Studied by 5 people
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
Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
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
Note
Flashcard