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