STEPS of HEALTH ASSESSMENT Flashcards by Athea Ordis

Q

What are the 3 Special Considerations During Interview?

A

Gerontologic Variations in Communication
Cultural Variations in Communication
Emotional Variations

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Q

The ff shows ____________

Speak clearly
Use straightforward language
Ask questions in simple terms
Avoid medical jargon and modern slang
Show respect
Have significant other present during the interview to provide or clarify the data

A

Gerontologic Variations

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Q

The ff shows ___________

Be sensitive
Seek help from expert “culture broker”
Seek an interpreter if difficulty in communicating or if there is misunderstanding

A

Cultural Variations

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Q

The ff shows _________

WHEN INTERACTING WITH:

An anxious client
Angry client
Depressed client
Manipulative client
Seductive client
Discussing sensitive issues

A

Emotional Variations

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Q

One of the ways in collecting objective data is to do ___________.

A

Physical Examination

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Q

Under Objective Data: The Physical Examination

What are the Basic Knowledge in 3 Areas?

A

Types and operations of equipment needed
Preparation of the setting, oneself, and the client
Performance of the four assessment techniques

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Q

IN PREPARING THE PHYSICAL SETTING

The room should be comfortable, ______ room temperature.

A

warm

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Q

IN PREPARING THE PHYSICAL SETTING

Provide area free of ________ from others.

A

interruptions

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Q

IN PREPARING THE PHYSICAL SETTING

Adequate _________.

A

lighting

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Q

IN PREPARING THE PHYSICAL SETTING

Firm examination table or bed at a heights that prevents __________.

A

stooping

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Q

IN PREPARING THE PHYSICAL SETTING

A bedside ___________ that hold the equipment needed.

A

tray or table

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Q

UNDER THE GENERAL PRINCIPLES

Wash ________.

A

hands

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Q

UNDER THE GENERAL PRINCIPLES

Always wear gloves if there is a chance to encounter ___________.

A

blood and fluids

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Q

UNDER THE GENERAL PRINCIPLES

If a pin or other sharp object is used, ________ it immediately.

A

discard

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Q

UNDER THE GENERAL PRINCIPLES

Wear a mask and protective goggle in cases which __________ can occur.

A

splashing

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Q

IN APPROACHING THE CLIENT

Establish __________ (Interview)

A

Nurse-Patient Interaction (NPI)

Note:

Build rapport and trust with the patient before starting the examination.
Gather health history and assess any concerns.
Use active listening and therapeutic communication.

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Q

IN APPROACHING THE CLIENT

Inform the client that ________ is needed based on the information gathered.

A

further assessment

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Q

IN APPROACHING THE CLIENT

Remove clothing and put on a gown. Leave the _________ until such time for vaginal examination.

A

underwear

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Q

IN APPROACHING THE CLIENT

Leave the room and let the patient change, _____ before re-entering again.

A

knock

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Q

IN APPROACHING THE CLIENT

Respect the client’s _______.

A

request

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Q

IN APPROACHING THE CLIENT

Sign ______ before the Physical Examination (PE) if necessary.

A

consent

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Q

IN APPROACHING THE CLIENT

Give a specimen cup for UA (Urinalysis), or if not tell the patient to ________ first before Physical Examination (PE).

A

void

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Q

FAMILIARIZE ONLY!

What are the Steps in Conducting a Physical Examination?

A

Begin with Less Intrusive Procedures

Start with non-invasive assessments (e.g., general inspection, vital signs, auscultation).
Helps the patient feel more comfortable before moving to more sensitive examinations.

Explain Each Procedure and Teach Health Promotion

Describe what you are doing and why to reduce anxiety.
Use this opportunity to educate the patient on health maintenance and disease prevention.

Approach the Client from the Right Side of the Examination Table

Most physical assessments are performed using the right hand for convenience and accuracy.
This is a standard practice in clinical settings to ensure consistency.

Ask the Client to Change Position When Necessary

Some examinations require different positions (e.g., sitting, supine, lateral, or lithotomy position).
Always inform and assist the patient when changing positions to maintain safety and comfort.

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Q

What are the 4 Assessment Technique in performing Physical Examination or Getting the Objective Data?

Study These Flashcards

A

Inspection
Palpation
Percussion
Auscultation

REMEMBER THE ACRONYM “IPPA”

What **Assessment Technique is this**? * Vision, smell, hearing * Close and careful **visualization** of the person as a whole and of each body system. * Ensure good lighting * Perform at every encounter with your client.

INSPECTION

What is the **good source of light**?

SUN

FAMILIARIZE ONLY! **What are the Guidelines in doing Inspection**?

* Comfortable room and temperature * Use good lighting * Look and observe before touching * Completely expose the body parts you are inspecting, while draping the rest. * Color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sounds. * Compare the appearance of symmetric body parts (like eyes, ears, arms, hands) of both sides of any individual body part.

What Assessment Technique is this? * Examination of the body using the **sense of touch**.

Palpation

The **pads of the fingers are used in Palpation** because the concentration of __________ makes them highly sensitive to tactile discrimination.

**nerve endings** Note: * Finger pads, ulnar/palmar surface & dorsal surface

FAMILIARIZE ONLY! Palpation is used to determine the ff

* **Texture** – Determines whether a surface is **smooth, rough, thin, or thick** (e.g., hair texture or skin roughness). * **Temperature** – Uses the dorsal side of the hand to check for warmth (fever/inflammation) or coolness (poor circulation, shock). * **Moisture** – Assesses if the skin is **dry, moist, or excessively sweaty** (could indicate dehydration, fever, or hormonal imbalances). * **Mobility** – Checks if a structure is **fixed, movable, still, or vibrating** (e.g., tumors or nodules). * **Consistency** – Determines if a mass is **soft, firm, hard, or fluid-filled**, which helps in identifying cysts, tumors, or swelling. * **Strength of Pulses** – Assesses blood circulation by checking if pulses are **strong, weak, thready** (barely palpable), or **bounding** (very strong pulse due to high blood flow). * **Size** – Determines if an organ, mass, or lump is **small, medium, or large** compared to expected normal size. * **Shape** – Identifies whether a structure is **regular, well-defined, or irregular** (useful in detecting abnormal growths or lumps). * **Degree of Tenderness** – Evaluates pain response when pressure is applied (e.g., abdominal tenderness may indicate infection or inflammation).

What are the **4 Types of Palpation**?

* Light palpation * Moderate palpation * Deep Palpation * Bimanual palpation

What type of Palpation is **less than 1 cm** deep?

Light palpation

What type of Palpation is 1-2 cm deep?

Moderate palpation

What type of Palpation is 2.5 - 5 cm deep?

Deep palpation

What type of Palpation uses **2 hands**?

Bimanual palpation

What Assessment Technique is this? * Is the **act of striking the body surface to elicit sounds** that can be heard or vibrations that can be felt.

Percussion

What are the **3 Types of Percussion**?

* Direct Percussion * Indirect Percussion * Blunt Percussion

What type of Percussion is this? * Tapping directly on the body surface using **1 or 2 fingers**.

**Direct Percussion** Note: * Used to identify pain and in checking the sinuses.

What type of Percussion is this? * One hand flat on the body. Use the fingers on the dominant hand. Tap the middle finger.

**Indirect Percussion** Note: * Used in lungs and abdomen to check high-pitched (air filled) and liquid.

What type of Percussion is this? * Use the first of ulnar side of the hand to apply force over an area. Use to assess the kidney.

**Blunt Percussion**

Different Uses of Assessment Techniques in Physical Examination

* Eliciting Pain * Determining location, size, and shape * Detecting abnormal masses * Eliciting reflexes

**Identify the inflamed underlying structure.** A. Eliciting Pain B. Determining location, size, and shape C. Detecting abnormal masses D. Eliciting reflexes

A. Eliciting Pain

**Percussion note changes between the borders of an organ and its neighboring organ.** A. Eliciting Pain B. Determining location, size, and shape C. Detecting abnormal masses D. Eliciting reflexes

B. Determining location, size, and shape

**Superficial abnormal structures or masses.** A. Eliciting Pain B. Determining location, size, and shape C. Detecting abnormal masses D. Eliciting reflexes

C. Detecting abnormal masses

**Deep tendon reflex** A. Eliciting Pain B. Determining location, size, and shape C. Detecting abnormal masses D. Eliciting reflexes

D. Eliciting reflexes

This is the process of **listening** to sounds produced within the body.

Auscultation

Auscultation may be ________ or _______.

Direct or indirect

A ___________ is used primarily to listen to sounds from within the body, such as bowel sounds, or valve sounds of the heart and blood pressure.

Stethoscope

What are the **4 Characteristics of Sound** mentioned on the part of Auscultation?

* Intensity * Pitch * Duration * Quality

**Loud and soft** A. Intensity B. Pitch C. Duration D. Quality

A. Intensity

**High or low** A. Intensity B. Pitch C. Duration D. Quality

B. Pitch

**Length** A. Intensity B. Pitch C. Duration D. Quality

C. Duration

**Musical, crackling, raspy.** A. Intensity B. Pitch C. Duration D. Quality

D. Quality

BOWEL SOUNDS

* Normal: **Normoactive** (5-30/minute) * Too Fast: **Hyperactive** (diarrhea, early obstruction) * Too Slow: **Hypoactive** (constipation, ileus) * Very Loud and Prolonged: **Borborygmi** (hunger, gas)

FAMILIARIZE ONLY! Do's and Don'ts

* Warm the diaphragm or the bell before placing it on the client's skin. * Explain what you are listening for. * Do not apply too much pressure. * Avoid listening through clothing, may obscure or alter the sound.

FAMILIARIZE ONLY! GUIDELINES

* Eliminate distracting sound from the environment * Expose the body part your are going to auscultate * Use the **diaphragm** of the stethoscope to listen for high sounds, breath sounds, and bowel sounds. * Use the **bell** for low-pitched sounds (heart sound and bruits)

What are the parts of Stethoscope? FAMILIARIZE ONLY! Practice on your stethoscope by pointing at the parts and determining what it is called.

* Earpieces * Ear tube * Headset * Tubing * Chest-piece * Stem * Bell * Diaphragm

POSITIONING FAMILIARIZE only!

* Supine * Prone * Right Lateral Recumbent * Left Lateral Recumbent * Fowler's * Trendelenburg * Lithotomy Position * Sims' (posterior view) * Dorsal recumbent * Standing * Knee-chest * Sitting * Squatting

For **Checking the Abdominal Area**, what is the right sequence to follow?

* **I**nspection * **A**uscultation * **P**ercussion * **P**alpation