Chapter 19 Health Assessment Flashcards
(39 cards)
What are the purposes of a physical examination? (6)
1.Obtain baseline data
2. Identify nursing diagnoses, collaborative problems, and wellness diagnoses
3. Further investigate a previously identified health problem
4. Monitor the status of a previously identified problem
5. Screen for health problems
7. To assess for access to health care resourses
Describe how you would prepare for a physical exam (3)
You must prepare the environment, yourself and the patient
1. Environment- selecting a quite private location with good lighting, gathering the equipment needed, and providing drapes for the pt
2. Prepare yourself by reviewing any knowledge or technical skills you feel unsure of, securing help (if needed), and reviewing the pt record and care plan
3. Patient: selecting an appropriate time, establishing rapport, explaining all steps of the exam, and properly positioning the pt
Identify the best position for examining the client’s lungs, heart, pulses, and abdomen?
Lungs and Heart: upright position- Fowler’s (60 degrees) or semi-Fowler’s (30-45 degrees)
Lateral recumbent- assessing heart murmurs
PULSES: Supine
ABDOMEN: Supine, or dorsal recumbent if the client has abdominal pain (relaxes abdominal muscles
Identify five physical assessment skills
- Inspection
- Palpating
- Percussion
- Auscultation
- Sometimes olfaction
In what order are the 5 physical assessment skills performed?
- Inspection
- Palpating
- Percussion
- Auscultate
5.Olfaction (if done)
If performing an abdominal exam:
1. Inspect
2. Auscultate
3. Percussion
4. Palpate
5. Olfaction (if done)
What exam modifications should you use for a toddler?
- Include parents
- Perform invasive procedures last
3.Give the child choices - Allow the child to show you his developmental skills
- Use praise freely
What exam modifications should you provide a preschooler?
- Combat fears by demonstrating the procedure on a doll or parent
- Allow the preschool child to sit in a parent’s lap if they wish
- Let the child help with the exam (eg have child hold equipment or remember their height and weight
- give reassurance (eg. your lungs sound healthy)
- Always compliment the child for cooperating
What exam modifications should you provide a school age child?
- Develop rapport by asking the child about their favorite school or play activities
- Support independence (allow child to undress themselves and get on table indecendently
- Demonstrate your equipment
- Allow time for teaching
What exam modifications do you provide an adolescent?
- Provide privacy
- bee certain to discuss the normal physiological changes that accompany puberty
- Be aware that adolescent behavior may be strongly influenced by peer values
- Emphasize lifestyle habits that promote wellness
- Discuss STIs and cancer, particularly testicular cancer and HPV
- Prepare adolescent, if necessary, for a pelvic exam and breast exam
- Screen for depression and suicide risk
What exam modifications should be provided for a young and middle adult?
May require modifications based on physical condition (i.e. If pt has knee pain, he may have difficulty getting up and down from the exam table and may not be able to assume a knee chest position
What exam modifications should be provided for the older adult?
- Assess the client’s support system and ability to perform ADLs
- Limit position change3es
- Be aware of difficulty assuming positions
- Adapt techniques and ensure pt is hearing and seeing you
- Asses energy and provide rest periods as needed
What aspects of the skin should you assess?(7)
- Color
- Odor
- temperature
- Turgor
- Edema
- Texture
- Visible lesions
What assessments should you perform if you find a lesion? (8)
- Size
- Shape
- Color
- Distribution
- texture
- Surface relationship
- Exudate
- Pain or tenderness
What warning signs lead you to suspect a malignant lesion? (5)
A- asymmetry
B- border irregularity
C- color variation
D- diameter greater than 0.5 cm
E-elevation above skin surface
What are the major components of an eye assessment? (6)
- Inspection of the external eye and lids
- S Ellen exam for distance vision
- Near vision assessment with newsprint
- Color vision check
- Visual field examination(related to peripheral vision and extraocular muscle function)
- Internal eye exam with an ophthalmoscope
Identify cranial nerves involved with eye movement and function (4)
- CN II (optic) worlds together with CN III (oculomotor) to control the pupillary reaction to light
- CN III (oculomotor)
- CN IV (trochlear)
- CN VI (abducen. s)
What does hearing involve?
Transmission of sound vibrations and generation of nerve impulses along CN VIII (acoustic)
What does the Weber test assess? How is it performed? How are results interpreted?
Tests both transmission of sound vibrations and generation of nerve impulses along CN VIII. When you place a vibrating tuning fork on the center of the client’s head, they should be able to sense the vibration equally in both ears. Record a positive Weber test if the vibration is louder in one ear. If the Weber test is positive, you will need to perform the Rivne test to assess thee type of hearing problem
What is the Rivne test?
Uses a tuning fork to compare air conduction (AC) and bone conduction (BC). Normally the ACis twice as long as the BC. Strike a tuning fork on the table. While it is still vibrating, place it on the client’s mastoid process (tests bone conduction of sound). Measure the elapsed time in seconds that the client hears the vibration. Move the tuning fork 1 inch in front of the ear and measure the elapsed time until the client can no longer hear the vibration (tests air conduction of sound
Results:
CONDUCTIVE LOSS: AC is less than 2x BC.
SENSORINEURAL LOSS: AC is greater than BC but not 2x longer; or the client is unable to hear the tuning for, through BC
What is the Romberg test? What does it test?
have pt stand with feet together, hands at side, with eyes opened and then with eyes closed. Note pt’s ability to maintain balance.
-POSITIVE ROMBERG: swaying is seen with vestibular and cerebellar disorders
What types of symptoms would you expect a client to be experiencing if they had a positive Romberg test?
Dizziness, recent falls, altered gait, and nausea
A client complains of sore throat, fever, chills, and a runny nose. What assessments should you perform?
Vital signs, assessment of the nose, mouth, and cervical lymph nodes. general survey and assessment of breath sounds
List and describe the location of the horizontal and vertical landmarks of the anterior chest`
-To locate sounds vertically, use the intercostal spaces (ICS). The 1st rib is tucked up next to the clavicle. The 1st ICS is betweeen the 1st and 2nd ribs. The space between the 2nd and 3rd ribs is 2nd ICS, and so forth
-The left midclavicular line begins at the midpoint of the pt’s left clavicle and extends vertically down the length of the chest. (SAME FOR RIGHT). The midsternal line is a vertical line running through the center of the sternum.
-The anterior auxiliary lines begin (on the right and on the left) at the anterior auxiliary folds. They are used to locate sounds both on the anterior and lateral chest
List and describe the location of the horizontal and vertical landmarks of the posterior chest
To locate sounds vertically, use the vertebrae. The prominent vertebra at the base of the neck is the 7th cervical vertebra (C7). The next one down is T1 (first thoracic). Counting down to about T9 should be adequate.
-The vertebral line extends vertically down the spine. The right and left scapular lines are vertical lines through the inferior angle of the scapula
