Introduction to Health Assessment (Components)

nonverbal reactions

facial expressions, posture, gestures, vocal tone and rate

tertiary health protection

minimize disability from illness/injury & facility optimal living

bimanual palpation

use of both hands to entrap an organ or mass betwen fingers

inspection

visual examination of every body system observed with a "critical eye"

cachexia

wasting syndrome of weight loss, muscle atrophy, fatigue, & weakness

1. BMI 2. cachectic 3. centripetal obesity

what 3 aspects do you consider when assessing a patient's nnutrition?

1. hand hygiene 2. personal protective equipment (PPE) 3. management of patient care equipment

what 3 standard precautions are used to practice infection control?

1. gait 2. range of motion 3. paralysis 4. tics/tremors

what 4 aspects of movement & ability do you assess in a patient?

1. age 2. sex 3. level of consciousness 4. skin color

what 4 aspects of physical appearance do you asses during the general survey?

1. finger pads 2. fingers & thumb 3. dorsal surface of hand 4. ulnar surface of hand

what 4 parts of the hand do you use when performing palpations?

1. stature 2. nutrition 3. symmetry 4. posture 5. position

what 5 aspects of body structure do you assess?

1. name 2. gender 3. address + phone number 4. birth date 5. birth place 6. race/ethnicity 7. marital status 8. occupation 9. emergency contact 10. source of data

what are 10 pieces of biographical data collected at the first patient visit and updated as necessary?

1. facial expressions 2. mood/affect

what are 2 aspects of behavior do you assess about a patient?

1. private 2. comfortable 3. quiet/without distractions

what are 3 important factors of the physical setting during the interview?

PBMB 1. Physical appearance 2. Body structure 3. Movement 4. Behavior

what are 4 areas to assess in the general survey of your patient?

1. breath (fruity, offensive) 2. alcohol 3. smoking 4. GI bleed 5. specific bacteria (pseudomonas, cdiff)

what are 5 smells that can commonly be observed during inspection?

1. using medical terminology 2. expressing judgement 3. interrupting patient 4. authoritarian demeanor 5. asking "why"

what are 5 techniques that diminish data collection during the interview? (AVOID THESE)

1. warm hands 2. gentle touch 3. short nails 4. cultural significance of touch 5. state purpose, manner, & location of touching 6. gloves (mucous membranes/body fluid)

what are 6 considerations to take when performing palpation on a patient?

1. active listening 2. facilitation 3. clarification 4. restatement 5. reflection 6. confrontation 7. interpretation 8. summary

what are 8 techniques to enhance data collection during the interview?

1. primary (prevent) 2. secondary (screen) 3. tertiary (treat)

what are the 3 levels of health protection?

1. history 2. physical examination 3. documentation of data

what are the 3 primary components of health assessment

1. evaluate size, borders, or consistency of internal organs 2. detect tenderness 3. determine extent of fluid in a body cavity

what are the 3 things percussion is performed to do?

1. identify abnormal findings 2. correctly interpreting findings & select appropriate plan of care 3. apply clinical judgement to interpret or draw conclusions about patient needs/problems 4. respond by determining appropriate interventions

what are the 4 steps in the cycle of how nurses make judgements?

(IPPA) 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

what are the 4 techniques of physical assessment?

1. tympany 2. resonance 3. hyperresonance 4. dullness 5. flatness

what are the 5 percussion tones?

1. comprehensive assessment 2. focused assessment 3. episodic (follow-up) assessment 4. shift assessment 5. screening

what are the 5 types of health assessments?

PQRSTU 1. Provocative/Palliative 2. Quantity/Quality 3. Region/Radiation 4. Severity/Scale 5. Timing (onset, duration, frequency) 6. Understanding (client's perspective/yoU)

what are the 6 parts of symptom analysis?

1. texture (smooth/rough) 2. temperature (hot/cold) 3. moisture (dry/moist) 4. organ location/size 5. vibrations/pulsations 6. lumps/masses (size/consistency) 7. tenderness/pain (exact location - patient's reaction)

what are the 7 factors to assess while performing palpation?

alert + oriented

what do you look for regarding level of consciousness in the physical exam?

even color tone + pigmentation is consistent with genetic background

what do you look for regarding skin color in the physical exam?

appear their stated age

what do you look for regarding the patient's age in the physical exam?

development is appropriate for age + gender

what do you look for regarding the patient's sex in the physical exam?

communication skills

what is the single most important factor for successful interviewing?

dorsal surface

what part of the hand do you use when feeling a patient's temperature?

ulnar surface

what part of the hand do you use when feeling the vibrations during palpation of a patient?

<5%

what portion of children on the growth chart are considered "short statured"

the moment you meet the patient

when do you begin the general assessment/survey of your patient?

jaundice

yellow coloring of the skin; caused by liver disease

severity/scale symptom analysis

"how bad is it (scale 1-10)" "is it better/worse/same as before"

quality/quantity symptom analysis

"how does the condition look/feel/sound" "how intense/severe is the condition" "how many spots does this condition appear in"

provocative/palliative symptom analysis

"what brings on the condition" "what makes the condition better/worse"

understanding symptom analysis

"what do you think this means" patient's perspective

timing symptom analysis

"when does it begin" "how long does it last" "how often does it occur"

region/radiation symptom analysis

"where is the condition" "does it spread"

subjective, objective

a patient's health history is ______, while the physical examination is _____

fowler's position

a semi-sitting position in hospital bed where the head of the bed is raised around 45 degrees

general inspection/survey

a study of the whole person that covers the general health state + physical characteristics; introduction to the physical exam

symptom analysis

a systematic way to collect data about the history and status of symptoms

dysphasia

difficulty speaking

episodic/follow-up assessment

done when a patient is following up with a health care provider for a previously identified problem

interview

during the ____, the nurse facilitates discussion to collect & record data, determine the patient's health beliefs, and use structured format to ensure consistency

active listening

empathetic listening in which the listener echoes, restates, and clarifies

palpation

examining what you can feel less than or equal to 1cm deep on the patient's body; follows/confirms findings on inspection

auscultation

listening to the sounds within the body using a stethoscope

tympany

loud, high-pitched sound heard over the abdomen

low fowlers position

lying in hospital bed at an angle less than 45 degrees but not lying down flat

high fowlers position

lying in hospital bed at an angle over 45 degrees; similar to sitting BUT the legs are up in the bed

prone position

lying on abdomen, face down

lithotomy position

lying on back with legs raised and feet in stirrups (typically for OBGYN exams)

sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

dorsal recumbent position

lying on the back with the knees flexed/up (typically for catheter insertion)

supine

lying on the back, face up

lateral recumbent position

lying on the side (right or left - doesn't matter)

direct percussion

strike finger or hand directly over patient's body

symptoms

subjective data that the patient says, feels, or communicates that is collected during the health history

screening

test or examination for the presence of disease

1. type of exam 2. problem being assessed

the equipment used during an assessment depends on 1. ____ 2. ____

documentation

- improves plan of care - baseline for evaluation + decisions related to care - must be accurate, concise, & without bias/opinon - legal document of patient's health status

comprehensive assessment

An in-depth assessment of the whole person, including physical, mental, emotional, cultural, and spiritual aspects of a patient's health collected the first time a patient is seen in an establishment

tripod position

An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward

focused assessment

Assessment based on the patient's problems that are happening at that moment; components include performing a general survey, taking vital signs, and assessing specific areas that relate to the problem

directive questions

Lead patient to focus on one set of thoughts; most often used in ROS or evaluating functional capabilities (ex: describe the drainage you have had from your nose)

fetal position

Refers to the direction of a reference point in the fetal presenting part to the maternal pelvis

shift assessment

The assessment performed at the beginning of the shift and including an abbreviated exam, with emphasis on risk areas (typically 1-2x per shift)

acromegaly

a condition of excess secretion of growth hormone AFTER puberty; overgrowth of bones in the face, hands, head, and feet

gigantism

a condition of excessive secretion of growth hormone BEFORE puberty; overgrowth of height

hyperresonance

an abnormal booming sound heard in overinflated lungs (as in emphysema)

health protection/prevention

behavior motivated by the desire to avoid illness, detect illness early, and maintain function when ill

health promotion

behavior motivated by the desire to increase well-being and actualize health potential

cyanosis

blue discoloration of the skin; caused by decreased circulation

centripetal obesity

fat in neck, face, and trunk with thin legs

1. measurement 2. facilitation

for what 2 reasons can equipment be used for assessment?

flatness

heard over bones and muscle

dullness

heard over dense organs, such as the liver

resonance

heard over normal lung tissue

percussion

hitting/tapping on a surface to determine the difference in the density of the underlying structure

number + nature

if a patient is in distress, limit the ____ + ____ of necessary questions

signs

objective data observed by the nurse that is collected during the physical examination

pallor

paleness of the skin/lack of color; caused by shock, anemia, and decreased circulation

fingers & thumb

part of the hand to use when performing palpation to detect position, shape, and consistency of an organ/mass

finger pads

part of the hand to use when performing palpation to feel texture, swelling, pulsation, and the presence of lumps

knee-chest position

patient is lying face down with the hips bent so that the knees and chest rest on the table

comprehensive health history

performed during hospital admission with an initial clinic or home visit or when a patient's reasons for seeking care are for the relief of a generalized symptom (like weight loss or fatigue)

primary health protection

prevent disease from developing through healthy lifestyle

close-ended questions

questions a person must answer by choosing from a limited, predetermined set of responses (ex: do you become short of breath?)

open-ended questions

questions that allow respondents to answer however they want (ex: how have you been feeling?)

erythmea

red coloring of the face; caused by fever, blushing, and inflammation

indirect percussion

requires both hands; strike finger or hand placed over body surface

secondary health protection

screening for early detection of disease/problems

dysarthria

slurred speech; difficulty with articulation