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Health Assessments

  1. What is the purpose of health assessments?
    to collect subjective and objective data about a patient to obtain information about his physical, psychological, sociocultural, developmental and spiritual health
  2. Type of data collected -- what the patient reports
    Subjective Data
  3. Type of data collected -- what the nurse obtains (ie: refusal of food)
    Objective Data
  4. Type of Health Assessment -- Conducted when patient first enters a healthcare setting, with information providing a baseline for comparing later assessments. (health history + complete physical exam)
    Comprehensive Assessment
  5. Tyep of Assessment-- conducted at regular intervals (ex: at the beginning of each home health visit, or each hospital shift), concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions
    Ongoing partial Assessment
  6. Type of Assessment-- condected to assess a specific problem (ie: abdominal pain...questions related to urinary pain, bowel problems, menstrual history)
    Focused Assessment
  7. Type of Assessment--  rapid focused assessment conducted to determine potentially fatal situations
    Emergency Assessment
  8. Steps for Preparing for the Assesment:
    • *Prepare the Patient
    • *Prepare the Environment
    • *Cultural Sensitivity
  9. Skills needed by the nurse for the assessment:
    • -Cognitive Knowledge
    •    *Ability to integrate knowledge
    •    *Ability to individualize
    •    *Interpretation of findings
    • -Technical Equipment/Techniques
    •    *Positioning
    •    *Flexibility
    •    *Documenting
    •  -Interpersonal Communication/Respect
    •    *Confidence
    •    *Identifying/ Responding to needs
    • -Ethical and Legal Skills Principles
    •    *Safe,quality care
    •    *Responsibility and accountability
    •    *Advocating for patients
    •    *Regulations
  10. Components of Health History:
    *Biographical

    *Chief Complaint

    *History of Present Health Concerns

    *Medical History

    *Family History

    *Lifestyle
  11. Health Assessment Overview:Image Upload 2
    Image Upload 4
  12. Palpations:
    Use hands/fingers

    Dorsum-temp

    Palmar-shape, texture, pulsations

    • Palm- vibrations
    • ----------------------------------------
    • Light- 
    • <1 cm/ 0.5 in

    • Moderate-
    • 1-2 cm/ 0,5-0.75 cm

    • Deep-
    • approx 2 cm/ 1 in

    • Characteristics- shape, size, consistency,
    • surface, mobility, tenderness, pulsatile

    Area of tenderness palpated last
  13. Striking one object against another to get a "tone":
    Percussion
  14. Types of Tones:
    • flat- thigh
    • dull- liver
    • resonance-lungs
    • hyperresonance- lung with emphysema
    • tympany- abdomen
  15. The act of listening with a stethescope to sounds produced within the body
    Auscultation
  16. Using the Stethescope:Image Upload 6
    • Bell = higher pitch sounds
    • Diaphram = lower pitch soundsImage Upload 8
  17. What to check in Appearance and Behavior:
    • -Posture, build
    • -Gait, coordination of movement
    • -Height/weight
    • -Hygiene/grooming
    • -Illness
    • -Affect. attitude, mood
    • -Speech, expression, eye contact
    • -Cognitive processes
  18. What are some Vital Signs???
    • *Blood Pressure
    • *Temperature
    • *Pulse
    • *Respirations
    • *Health Status & Changes
    • *PAIN
  19. When are Vital Signs reported??
    Every Morning!


    (in addition to as often as needed)
  20. Why are Vital Signs reported???
    Fluctuation of vital sign readings allows the health care team (and specifically nurses) to assess what/how the body is doing/responding to situations. The nurses are to report any abnormal readings. 
  21. Facts about Oral Temperature:
    • Taken routinely
    • Taken per MD order
    • Taken when fever is suspected
  22. •Contraindicated with (do NOT use) Oral Temp:
    •Unconscious patient

    •Disorders of mouth

    •Recently had fluids/smoked

    •Wait 15 minutes

    •Receiving nasal oxygen
  23. When do you use rectal temperature?
    • *assessing most accurate temperature
    • *last alternative to oral site
  24. *Contraindicated with (do NOT use) Rectal Temp:
    • •Newborns, small children
    • •Diarrhea
    • •Rectal surgery
    • •Rectal disease
    • •Concern re: vagus nerve stimulation
    • •Neurological disease
  25. When do you use Axillary Temp?
    • *When you can't use Oral or Rectal
    • *Newborns
  26. Contraindicated with (do NOT use) Axillary Temp:
    • •Axillary/Arm disorders
    • •After bathing
  27. Normal Temperature Readings for ORAL:
    98.6 F   OR   37 C
  28. Normal Temperature Readings for RECTAL:
    99.5 F   OR   37.5 C
  29. Normal Temperature Readings for AXILLARY:
    97.6 F   OR   36.5 C
  30. Factors Influencing Temperature:
    • *Circadian Rhythm (24 hours)
    • (Predictable fluctuations)
    • Temp
    • 1-2 degrees lower in early morning...peaks late afternoon (4-7 pm)
    • *AGE-- very young and very old affected 
    • *GENDER-- women tend to have higher levels of progesterone at ovulation which increases temp 0.5-1 degree
    • *ENVIRONMENT
  31. Hypothermia
    LOW body temperature
  32. Hyperthermia
    HIGH body temperature
  33. Manifestations of a Fever:
    • Loss of appetite, headache, flushed, malaise
    • **Severe- dehydration, alt urine output,seizures, electrolyte imbalance
  34. How to Reduce a fever:
    •Cooling the body

    •Increase fluids

    •Monitor intake

    •Monitor labs

    •Antipyretics

    •Antibiotics
  35. Normal Range of a pulse:
    60-100 bpm
  36. More than 100 bpm
    Tachycardia
  37. Reasons/Causes for Tachycardia:
    •Decreased blood pressure

    •Elevated temp

    •Decreased oxygen

    •Heat, Pain, Medicatioins
  38. Less than 60 bpm:
    Bradycardia
  39. Reasons/Causes for Bradicardia:
    •Slower in men

    •Thin person

    •Sleep

    •Hypothermia

    •Aging

    Medications
  40. Pulse Strength:
    0-  Absent

    1+- Thready

    2+- Weak

    3+- Normal

    4+- Bounding

    **anything other than 3+ is reported
  41. Pulse Sites:
    • •Temporal (Temple)
    • •Carotid (Neck)
    • •Brachial (Bend of arm)
    • •Radial- used
    • frequently/palpate (Wrist)
    • •Femoral (Groin)
    • •Popliteal (Behind knee)
    • •Posterior tibial (Inner ankle)
    • •Dorsalis pedis (Top of foot)
    • •Apical- used frequently/ auscultate (heart)
  42. What kind of equipment can be used to check the pulse???
    • *Hand
    • *Doppler
    • *Stethescope
  43. What makes a full Respiration Cycle:
    • *Ventilation
    • *Exhalation
    • *Inhalation
  44. What is the normal Resp. rate for Adults??
    12-20 breaths per min
  45. More than 24 breaths per min:
    • Tachypnea
    • (fever, anxiety, resp disease)
  46. Less than 10 breaths per min:
    • Bradypnea
    • (meds, brain injury)
  47. Hyperventilation:
    increased rate and depth of breathing (Kussmaul’s)
  48. Hypoventilation:
    • decreased rate and depth of breathing 
    • (narcotics/anesthesia)
  49. Respiration Disorders:
    • •Cheynes-Stokes-
    • alt. deep/rapid with apnea

    • •Biot’s-
    • erratic depth and apnea
    • (brain injury)
  50. No Breathing
    Apnea
  51. Difficulty breathing
    Dyspnea
  52. Breathing sitting upright
    Orthopnea
  53. Factors Affecting Respirations:
    •Age- decreases with older age

    •Gender- males- diaphragmatic

    •Exercise- increases respirations

    •Disease- brain injury

    •Anemia- increases respirations

    •Anxiety- increases respirations

    •Medications- narcotics lower; amphetamines-increases

    •Acute pain- increases
  54. Contraction of the ventricles/ Highest pressure on arterial wall:
    Systolic Pressure
  55. Relaxation of the heart/ Lowest pressure on arterial wall:
    Diastolic Pressure
  56. Normal Values of an Adult Blood Pressure:
    <120/<180
  57. Prehypertension levels:
    120-139/80-89
  58. Stage 1 Hypertension levels:
    140-159/ 90-99
  59. Stage 2 Hypertension levels:
    >160/>100
  60. Risk Factors for Hypertension:
    Hx, obesity, smoking, sedentary, stress, diet
  61. Orthostatic Hypotension
    • •Postural hypotension;
    • weakness/ fainting when standing (esp when on prolonged bedrest)
  62. Phases of Sounds heard when taking Blood Pressure:
    •Korotkoff Sounds
  63. Phases of Korotkoff sounds:
    Phase I- first faint clear tapping

    Phase II- Swishing

    Phase III- Distinct loud sounds

    Phase IV- Muffling sounds

    Phase V- Last sound
  64. B.P. assessment sites:
    • -Brachial Artery B/P
    • **Do not take in arm with IV, side of mastectomy, AV shunt

    •  -Popliteal Artery B/P
    • **Systolic may be higher
  65. How would a nurse accidently receive false lows while checking Blood Pressure???
    • •Releasing valve rapidly
    • •Not pumping cuff high enough
    • •Using faulty equipment
    • •Did not insert earpieces correctly
    • •Cuff too wide
    • •Looking at meniscus above eye level
  66. How would a nurse accidently obtain false HIGHs while taking Blood Pressure?
    • •Cuff is not calibrated
    • •Looking at meniscus below eye level
    • •Cuff is too narrow
    • •Releasing valve too slowly
    • •Reinflating cuff during auscultation
  67. Factors Affecting Pain (the 5th vital sign):
    • ***It is what the patient says it is
    • •Culture
    • •Ethnicity
    • •Gender
    • •Age
    • •Support of Others
    • •Anxiety
    • •Past experiences
  68. Pain Assessment:
    • •Patient’s description
    • •Duration
    • •Location
    • •Quantity/ Intensity
    • •Quality
    • •Chronology
    • •Aggravating factors
    • •Alleviating factors
    • •Physiologic indicators of pain
    • •Behavioral responses
    • •Effect on activities and lifestyle
  69. How would you help your patients rate pain?
    • •Simple descriptive Pain Distress Scale
    • •Numeric Pain Scale
    • •Visual Analog Scale
    • •Wong-Baker Faces
  70. When you do an Integument Assessment, what are you checking on the patient???
    • *Hair
    • *Skin
    • *Nails
    • *Scalp
  71. What are some health history questions asked when doing an Integument Assessment??
    • *Skin Lesions
    • *Ecchymosis
    • (bruising)
    • *Sun exposure
    • *Changes in moles or other lesions
    • *Recent therapies (Chemo, Radiation)
    • *Chemical exposure
    • *Mobility
    • *Nutrition
  72. How do you prepare the patient for an Integument Assessment?
    • *Patient gown
    • *Sit most of examination
    • *Lie down- posterior
    • *Privacy

    **If lesions, wear gloves
  73. Image Upload 10
    Erythema
  74. Image Upload 12
    Cyanosis
  75. Image Upload 14
    Jaundice
  76. Image Upload 16
    Pallor
  77. Image Upload 18
    Vitiligo
  78. Image Upload 20
    Ecchymosis
  79. Image Upload 22
    • Petechiae
    • (vascularity)
  80. Macule
    • *Primary skin lesion
    • *Petechiae
    • *Freckles
    • < 1 cm
  81. Patch
    • *Primary skin lesion
    • *Vitiligo
    • * >1cm
  82. Papule
    • *Primary skin lesion/ mass
    • *Mole
    • * <.5cm
  83. Plaque
    • *Primary skin lesion
    • *Peels off
    • *Mass > .5 cm
  84. Nodule
    • *Primary skin lesion
    • *Nevus (wart)
    • *Mass .5-2cm
  85. Tumor
    • *Primary Skin Lesion
    • *Lipoma
    • *Mass > 2cm
  86. Vescicle
    • *Primary skin lesion
    • *Filled with serous fluid
    • *Herpes Simplex Virus
    • * <.5cm
  87. Bulla
    • *primary skin lesion
    • *Filled with serous fluid
    • *Burn
    • * >.5 cm
  88. Pustule
    • *primary skin lesion
    • *filled with pus
    • *Impetigo (very contagious)
  89. UlcerImage Upload 24
    • *secondary skin lesion
    • *loss of dermis and epidermis
  90. Image Upload 26
    • Fissure
    • (secondary skin lesion)
  91. cImage Upload 28
    • Crust
    • (secondary skin lesion)
  92. Image Upload 30
    • Keloid
    • (secondary skin lesion)
  93. What do you assess for while you perform a palapation??
    • *Temperature
    • *Texture
    • *Moisture
    • *Turgor
  94. When assessing the nails, you should check what???
    Shape

      Angle

      Texture

      Color
  95. Acute Illness of the nailsImage Upload 32
    Beau's lines
  96. Nail lifting/separatingImage Upload 34
    Onycholysis
  97. Condition of nails caused by anemiaImage Upload 36
    Brittleness
  98. Chronic Illness (lack of Oxygen)Image Upload 38
    Clubbing
  99. When assessing the hair and scalp, assess:
    • Color
    • Texture
    • Distribution

    • Scalp:
    • Dry, color, lumps, lesions, lice
  100. Image Upload 40
    Senile Keratosis
  101. Image Upload 42
    Senile lentigines (liver spots)
  102. Image Upload 44
    Cherry Angioma
  103. Common things you will see during integument assessments with older patients:
    • Balding
    • Women with coarse facial hair
    • Thick yellow toenails
Author
KristaDavis
ID
168247
Card Set
Health Assessments
Description
Exam 1
Updated

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