HEALTH ASSESSMENT EXAM REVIEW PT 1

What are the components of the health history

1. biographical data/Demographics
2. chief complaint (reason for care)
3. History of present illness
4. Past medical/ surgical history
5. Family History
6. Functional Assessment
7. Review of symptoms

what are the components of functional/social history?

PSYCHOSOCIAL ASSESSMENT

* ADL
* exercise
* sleep/rest
* nutrition/elimination
* self-esteem/self-concept

Objective data

* sign


* what the NURSE sees, feels, hears, etc.
* THINGS THAT CAN BE MEASURED
* Vital signs, PA, Images, lab results

Subjective data

* symptoms
* what the patient tells/reports you
* can come from multiple sources

Allergic reaction to medications versus side effects

Allergic reactions trigger inflammatory response and side effects are discomfort

How to measure pain in children

using a face pain scale

how to measure pain in adults

using a number scale

how do you properly measure height

align piece with top of head & person should be shoeless, standing straight, looking straight with feet and shoulders on hard surface

how do you properly obtain weight

remove shoes and heavy outer clothing and record in Kg and lbs

what is a patients ideal body weight

Normal BMI is 18.5-24.9 kg/m2

what is considered underweight

< 18.5 kg/m2

what is considered overweight

25- 29.9 kg/m2

what is considered obese

30- 39.9 kg/m2

what extreme or morbidly obese

greater than or equal to 40

what is a normal temperature

oral: 96.4- 99.1

Axillary: 97.6

Rectal: 99.6

what is a normal pulse for adults

50-95 bpm for adults

what does bradycardia look like in a pulse

less than 50 bpm

what does tachycardia look like when taking a pulse

more than 100 bpm

what are normal respirations

12-20

what is a normal pulse for a newborn

120-140 bpm

what is the normal pulse rate for 1-4 yrs

70-110 bpm

what are normal respirations for a newborn

30-60

what are normal respirations for 1-4 yr olds

20-60

what are normal respiration rates for 5-12yr olds

16-22

what is a normal BP

120/80

what are the rates for adult hypotension

< 95/60

what are the BP rates for adult stage 1 hypertension

140-159/90-99

what are the BP rates for stage 2 hypertension

>= 160/100

Inspection

begins with general survey. make sure you have good lighting , adequate posture, occasional use of instruments

Palpation

applies sense of touch to asses the following: texture, temperature, moisture, swelling, etc.

percussion

tapping a persons skin with short, sharp strokes to assess underlying structures

direct percussion

aka immediate, the striking hand directly contacts the body wall

indirect percussion

mediate, using both hands, striking hand strikes the other hand

flat percussion

silent, very soft over bones and large muscle

dull

soft, muffled thud over liver, heart, and spleen

resonance

low pitched clear hollow song heard over lungs

Tympany

musical and drum-like sound heard over stomach or intestines

Auscultation

stethoscopes needed to sound proof