Comp Health Assessment Exam 1 IUSON IU Indianapolis

Assessment

Collect data and information pertinent to the client

Objective Assessment

Physical Exam (Seen by Nurse)

Subjective Information

Given by patient (Gathered from interviewing patient)

Diagnosis

Analyze the data to determine what the problem is

Outcome Identification

What is the goal now?

Planning

How will you attain the outcome? what will you do?

Implement

Coordinate care and initiate the plan

Evaluation

Reassess! collect data - was the goal met?

Components of health assessment

Health History

Physical Exam

Reviewing data from health record

documenting findings/data

Levels of Health Promotion

Primary: (______) ex. exercise or sunscreen

Everyone, Preventing Problems

Levels of Health Promotion

Secondary: (_____) ex. mammogram

at risk people, Early detection before a possible/expected problem occurs

Levels of Health Promotion

Tertiary: (____) ex. medications or BP meds.

People diagnosed with disease. Treating and/or preventing complications from disease.

Biographic data

Name, gender, address, etc

Review of systems

description of individual body systems in order to discover any symptoms not directly related to the main problem

Objective data examples

Signs, observed, felt, measured, heard

Subjective data examples

Symptoms, perceived/reported by patient

Abdominal Pain is ____ data

Subjective

Dark circles un the eyes is an example of ___ data

Objective

Comprehensive Assessment

detail history at onset of care in primary care setting )admission to hospital, long term care facility)

Problem based/focused assessment

History and exam are limited to specific problem (walk in clinic. emergency room)

Screening assessment

short focused on a specific potential problem

Episodic/follow up

follow up from previous identified problem ( diabetes, pneumonia)

Shift assessment

Head to toe checkup

Chief complaint

presenting problem (chart in quotes)

What do you use for conducting a symptoms analysis

OLDCARTS

O: (in oldcarts means?)

Onset

L: (in oldcarts means?)

Location

D: (in oldcarts means?)

Duration

C: (in oldcarts means?)

characteristics

A: (in oldcarts means?)

Aggravators

R: (in oldcarts means?)

reliver

T: (in oldcarts means?)

Timing

S: (in oldcarts means?)

Severity

For pediatric patients ____ their ____ for determining pain

observe, behavior

Before using a medication ask about ____?

allergies

If a patient tells you they have had a bad reaction to a medication what will you do?

Ask to describe the reaction

Genogram

family tree of ages, conditions, gender, health, death

Vital signs

measurement of the body's most basic functions

Expiration Involves the ____ moving up, it is a ____ process

diaphragm, passive

When expiration occurs the _______ muscles are relaxing

external intercostal

The ____ is the respiratory center in the brain

medulla

A healthy rate for adults for breathing is ___ to ____ bpm

12-20

Tachypnea

A respiratory rate greater than 20 Bpm

Bradypnea

A respiratory rate slower than 12 Bpm

Apnea

Absence of spontaneous respirations

Biot's respirations

Involve slow and deep or rapid and shallow breathing followed by apnea (CNS abnormalities)

Kussmauls respirations

Deep gasping respirations, likely due to renal failure, septic shock, or diabetic ketoacidosis

Tidal volume

depth of client breathing

The best sound of the apical pulse can be found at the

Point of maximal impulse

Bell on stethoscope

low pitched sounds

Diaphragm on stethoscope

high pitched sounds

Palpate

examination of body using fingers to determine texture, location, size, and consistency of organs, masses

A pulse rate lower the 60/min is

bradycardia

a pulse rate faster than 100/min is

tachycardia

Dyspnea

sensation of difficult or labored breathing

S1 heart sound

closure of atrioventricular valves

S2 heart sound

Closing of semilunar valve

Pulse deficit

difference between the apical and radial pulse rates

Cardiac output

Volume of blood ejected by the ventricles in one minute

Systole

contraction phase of cardiac cycle. during this phase blood is driven into the aorta and pulmonary artieries

Diastole

Relaxation phase of the cardiac cycle where the heart is relaxed and the chambers fill with blood

Normal BP is ___-___ systolic and ___-___ Diastolic

90-119 mmHg, 60-79 mmHg

Pulse pressure

difference between systolic and diastolic pressure

Hypertension

high blood pressure

Hypotension

low blood pressure

Orthostatic hypotension

Decrease in blood pressure upon standing, when BP drops 20mmHG or more

Oral temp is taken in?

posterior sublingual pocket (under the tongue)

Tympanic membrane

thin, semi-transparent membrane that separates the auditory canal from the middle ear or tympanic cavity

Acceptable oral temp

96.8-100.4 degrees F (36-38 degrees C)

Axillary =

armpit

Tympanic expected temperature range

96.2-100 degrees F (36.8-37.8 degrees C)

Healthy oxygen saturation for an adult is

95-100%

Acute pain

severe with a rapid onset and short duration

Chronic pain

long term pain

PPE order

gown, mask, goggles, gloves

Inspection

physical examination of the body

Percussion

Evaluate size, borders and consistency of internal organs

Auscultation

listening to sounds within the body

Dorsal recumbent

Lying on back, knees bent

Sims

on stomach with one knee out exposing rectal area

Lateral recumbent

lying on the side

Knee chest

The body position of lying facedown with knees bent while resting on the knees and chest. (rectum exposed)

Woodlamp function

detects fungal infections of skin or corneal abrasions of the eyes

Ophthalmoscope function

instrument used to examine the interior of the eye

Otoscope function

Illuminates the ear canal and tympanic membrane.

Doppler function

amplifies noises difficult to hear from an acoustic stethoscope

Body temp is regulated by the?

hypothalamus

Average body temp is?

98.6 degrees F (37 degrees C)

Korotkoff phases characteristics

1:

2:

3:

4:

5:

1: sharp thump

2: blowing or washing sound

3: a softer thump than phase one

4: softer blowing sound that fades

5: silence

A delta fibers

feel sharp pricking acute pain (short duration)

C fibers

feel dull aching throbbing burning

limbic system function

generates emotional response to pain

neuropathic pain

occurs from abnormal processing of sensory input by CNS or PNS

Nociceptive Pain

reaction from normal neural activity

Pain threshold

pain where stimulus can be received as pains

Pain tolerance

pain tolerated before responding outwardly

Onset question

when did this pain begin?

Location question

where do you feel the pain?

Duration question

is the pain consistent or does it come and go?

Characteristics question

what does the pain feel like? (sharp, dull, aching)