separated, acne, or skin tags

zosteriform

shingles; never cross the middle

Linear lesions

one line down the skin where contact happened

how to assess skin mobility and turgor

Use back of hands to palpate the temperature

skin should be warm

abnormal findings of skin

vascularity and turgor

Edema

Dry mucus membranes

Diaphoresis

excessive sweating

Xerosis

extremely dry

pallor

white

erythema

blood

cyanosis

blue

jaundice

yellow

sebum

holding water in the skin producing milia

pruitis

grass poison ivy, allergies, liver failure, dialysis (systemic) itching but no rash

ABCDE

A-Asymmetry

B-Border

C-Color

D-Diameter

E-Elevation and enlargement

what is the purpose of ABCDE’s

danger signs for cancerous lesions

macules

non-palpable

<1 cm diameter (freckle)

papules

palpable

<1 cm diameter (mole)

vesicles

<1 cm; chicken pox, shingles, poison ivy,

Bulla

1 cm- thin layered and easily rupture

perfect line of demarcation

wheal

localized, epidermis, TB skin test and mosquito bites

Senile purpura

benign, easy bruising that affects older adults.

lentigines

flat spots of increased pigmentation

seborrheic keratosis

a common noncancerous (benign) skin growth

herpes zoster

shingles

lichenification

Diffuse thickening of the epidermis, with resulting accentuation of skin lines= use crisco (thick oil)

normal angle of nailbeds

160º

signs of early clubbing

180º

what do you inspect and palpate for?

presence

growth

curvature

color

thickness

capillary refill

clubbing of the fingers is a sign of what?

chronic lung disease

Normal capillary refill

when the blood refills the nail beds less than or up to 1-2 seconds.

chloasma

Discoloration changes on face representing the “mask of pregnancy”

Linea nigra

Increased pigmentation midline of abdomen

Striae gravidarum

Stretch marks, which can develop over the abdomen, breast, and thighs

Mongolian Spots

lat bluish- to bluish-gray skin markings commonly appearing at birth or shortly thereafter.

mostly seen in African American and Asian populations

café au lait spots

flat areas of darkened skin, anywhere from tan to dark brown

can affect anyone

How are tonsils graded?

+1

+2

+3

+4

+1 tonsils

barely visible

+2 tonsils

normal

+3 tonsils

large and touching the uvula

+4 tonsils

too big or abnormal

assessment of the thyroid

Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid.

what do you instruct the patient to do when palpating the thyroid?

drink water

how to inspect and assess the nose internally

use otoscope

inspect mucosa

deviation and polyps

where are the lymph nodes on your head

head- back of your head (occipital nodes) and near the base of your skull

where are the lymph nodes on your neck

on either side of the front of the neck, both sides of the neck, and down each side of the back of the neck) Under the jaw and chin. Behind the ears.

What is the best technique for palpating the lymph nodes?

Start with the perauricular

note the characteristics

note location, size, shape, mobility, consistency, and tenderness

an infected node feels like what?

tender and swollen

which sinuses are accessible to examination

Frontal

Ethmoid

Maxillary

Sphenoid

epistaxis

a nose bleed

rhinorrhea

nasal drainage

purulent nasal discharge

drainage that is thick, opaque and colored

boogers

dried up bacteria