Comprehensive Health Assessment Techniques in Nursing

Subjective data

Information that the patient experiences and communicates to the nurse.

Objective data

Information that the nurse measures or observes during the assessment.

Nursing Process

A systematic approach that includes assessment, diagnosis, planning, intervention, and evaluation.

Health History

A detailed account of the patient's subjective experiences, including biographic data and reasons for seeking care.

Biographic data

Information about the patient's identity, including name, address, age, gender, race, and occupation.

Source of History

The individual providing the health information, typically the patient, but may also include relatives or friends.

Reliability

The consistency and willingness of the informant to provide accurate information.

Chief Complaint (CC)

A brief statement made by the patient describing the primary reason for seeking medical care.

Symptom

A subjective sensation that a person feels as a result of a disorder.

Sign

An objective abnormality that can be detected through physical examination or laboratory tests.

History of Present Illness (HPI)

A detailed exploration of the patient's current health issue, including symptom characteristics.

PQRSTU

A mnemonic used for symptom analysis, focusing on provocative/palliative factors, quality, region/radiation, severity, timing, and understanding the patient's perception.

OLD CARTS

A mnemonic for assessing symptoms, including onset, location, duration, characteristics, associated symptoms, relieving/aggravating factors, timing, and severity.

Past Medical History (PMH)

A record of the patient's previous health issues, including childhood illnesses, surgeries, and hospitalizations.

Medical Reconciliation

The process of comparing current medications with previous lists to ensure accuracy and safety.

Family History

A record of health issues in the patient's family, typically covering three generations.

Activities of Daily Living (ADLs)

Self-care activities that are essential for daily living and reflect the patient's overall health status.

Lifestyle and Living Environment

Factors that influence health, including self-esteem, exercise, nutrition, and interpersonal relationships.

Occupational Health History

Information regarding the patient's current and past employment, including job satisfaction and working conditions.

Health Beliefs

Personal perceptions and attitudes regarding health, illness, and wellness that influence health behaviors.

Review of Systems (ROS)

A systematic approach to gathering information about a patient's symptoms across various body systems.

General Survey

An initial assessment that provides an overall impression of a person's health status based on physical appearance and behavior.

Vital Signs

Measurements of essential body functions, including temperature, pulse, respiration, and blood pressure, used to assess health.

Body Mass Index (BMI)

A numerical value derived from height and weight used to categorize individuals into weight categories such as underweight, normal, overweight, or obese.

Hypothermia

A medical emergency that occurs when the body temperature drops below the normal range, often due to prolonged exposure to cold.

Hyperthermia

A condition where the body temperature rises above the normal range due to the body's inability to dissipate heat.

Symptom Analysis

A detailed examination of reported symptoms to determine their significance and potential underlying causes.

Assistive Devices

Tools or equipment designed to aid individuals in performing daily activities, often used to enhance mobility.

Mobility

The ability to move freely and easily, which can be assessed through gait and the use of assistive devices.

Skin Color

The pigmentation of the skin, which can indicate various health conditions and overall well-being.

Nutrition

The process of obtaining and utilizing food for growth, metabolism, and repair of the body.

Posture

The position in which someone holds their body when standing or sitting, which can reflect health and physical condition.

Temperature Measurement

The process of determining body temperature using various methods such as oral, rectal, axillary, or tympanic.

Facial Features

The characteristics of a person's face that can provide insights into their health and emotional state.

Symmetry

The balanced distribution of body parts, which can indicate normal development and health.

Waist Circumference

A measurement used to assess abdominal fat and the risk of metabolic syndrome.

Gait

The manner or pattern of walking, which can reveal information about a person's physical health.

Emotional Behavior

Visible expressions of feelings or moods that can provide insight into a person's mental health.

Core Body Temperature

The internal temperature of the body, regulated by the hypothalamus, crucial for normal physiological functions.

Tympanic Temperature

A method of measuring body temperature using the ear, which can provide quick and accurate readings.

Oral Temperature

A common method for measuring body temperature by placing a thermometer in the mouth.

Axillary Temperature

A method of measuring body temperature in the armpit, considered safe but less accurate.

What is a normal oral temperature?

36-38 C or 96.8-100.4F

What types of patients should oral temperature should be avoided for?

Patients who have undergone jaw or mouth injury or surgery, have trouble breathing through nose, those who might bite the thermometer, and those who are likely to have a seizure

When should you not take an oral temperature?

After a person has eaten, drank, smoked, or chewed gum in the last 15 minutes

Rectal Temperature

The most accurate method of measuring body temperature, typically used for patients who are comatose, confused, or unable to close their mouth.

What is a normal axillary temperature?

36-37C or 96.6 - 98.6F

Who should axillary temperature be performed on?

newborns or unconscious people

Tympanic Membrane Thermometer (TMT)

A device that measures temperature from the eardrum, providing results almost as accurate as rectal measurements.

What is a normal rectal temperature?

37-38.1C or 98.6-100.6F

What type of patients should not get their temperature taken rectally?

Those with hemorrhoids, diarrhea, lesions around the anus, recently had surgery around butt area, immunocompromised, and those at risk for bleeding

Which way should a patient be rolled to get a rectal temperature?

To the left

Temporal Artery Temperature

A method of measuring body temperature that is more accurate than oral and axillary methods, but can be affected by hair and sweat.

Normal Tympanic Membrane temperature?

37 C or 98.6F

Pulse Rate

The number of times the heart beats in one minute, typically ranging from 60 to 100 beats per minute in a healthy adult.

Normal Temporal Artery temperature?

37 C or 98.6 F

Tachycardia

A condition characterized by a pulse rate that is faster than normal, often due to factors like exercise, fever, or anxiety.

What is the measurement scale for pulse amplitude?

0 = absent

+1 = weak

+2 = normal

+3 = strong

+4 = bounding

What are some variations in BP?

Estrogen can effect BP, African descent typically has an increased BP, and BP increases with age

What are some factors that dictate which arm to use to take a BP?

Arms that injured, Cast, IV, Dialysis access site, mastectomy, Stroke

Proper Cuff Size

Width: 40% of upper arm

Length: >80%

How does an overally small cuff affect BP?

Readings too high

How does an overally large cuff affect BP?

Readings too low

How does a loosely wrapped cuff affect BP?

Reading too high

What happened to the BP if the arm is above heart level?

BP lower

What happened to the BP if the arm is below heart level?

BP higher

Does oxygenated blood absorb more or less light?

More light

Types of Oxygen Saturation probes

Earlobe probes, forehead, clip or adhesive finger probe

What are some things that need to be taken into consideration when taking SpO2?

Remove nail polish, don't put probe on the same arm as BP cuff, avoid bright lights

Bradycardia

A condition where the pulse rate is slower than normal, which can indicate heart problems or be a side effect of certain medications.

Pulse Rhythm

The pattern of beats in a pulse, which can be regular or irregular, indicating potential heart issues if irregular.

Pulse Amplitude

The strength or forcefulness of a pulse, which can be classified as weak, normal, or bounding.

Blood Pressure

The force exerted by circulating blood on the walls of blood vessels, measured in systolic and diastolic values.

Systolic Blood Pressure

The first and highest value in a blood pressure reading, representing the pressure during heart contraction.

Diastolic Blood Pressure

The second value in a blood pressure reading, indicating the pressure during heart relaxation.

Normal Blood Pressure

A healthy blood pressure range typically defined as systolic between 90-130 mmHg and diastolic between 60-80 mmHg.

Hemorrhoids

Swollen veins in the lower rectum or anus that can make rectal temperature measurement uncomfortable or risky.

Cerumen

Earwax that can affect the accuracy of tympanic temperature measurements if present in excess.

Radial Pulse

The pulse felt at the wrist, which is the most accessible site for measuring heart rate.

Irregular Pulse

A pulse that does not follow a consistent rhythm, which may indicate underlying health issues.

Bounding Pulse

An abnormally strong pulse that can indicate conditions such as fever or anxiety.

Weak Pulse

A pulse that is difficult to detect, often associated with low blood pressure or serious heart problems.

Aneurysms

Bulges in weakened blood vessel walls that can result from high blood pressure and pose serious health risks.

Myocardial Infarction

Commonly known as a heart attack, it occurs when blood flow to a part of the heart is blocked.

Stroke

A medical emergency that occurs when blood flow to the brain is interrupted, leading to brain damage.

Hypertension

A condition characterized by persistently elevated blood pressure, defined as a systolic reading of 130 mmHg or higher and a diastolic reading of 80 mmHg or higher.

Hypotension

A condition where blood pressure is persistently lower than normal, defined as a systolic reading of less than 90 mmHg and a diastolic reading of less than 60 mmHg.

Orthostatic Hypotension

A form of low blood pressure that occurs when standing up from sitting or lying down, often causing lightheadedness or fainting.

Cardiac Output

The total volume of blood that the heart pumps in one minute, influenced by heart rate and stroke volume.

Vasoconstriction

The narrowing of blood vessels, which increases resistance and can lead to elevated blood pressure.

Korotkoff Sounds

Sounds heard through a stethoscope during blood pressure measurement, used to determine systolic and diastolic pressures.

Pulse Pressure

The difference between systolic and diastolic blood pressure, indicating the force that the heart generates each time it beats.

Mean Arterial Pressure (MAP)

An average blood pressure in a person's arteries during one cardiac cycle, calculated using the formula MAP = ((2 * DBP) + SBP) / 3.

Respiratory Rate

The number of breaths taken per minute, typically ranging from 12 to 20 breaths per minute in a healthy adult.

Tachypnea

An abnormally rapid breathing rate, often exceeding 20 breaths per minute, which can be caused by various factors such as fever or anxiety.

Bradypnea

An abnormally slow breathing rate, typically defined as fewer than 12 breaths per minute.

Oxygen Saturation (SpO2)

The percentage of hemoglobin in the blood that is saturated with oxygen, indicating how well oxygen is being transported in the bloodstream.

Hypoxia

A condition in which there is insufficient oxygen available to meet the needs of the body.

Nociceptive Pain

Pain that results from the activation of pain receptors due to actual or potential tissue damage.

Neuropathic Pain

Pain caused by damage or dysfunction of the nervous system, often described as shooting, burning, or electric shock-like.