Presentation on theme: "Health Assessment Chapter 25. Competencies for Ch 25, Health Assessment By the end of this unit, the student will: Demonstrate techniques to obtain."— Presentation transcript:
Competencies for Ch 25, Health Assessment By the end of this unit, the student will: Demonstrate techniques to obtain patient information Describe the components of a health assessment Describe how to prepare the patient for the exam List the equipment needed for an examination Demonstrate a brief head to toe physical assessment
Health Assessment Two components of the health assessment Health History Physical Assessment
What happens during a health assessment between a patient and nurse? Establish the nurse- patient relationship Gather data- physiological, psychological,cognitive, sociocultural, developmental, spiritual Identify patient strengths Identify actual and potential health problems Establish a base for the nursing process (Assessment)
General Guidelines for Physical Assessment Instrumentation Positioning Draping Preparation of the environment Patient preparation Techniques of physical assessment
Positioning Sitting –used in an upright chair or dangling off exam table Supine-lie flat on your back Dorsal recumbent-lie back with knees bent Sims’s-lies on either right or left side lower arm behind the body and the upper arm is bent at the shoulder and elbow and knees are both bent Prone-Pt. Lies on abdomen Lithotomy- patient is in a dorsal recumbent position with buttock at the edge of the examining table and feet support in stirrups. Knee to Chest-using the knees and chest to bear the weight of body. Standing
Draping, preparing the environment Draping prevents unnecessary exposure, provides privacy, and keeps the patient warm during the physical exam (P.E.). Prepare examination table Place a gown and drape on the table Set up any supplies that are needed. -Example: otoscope, tuning fork, ophthalmoscope. Pull curtain around or close door to exam room
Techniques for examination Inspection- observing, listening or smelling to gather data Palpation-assessment that uses sense of touch Percussion-act of striking on e object against another to produce a sound Auscultation-act of listening with a stethoscope to sounds produced with in the body.
Inspection Deliberate, purposeful, observations in a systematic manner Nurse use the physical senses: visualizing, hearing, and smelling
Instrumentation or Equipment used for inspecting Ophalmoscope- Exam the eyes Otoscope- examine the ears, mouth and nostrils Tuning fork - hearing Nasal speculum-visualized the turbinates of the nose Stethoscope
Instrumentation or Equipment used for vision screening Snellen chart- used to check eye sight
Palpation technique using the sense of touch The hands and fingers are sensitive tools and assess: Temperature- use the dorsum of the hand Turgor Texture Moisture Vibrations Shape Use the palmer (front side) of the hand
Percussion- the act of striking one object against another to produce a sound Percussion tones are used to assess location, shape, size and density of tissue Percussion Tones Flat Dull Resonance Hyper resonance Tympany
Auscultation - act of listening with a stethoscope to sounds produced with in the body Four characteristics assessed by auscultation Pitch- ranging from high to low Loudness- ranging from soft to loud Quality- gurgling or swishing Duration (short, medium, long)
General Survey Gather information regarding Patient's appearance, behavior Measuring vitals signs Height, and weight General appearance Gender and race Body build, posture and gait General appearance Hygiene, grooming (note body odor, cleanliness). Signs of illness Affect, mood, attitude (speech and facial expressions) Cognitive process (speech content, patterns, orientation, appropriate verbal responses)
Vital Signs, Height and Weight Take Vital signs (VS) and determine normal or abnormal -document Height and weight- document (Check the height and weight table to determine if a patient is under, normal or over weight.)
Physical Assessment Head to Neck General survey Height and weight Vital Signs Neck Skin Lymph nodes Muscles Thyroid Trachea Carotid arteries Neck veins Head –Skin –Face, skull, scalp, hair –Eyes –Nose and sinuses –Mouth and or pharynx –Cranial nerves
Integument structures Skin Nails Hair Scalp Obtain history of rashes, lesions, changes of color or itching History of bruising or bleeding Exposure to sun Note presence of wounds, abrasions Changes in mole size, shape or color
SKIN Inspect for color, vascularity, lesions and body odors Color-pinkish white to various shades of brown.
Skin Color variations Assessment areasPossible causes Redness (erythema, flushing Facial areaBlushing, ETOH intake, fever, injury or infection Bluish (cyanosis) Exposed areas, ears,lips, inside of mouth, hands feet, nail beds Cold environment, cardiac or respiratory Yellowish (jaundice)Overall skin areas, mucus membranes, sclera Liver disease (increased bilirubin) VitiligoWhitish patchy areasDe-pigmentation (autoimmune) Tanned or brownSun-exposedMelanin production Pregnancy brown spots?
Head and Neck Assessment includes Skull Face Eyes Ears Nose Sinuses Mouth Pharynx Trachea Thyroid glands Lymph nodes
Skull and face Inspect size and shape Symmetry Face- examine color Symmetry Distribution of facial hair Assess facial nerve and facial muscles-
Eye and Ears EYE Inspect external structures Pupils and Iris Internal structures Vision Extra ocular movement Peripheral vision EAR Inspect external ear for shape, size, location bilaterally, ear should be smooth Gently palpate ear for pain, edema, or presence of lesions Check hearing Inspect internal ear
Nose and Sinuses Nose Inspect size, shape and location Check for patency (open air passageways.) Inspect using otoscope nares and turbinates Sinuses Inspect the sinuses and gently palpate maxillary bone and frontal sinus Normally the sinuses are not painful.
MOUTH AND PHARYNX Composed of many structures Lips, tongue, teeth, gums hard and soft palate,salivary gland, tonsillary pillars, and tonsils Equipment needed: Penlight, tongue blade, 4X4 gauze sponge, and gloves
Neck Trachea- note location Midline at the suprasternal notch Thyroid- thyroid is normally not palpable. Palpate for size shape, symmetry tenderness and presence of any nodules Lymph nodes Generally not palpable If palpated, should be small mobile, smooth non-tender Abnormal- enlarged, indicate infection, autoimmune, or metastasis of cancer
COURSE OBJECTIVES Students will learn: Components of a health assessment To prepare the patient for the exam What equipment is needed for the exam A variety of techniques to obtain patient information How to examine the patient head to toe
HEALTH ASSESSMENT Two components of the health assessment Health History Physical Assessment
WHAT HAPPENS DURING THE ASSESSMENT Establish the nurse patient relationship Gather data in the following areas Physiological Psychological Cognitive Sociocultural Developmental Spiritual Identify patient strengths Identify actual and potential health problems Establish base for nursing process
GENERAL GUIDELINES Instrumentation Positioning Draping Preparation of the environment Patient preparation Assessment techniques
POSITIONING Sitting – use upright chairor dangle of exam table. Supine – flat on the back Dorsal Recumbant – on back with knees bent Sim’s – lie on side, lower arm behind back, upper arm bent at the shoulder and elbow, knees both bent