Chapter 25 Flashcards
(43 cards)
1
Q
Purposes of the Health Assessment
A
- Establish the nurse–patient relationship.
- Gather data about the patient’s general health status.
- Identify patient strengths.
- Identify actual and potential health problems.
- Establish a base for the nursing process.
2
Q
Types of Health Assessments
A
Comprehensive
Ongoing partial
Focused
Emergency
3
Q
Comprehensive Health Assessment
A
conducted upon admission to health care facility
4
Q
Ongoing partial Health Assessment
A
conducted at regular intervals
5
Q
Focused Health Assessment
A
conducted to assess a specific problem
6
Q
Emergency Health Assessment
A
conducted to determine life-threatening or unstable conditions
7
Q
Components of a Preventive Health Assessment
A
- Health history
- Risk for depression
- Functional ability
- Level of safety
- Physical examination
- Patient education and counseling
8
Q
Considerations When Performing Health Assessment
A
- Lifespan considerations
- Cultural considerations and sensitivity
- Patient preparation
- Environmental preparations
9
Q
Factors to Assess During a Health History
A
- Biographical data
- Reason for seeking health care
- History of present illness
- Past health history
- Family history
- Functional health
- Psychosocial and lifestyle factors
- Review of systems
10
Q
Preparing the Patient for Physical Assessment
A
- Consider the physiologic and psychological needs of the patient.
- Explain the process to the patient.
- Explain that physical assessments will not be painful
- Explain each procedure in detail as it is conducted.
- Ask the patient to change into a gown and empty bladder.
- Answer patient questions directly and honestly.
11
Q
Preparing the Environment for Physical Assessment
A
-Agree on a time for the assessment.
The time should not interfere with meals, daily routines, or visiting hours.
-Make sure patient is as free of pain as possible.
-Prepare the examination table.
-Provide a gown and drape for the patient.
-Gather the supplies and instruments needed.
-Provide a curtain or screen if the area is open to others
12
Q
Equipment Used During a Physical Examination
A
- Thermometer and sphygmomanometer
- Scale
- Flashlight or penlight
- Stethoscope
- Metric tape measure and ruler
- Eye chart
- Tuning fork
13
Q
Supine position
A
- lying flat on back
- used to assess head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
- allows relaxation of abdominal muscles
14
Q
Sims Position
A
- lying on side with lower arm below the body and upper arm flexed at shoulder and elbow
- used to assess the rectum and vagina
15
Q
dorsal recumbent position
A
- lying on back with legs separated and knees flexed
- used for patients having difficulty maintaining supine position
- used to assess head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
16
Q
Prone position
A
- lying on stomach with head turned to the side
- assessment of hip joint and posterior thorax
17
Q
Standing position
A
assessment of posture, balance, and gait
18
Q
Sitting position
A
allows visualization of upper body
19
Q
Lithotomy position
A
- assessment of female genitalia and rectum
- giving birth position
20
Q
Knee–chest position
A
assessment of anus and rectum
21
Q
Inspection
A
- the process of performing deliberate, purposeful observation in a systematic manner
- assessing size, color, shape, position, and symmetry
22
Q
Palpation
A
- touch
- assessing temperature, turgor, texture, moisture, vibrations, and shape
23
Q
Percussion
A
- is the act of striking one object against another to produce sound
- assessing location, shape, size, and density of tissues
24
Q
Auscultation
A
- the act of listening with a stethoscope to sounds produced in the body
- assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration
25
Characteristics of Masses Determined by Palpation
- Shape
- Size
- Consistency
- Surface
- Mobility
- Tenderness
- Pulsatile
26
Right Upper Quadrant
- Pylorous
- Duodenum
- Liver
- Right kidney and adrenal gland
- Hepatic flexure of colon
- Head of pancreas
27
Left Upper Quadrant
- Stomach
- Spleen
- Left kidney and adrenal gland
- Splenic flexure of colon
- Body of pancreas
28
Right Lower Quadrant
- Cecum
- Appendix
- Right ovary and fallopian tube(female)
- Right ureter and lower kidney pole
- Right spermatic cord(male)
29
Left Lower Quadrant
- Sigmoid colon
- Left ovary and fallopian tube(female)
- Left ureter and lower kidney pole
- left spermatic cord(male)
30
Midline
- urinary bladder
| - urethra(female)
31
Characteristics of Sound Heard When Using Auscultation
- Pitch: ranging from high to low
- Loudness: ranging from soft to loud
- Quality: for example, gurgling or swishing
- Duration: short, medium, or long
32
General Survey
- General appearance
- Vital signs
- Height, weight, waist circumference
- Calculating BMI
33
Common Thorax and Lung Variations in Older Adults
- Increased anteroposterior chest diameter
- Increase in the dorsal spinal curve (kyphosis)
- Decreased thoracic expansion
- Use of accessory muscles to exhale
34
Cardiovascular and Peripheral Vascular Variations in Newborns and Children
- Visible cardiac pulsation if the chest wall is thin
- Sinus dysrhythmia (the rate increases with inspiration and decreases with expiration)
- Presence of S3 (in about one-third of all children)
- More rapid heart rate (until about 8 years of age)
35
Common Cardiovascular and Peripheral Vascular Variations in Older Adults
- Difficult-to-palpate apical pulse
- Difficult-to-palpate distal arteries
- Dilated proximal arteries
- More prominent and tortuous blood vessels; varicosities common
- Increased systolic and diastolic blood pressure
- Widening pulse pressure
36
Common Abdominal Variations in Newborns
umbilical cord in newborns; dries and falls off within the first few weeks of life
37
Common Abdominal Variations in Children
a “pot-belly” (under 5 years of age), visible peristaltic waves
38
Common Abdominal Variations in Older Adults
- Decreased bowel sounds
- Decreased abdominal tone
- Fat accumulation on the abdomen and hips
39
Common Genitalia Variations in Newborns and Children
- Enlarged labia and clitoris
- Breast enlargement in both boys and girls
- Vaginal discharge in girls, called pseudomenstruation
- Pubic hair and breast development occur at puberty and follow a regular sequence of development.
- Menstruation begins about 2.5 years after puberty begins.
- Irregular menstrual cycle for first 2 years
40
Risk Factors for Altered Health Assessed in Health History
- History of trauma, arthritis, or neurologic disorder
- History of pain or swelling in the muscles and/or joints
- Frequency and type of usual exercise
- Dietary intake of calcium
- History of any surgery on muscles or joints
- History of smoking (how long, how many packs/day)
- History of alcohol intake
41
Assessing Level of Awareness
- Time: What is today’s date? What day of the week is it? What season of the year is this? What was the last holiday?
- Place: Where are you now? What is the name of this city? What state are we in?
- Person: What is your name? How old are you? Who came to visit you this morning?
42
Purposes of Documentation
- Identify actual and potential health problems
- Make nursing diagnoses
- Plan appropriate care
- Evaluate patient’s responses to treatment
43
Nurse’s Role in Diagnostic Procedures
-Assist before, during, and after diagnostic tests.
-Be responsible for other activities associated with diagnostic tests.
-Witness the patient’s consent.
-Schedule the test.
-Prepare the patient physically and emotionally for the test.
-Provide care and teaching after the test.
-Dispose of used equipment.
Transport specimens.
