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Purposes of a Health Assessment
Establishment of nurse-patient relationship
Gather data of pt general health status
Identify pt strengths
Identify actual and potential health problems
Establish base for nursing process
Different Types of Health Assessment
Comprehensive
Ongoing/Partial/Follow Up
Focused
Emergency
Comprehensive Health Assessment
A health assessment done upon admission, a broad health assessment that includes a complete health history and a physical assessment.
Ongoing/Partial/Follow Up Health Assessment
A type of health assessment done at regular intervals. This assessment concentrates on specific problems to monitor positive or negative trends and evaluate interventions effectiveness. These assessments are also used to find new problems.
Focused Health Assessment
A type of health assessment done to assess a specific health issue and focuses on pertinent history and body regions, usually involving 1 or 2 systems. Thus type of assessment can also be used to address immediate and highest priority concerns.
Emergency Health Assessments
A type of focused assessment done when addressing life-threatening or unstable conditions.
What are some ways that you may prepare a patient for a physical assessment?
Consider physiologic and psychological needs of patient
Explain general process to patient to decrease fear and anxiety
Explain each procedure more in depth as you do them
Have patient change into a gown and empty bladder
Answer questions directly and honestly
How would you prepare the environment for a physical assessment?
Ensure privacy and respect
Agree on specific time for assessment
Ensure patient is free of pain
Prepare bed/examination table
Provide gown and drape
Gather needed supplies beforehand
Standing
Position used to assess posture, balance, and gait. Do not use for pt who are weak, dizzy, or fall-risk.
Sitting
Position that allows for visualization of upper body, full lung expansion, VS assessment, and assessment of the body above the abdomen.
Supine
Position that allows for relaxation of abdominal muscles, assessment of VS, and assessment of the anterior body.
Dorsal Recumbent
Position used for patients that have difficulty maintaining supine position. Used for assessment of the anterior body with exception to the abdomen as this position causes abdominal muscle contraction.
Sim’s
Position used for assessment of rectum or vagina.
Prone
Position used to assess hip joint and posterior thorax.
Lithotomy
Position used for assessment of female genitalia and rectum.
Knee-Chest
Position used for assessment of anus and rectum.
What factors should you assess during a health history?
Biographical data
Reason for seeking care
History of present illness
Past medical history
Family history
Functional health
Psychosocial and lifestyle factors
Review of systems
What type of questions would you ask regarding present health history?
Questions that are directly related to the primary problem the patient is complaining of.
What type of questions would you ask regarding past health history?
Questions related to the patient’s health in the past (Ex. childhood injuries) or simply not related to the illness the patient is currently presenting with (Ex. Prescribed medications).
What types of questions would you ask regarding family history?
Health history of the patient’s family that can be explicitly or implicitly related to the patient.
What type of questions would you ask regarding functional health?
Questions regarding the daily/typical life of the patient.
What are the techniques used during a physical assessment?
Inspection
Palpation
Percussion
Auscultation
Inspection
A technique used in a physical assessment that starts upon initial contact and continues throughout the assessment. Appearance, behavior, movement, size, color, shape, position, and symmetry are assessed.
Palpation
A technique used during a physical assessment that uses touch to assess for temperature, turgor, texture, moisture, vibrations, and sharp or structures. There are two types of palpation: light (1-2cm) and deep.
Percussion
A technique used during a physical assessment that assesses location, shape, size, and density of tissues. Fingertips are tapped over body tissues to produce sounds/vibrations.
Auscultation
A technique used during a physical assessment that assesses the four characteristics of sound: pitch, loudness, quality, and duration. Auscultation is performed using a stethoscope.
How would safety be assessed?
Bed position
Call light position
Appropriate emergency equipment
Assistive devices
Fall risk/hazards
List the Vital Signs
Temperature
Pulse
Respirations
BP
O2 sat
Pain
How would you assess mental status?
LOC
A&O x? (Person, place, time, event)
Speech
How would you assess the psychosocial status of a patient?
Assess behavior and affect.
How would you assess the head, eyes, ears, and nose of a patient?
Assess the following:
Eyes
Pupils
Mouth
Carotid arteries
Swallowing
Throat
Neck and facial color
Moisture
Lesions
Wounds
Glasses?
Hearing aids?
Ability to hear
Ability to see
How would you assess the chest of a patient?
Color
Moisture
Lesions
Wounds
Respirations and their quality
Heart sounds
Lung sounds
Cough
Sputum
How would you assess the abdomen of a patient?
Color
Moisture
Lesions
Wounds
Bowel sounds
Tenderness
Distention
Pain/discomfort
Ability to eat
Urine elimination patterns
Urine characteristics
Bowel elimination pattern
Stool characteristics
How would you assess the upper and lower extremities of a patient?
Skin
Color
Pulses
Temperature
Tenderness
Edema
Capillary refill
Strength
Sensation
ROM
Lesions
Wounds
How would you assess the activity of a patient?
Assess the following:
Movement and ambulating
Ability to move in bed
Ability to get out of bed
Ability to walk and distance walkers
Gait
What is important about vital signs?
They indicate the general physiologic functioning and health status of a patient.
Can VS be delegated?
Yes, only if the patient is stable.
What is the responsibility of the RN regarding VS?
Accuracy
Interpretation
Reporting of abnormal findings
Redness
Also known as erythema or flushing, a skin color that can be found on the face or in a localized area of skin. Can be caused by blushing, alcohol, fever, trauma, or infection.
Bluish
Also known as cyanosis, a skin color that can be noticed in exposed area, ears, lips, mouth, hands, feet, nail beds, and exposed areas in general. Can be caused by coldness or hypoxemia.
Yellowish
Also known as jaundice, a skin color that can be seen throughout the body. Can be caused by liver disease due to increased bilirubin levels.
Paleness
Also known as pallor, a skin color that can be seen in the face, lips, conjunctivae, mucous membranes, and exposed areas in general. Can be caused by anemia (Decreased hemoglobin) or shock (Decreased blood volume).
White patchy areas on skin
Also known as vitiligo, a skin color assessment that can be seen throughout the body. Usually caused by congenital or autoimmune conditions leading to depigmentation.
Tanned or Brown
A skin color assessment that can be seen in sun-exposed areas. Usually caused by overexposure causing increased melanin production or pregnancy.
Purplish
Also known as ecchymosis, a skin color assessment caused by collection of blood within subcutaneous tissue.
Small, nonblanchable purple spots
Also known as petechiae, a skin color assessment where there are small hemorrhagic spots that do not blanch when pressure is applied.
Excessive Perspiration
Also known as diaphoresis, a skin color assessment in which the patient is excessively wet with sweat.
Skin Tension
Also known as turgor, a skin assessment measuring skin tension which is dependent upon hydration.
Excessive extracellular accumulation of fluid
Edema
What assessment tool would you use for melanoma?
A (Asymmetry)
B (Border)
C (Color)
D (Diameter)
E (Evolving)
Describe asymmetry when assessing for melanoma
If a line is drawn through a mole, both sides will not match.
Describe border when assessing for melanoma
Early melanoma borders are usually uneven with the edges possibly being scalloped or notched.
Describe color when assessing for melanoma
Color variety is a warning sign. Melanomas can be different shades of brown, tan, black, red, white, or blue.
Describe diameter when assessing for melanoma
Melanomas are usually larger than the size of a pencil eraser, but may be smaller when initially detected.
Describe evolving when assessing for melanoma
Any change in the mole/site points towards danger.
How would you test for pupillary reaction?
Darken a room and have the pt look ahead
Using a penlight, move light from the side of the pt head towards his/her eyes
Observes for contraction and size
Repeat on the other side
Equal bilateral pupil size and constriction upon contact with light are normal results
How would you assess for convergence?
Hold an object 6-8 inches away from pt nose and have pt look at point/tip of object
Move object closer to pt nose
Eyes converging (Pt appearing cross-eyes) are normal results
How would you test for accommodation?
Hold an object with a tip 4-6 inches away from pt nose
Have pt look at object first ten a more distant object
Finally, have pt refocus back on the near object
Pt pupil constriction when looking at near object and pupil dilation when looking at distant object are normal results
How would you test extraocular movements?
Position pt 2 ft away facing you at eye level
Have patient hold still and follow movement of penlight with eyes
Move penlight through cardinal positions
Pt following penlight with no lag in eyes are normal results
How would you test peripheral vision?
Have pt stand 2 ft away and face you at eye level
Have pt cover one eye
Have pt fix gaze upon your nose
Outstretch your arm to one side so that neither you nor the pt sees your fingers
Bring arm and fingers into your and the pts peripheral vision and tell pt to inform you when he/she sees tour fingers
Repeat steps on other side
Pt and you should see finger within peripheral vision around the same time for normal results
What are the characteristics of sound you can assess during auscultation?
Pitch
Loudness
Quality
Duration
Describe Pitch (Auscultation)
Ranges from high to low
Describe Loudness (Auscultation)
Ranges from soft to loud
Describe Quality (Auscultation)
Descriptions such as gurgling or swishing.
Describe Duration (Auscultation)
Short, medium, or long
What are the normal breath sounds?
Bronchial/Tubular
Bronchovesicular
Vesicular
What are the adventitious/abnormal breath sounds?
Wheeze (Sibilant)
Rhonchi (Sonorous wheeze)
Crackles
Strider
Friction Rub
Bronchial/Tubular Lung Sounds
A normal lung sound characterized as blowing, hollow sounds. This sound is auscultated over the larynx and trachea and expiration sound is longer, lower, and higher pitched.
Bronchovesicular Lung Sounds
A normal lung sound that is medium-pitched, medium intensity, and is characterized by blowing sounds. This sound is auscultated over the anterior first and second intercostal space and over the scapula posteriorly. Inspiration and expiratory sounds are similar.
Vesicular Lung Sounds
A normal lung sound characterized by soft, low-pitched, whispering sounds. Heard over most lung fields, inspiration is longer, louder, and higher pitched.
Wheeze (Sibilant)
An abnormal lung sound characterized by musical/squeaking sounds that are high-pitched and continuous. This sound can be heard during inspiration and expiration and indicated air passing through narrow airways.
Rhonchi (Sonorous Wheeze)
An abnormal lung sound characterized by sonorous/coarse, low-pitched continuous sounds. This lung sound is heard during inspiration and expiration and indicated air passing through or around secretions. Coughing may somewhat clear this sound.
Crackles
An abnormal lung sound characterized by bubbling, crackling, or popping sounds that have a low- to high-pitch and is discontinuous. Heard during inspiration and expiration, this sound indicates opening of small deflated airways and alveoli with air passing thru fluid in these airways.
Stridor
An abnormal lung sound characterized by harsh, loud, and high-pitched sounds that are heard upon inspiration. This sound indicates a narrowing of the upper airway and/or presence of foreign body in airway.
Friction Rub
An abnormal lung sound characterized by rubbing or grating sounds that are lowest over the lower lateral anterior surface. This sound is heard upon inspiration and expiration and indicates inflamed pleura rubbing against chest wall.
What are the two normal heart sounds?
S1 (“lub”)
S2 (“dub”)
Describe the S1 heart sound
Normal heart sound that sounds like “lub”. This sound represents the closing off the mitral and tricuspid valves and initiation of ventricular contraction and is best heard in the tricuspid and apical areas.
Describe the S2 heart sound
Normal heart sound that sounds like “dub”. This heart sound indicates the closing of the aortic and pulmonic valves, termination of systole, and initiation of ventricular diastole. This sound is best heard over the aortic and pulmonic areas.
What extra heart sounds may you auscultate?
S3 and S4
Describe S3 heart sounds
An extra heart sound that may follow S2 and can be heard as “dee”. This sound is best heard over the mitral area and is considered normal in children and young adults, but abnormal in middle-age and older adults.
Describe S4 heart sounds
An extra heard sound that may precede S1 and can be heard as “dee”. This sound is considered normal in older adults, but is considered abnormal in all other age groups.
What are the five areas for listening to the heart?
Aortic (Right second intercostal space, sternal border)
Pulmonic (Left second intercostal space, sternal border)
Eros Point (Left third intercostal space, sternal border)
Tricuspid (Left fourth intercostal space, sternal border)
Mitral (Left fifth intercostal space, midclavicular line)
How is the female breast divided?
How would you assess a female breast using the circular technique?
Using the pads of your first three fingers, gently compress the breast against the chest wall beginning at the tail of spence and going in gradually smaller circles.
How would you assess a female breast using the wedge technique?
Using the pads of your first three fingers, gently compress the breast against the chest wall and palpate from the periphery towards the areola. Go in a clockwise fashion.
How would you assess a female breast using the vertical strip technique?
Using the pads of your first three fingers, gently compress the breast against the chest wall and begin at the outer edge of the breast and palpate up and down, eventually covering the whole breast.
What structures are in the right upper quadrant (RUQ)?
Pylorus
Duodenum
Liver
Right kidney and adrenal gland
Hepatic flexure of colon
Head of pancreas
What structures are in the left upper quadrant (LUQ)?
Stomach
Spleen
Left kidney and adrenal gland
Splenic flexure of colon
Body of pancreas
What structures are in the right lower quadrant (RLQ)?
Cecum
Appendix
Right ovary and fallopian tube (Female)
Right ureter and lower kidney pole
Right spermatic cord (Male)
What structures are in the left lower quadrant (LLQ)?
Sigmoid colon
Left ovary and fallopian tube (Female)
Left ureter and lower kidney pole
Left spermatic cord (Male)
What structures are midline?
Urinary bladder
Urethra (Female)
What four things should you look for when assessing for scoliosis?
Head level and centered over trunk
Shoulders same height
Hips at same level
When bent forwards with arms drooping towards feet, is the rib cage level on both sides?
How would you assess grip?
Have pt squeeze your index and middle fingers.
How would you test knee flexion?
Have pt bend their knee and keep his/her foot on the table. Have the pt attempt to keep this position with foot down while you try to straighten his/her knee.
How would you test knee extension?
While you support pt knee and provide resistance at the ankle. Have patient attempt to straighten the leg.
How would you generally test for muscle strength?
Have patient move against resistance. Bilateral equal resistance should be present. Slightly high resistance on dominant side is normal.
How would you assess for shoulder flexion?
Have patient raise arm forward against resistance.
How would you test for wrist extension?
Pt makes fist and resists you attempt to pull wrist down.
How would you assess hip flexion?
Have pt raise thigh against resistance.
How would you assess ankle plantar flexion?
Have pt push using balls of feet against your resistance as if he/she was stepping on a pedal.