Health Assessment lecture #1

what are the elements of physical appearence in the general survey

sex, age, level of conciousness, skin color, facial features, and overall apearence

body structure general survey

stature, nutrition, symmetry, posture, position, build, and any obvious physical deformities

mobility

gait and range of motion

what is gait

a person's manner of walking, including the rhythm and speed of movement.

elements of behavior

facial expression, mood and affect, speech, speech pattern, and dress, and personal hygiene

how does a nursing diagnosis differ from a medical diagnosis

a nursing diagnosis identifies the patients response to a health problem, focusing on how the illness affects the patients daily life. the nursing diagnosis identifies how the patient is experiencing and responding to their illness.

what is a cue in nursing

a sign or symptom that indicates the patient may be in duressor experiencing a particular health issue.

define SMART goals

specific, measurable, attainable, realistic, and timely

what is the specific depth of light percussion

1 centimeter

what is the depth of deep percussion

4 centimeters

what are the 3 percussion techniques

immediate, mediate, or blunt/fist

differentiate between a general survey and inspection

a general survey takes place immediately upon seeing your patient and involves overall observation, while inspection is a focused examination of specific areas or systems to gather detailed information. inspection can technically take place during anytime of the physical exam whereas a genrral survey is done first always

nonsocomial infection

Infection acquired in a healthcare setting, not present upon admission.

what should you do before applying medication

make sure the 5 rights are accurate and ask the client if they have any allergies

when can someone first begin a full head to toe assessment

school age or approximately 6 years old

what is the bigger part of the stethoscope called

diaphragm

what sounds does a diaphragm specifically pick up

high-frequency sounds such as breath and heart sounds.

what sounds does the bell of a stethoscope pick up

low-frequency sounds such as heart murmurs and certain vascular sounds.

what does an assessment allow us to determine about our patient

a baseline- a baseline is important because it is the foundation we go off of and helps us easily determine if a patient is getting better or worse

at what stage in ADPIE do we set priorities, goals, and generate solutions

planning

what does a nasal speculum do

A nasal speculum is an instrument used to widen the nostrils for better visualization of the nasal passages during an examination. It helps healthcare providers assess the condition of the nasal mucosa and detect any abnormalities.

what is a fecal occult blood test

A fecal occult blood test is a diagnostic screening tool used to detect hidden blood in a person's stool. This test is important for identifying gastrointestinal bleeding, which may indicate conditions such as polyps or cancer.

what does cytologic mean

pertaining to the study of cells, including their function, structure, and chemistry. It is often used in the context of diagnosing diseases through examination of cellular samples.

otoscope

A medical instrument used to examine the ear canal and eardrum. It provides a visual assessment of the outer ear and can help detect infections or other ear-related conditions. oto means ear

ophthalmoscope

A medical device used to examine the interior of the eye, including the retina, optic disc, and blood vessels. It helps in diagnosing eye diseases and conditions such as glaucoma and diabetic retinopathy. opthalmo means eye

what does augment mean

to enhance or increase something, often referring to improving a function or quality in a healthcare context.

doppler sonometer

A medical device that uses Doppler ultrasound to measure and assess blood flow in the vessels. It is commonly used in vascular studies and fetal monitoring.

goniometer

A device used to measure angles, particularly in assessing joint range of motion in physical therapy and rehabilitation settings.

monofilament

A thin, single-strand filament used in monofilament testing to assess sensation in diabetic patients' feet and detect peripheral neuropathy.

Which part of the hand would the nurse use to palpate pulsations?

Finger pads

Finger pads are best used for assessing texture, shape, and pulsations, not vibrations.

when is immediate percussion useful

helpful for percussing the back (fist) and sinuses (fingers).

when is mediate percussion useful

useful for percussing the thorax and abdomen.

when is blunt or fist percussion useful

used to elicit tenderness arising from the liver, gallbladder, or kidneys

A patient presents to the emergency department in acute respiratory distress, with a respiratory rate of 32 breaths/minute, audible wheezing, and intercostal retractions. What is the nurse's most appropriate action regarding the physical assessment?

B. Collect a mini-database focusing only on the problem area until the distress is resolved.

A nurse is preparing to conduct a physical examination on a 15-year-old adolescent male. Which strategy should the nurse implement to reduce the patient's anxiety and maintain rapport?

save genital exam for last and perform it quickly

The nurse is assessing the visual acuity of a 3-year-old child. Which visual acuity charts are appropriate for this developmental level?

tumbling e chart, LH symbols, HOTV chart

the nurse is caring for a patient admitted with suspected active pulmonary Tuberculosis (TB). Which transmission-based precautions must the nurse implement?

The nurse must implement airborne precautions, which include wearing a fit-tested N95 respirator, placing the patient in a negative pressure room, and limiting the patient's movement outside of the room.