2 Competencies for Ch 25, Health Assessment By the end of this unit, the student will:Demonstrate techniques to obtain patient informationDescribe the components of a health assessmentDescribe how to prepare the patient for the examList the equipment needed for an examinationDemonstrate a brief head to toe physical assessment
3 Health Assessment Health History Physical Assessment Two components of the health assessmentHealth HistoryPhysical AssessmentNurses use communication skills and interviewing techniques during the health history to gather data.Physical Assessment – may focus on one specific body system or health to toe or system by system assessment.In performing a health assessment the nurse uses cognitive skills (the nurse has basic knowledge to individualize the assessments (for example treatment a pregnant women, who be different than care for an Alzheimer's pt.)_Technical skills- ability to use the equipment to assess and document health status.Interpersonal skills strong people skills, ability to communicate and interact with peopleConfidence in your own abilities.Ethical and legal skills- commitment to safety and qualityAbility to document health findingsKnowledge of special regulations and legalization dealing with nursing responsibilities.
4 What happens during a health assessment between a patient and nurse? Establish the nurse-patient relationshipGather data-physiological, psychological,cognitive, sociocultural, developmental, spiritualIdentify patient strengthsIdentify actual and potential health problemsEstablish a base for the nursing process (Assessment)
5 General Guidelines for Physical Assessment InstrumentationPositioningDrapingPreparation of the environmentPatient preparationTechniques of physical assessment
6 Positioning Prone-Pt. Lies on abdomen Sitting –used in an upright chair or dangling off exam tableSupine-lie flat on your backDorsal recumbent-lie back with knees bentSims’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 bentProne-Pt. Lies on abdomenLithotomy- 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.StandingSitting-allows the visualization of the upper body and facilitates full lung expansion. Take VS and assess the head and neck, posterior and anterior thorax and lungs, breast, heart and upper extremities.Supine- This position allow relaxation of abd.muscles and can be used to assess the head and neck, anterior thorax and lungs breasts, heart, abdomen, extremities, and peripheral pulses.Dorsal recumbent- used to exam head and neck anterior thorax and lungs breast heart extremities and peripheral pulses.Sims Used to assess the rectum or vaginaLithotomy used to exam female rectum and genitalia.Knee – chest- rectal areaStanding- assess posture, gait, and balance.
7 Draping, preparing the environment Draping prevents unnecessary exposure, provides privacy, and keeps the patient warm during the physical exam (P.E.).Prepare examination tablePlace a gown and drape on the tableSet up any supplies that are needed.-Example: otoscope, tuning fork, ophthalmoscope.Pull curtain around or close door to exam room
8 Techniques for examination Inspection- observing, listening or smelling to gather dataPalpation-assessment that uses sense of touchPercussion-act of striking on e object against another to produce a soundAuscultation-act of listening with a stethoscope to sounds produced with in the body.
9 Inspection Deliberate, purposeful, observations in a systematic manner Nurse use the physical senses: visualizing, hearing, and smelling
10 Instrumentation or Equipment used for inspecting Ophalmoscope-Exam the eyesOtoscope- examine the ears, mouth and nostrilsTuning fork - hearingNasal speculum-visualized the turbinates of the noseStethoscope
11 Instrumentation or Equipment used for vision screening Snellen chart- used to check eye sightConsists of 11 lines of different sized letters. Scores range from 20/20 to 20/200.
12 Palpation technique using the sense of touch The hands and fingers are sensitive tools and assess:Temperature- use the dorsum of the handTurgorTextureMoistureVibrationsShapeUse the palmer (front side) of the hand
13 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 tissuePercussion TonesFlatDullResonanceHyper resonanceTympany
14 Auscultation-act of listening with a stethoscope to sounds produced with in the body Four characteristics assessed by auscultationPitch- ranging from high to lowLoudness- ranging from soft to loudQuality- gurgling or swishingDuration (short, medium, long)
15 General Survey Gather information regarding General appearance Hygiene, grooming (note body odor, cleanliness).Signs of illnessAffect, mood, attitude (speech and facial expressions)Cognitive process (speech content, patterns, orientation, appropriate verbal responses)Gather information regardingPatient's appearance, behaviorMeasuring vitals signsHeight, and weightGeneral appearanceGender and raceBody build, posture and gait
16 Vital Signs, Height and Weight Take Vital signs (VS) and determine normal or abnormal -documentHeight and weight- document(Check the height and weight table to determine if a patient is under, normal or over weight.)
17 Physical Assessment Head to Neck General surveyHeight and weightVital SignsNeckSkinLymph nodesMusclesThyroidTracheaCarotid arteriesNeck veinsHeadSkinFace, skull, scalp, hairEyesNose and sinusesMouth and or pharynxCranial nerves
18 Integument structures SkinNailsHairScalpObtain history of rashes, lesions, changes of color or itchingHistory of bruising or bleedingExposure to sunNote presence of wounds, abrasionsChanges in mole size, shape or color
19 SKIN Inspect for color, vascularity, lesions and body odors Color-pinkish white to various shades of brown.NAILS- NOTE COLOR, SHAPE OF NAILNORMAL 160 DEGREE, SPOON, CLUBBING 180 DEGREES OR GREATER
20 Redness (erythema, flushing Facial area Skin Color variationsAssessment areasPossible causesRedness (erythema, flushingFacial areaBlushing, ETOH intake, fever, injury or infectionBluish (cyanosis)Exposed areas, ears,lips, inside of mouth, hands feet, nail bedsCold environment, cardiac or respiratoryYellowish (jaundice)Overall skin areas, mucus membranes, scleraLiver disease (increased bilirubin)VitiligoWhitish patchy areasDe-pigmentation (autoimmune)Tanned or brownSun-exposedMelanin production Pregnancy brown spots?PediatricNewborns may be jaundiced and have milia (white heads)Newborns are covered with fine downy hair (lanugo for first 2 weeks of life)Geriatrics- wrinkles, dryness, scaling, decreased turgor. (know the geriatric skin assessment p 466, cherry angioma, senile lentigines, senile keratosis)Geriatrics – nails thick and yellow.
21 Head and Neck Assessment includes Skull Face Eyes Ears Nose Sinuses MouthPharynxTracheaThyroid glandsLymph nodes
22 Skull and face Inspect size and shape Symmetry Face- examine color Distribution of facial hairAssess facial nerve and facial muscles-Symmetry (abnormality may be from trauma or disease effecting bone growthTesting nerves and muscles of the face: raise eyebrows, tightly close eyes, puff out the cheeks and show their teeth,smile.Document: any tremors
24 Eye and Ears EYE Inspect external structures Pupils and Iris Internal structuresVisionExtra ocular movementPeripheral visionEARInspect external ear for shape, size, location bilaterally, ear should be smoothGently palpate ear for pain, edema, or presence of lesionsCheck hearingInspect internal ear
31 Nose and Sinuses Nose Inspect size, shape and location Check for patency (open air passageways.)Inspect using otoscope nares and turbinatesSinusesInspect the sinuses and gently palpate maxillary bone and frontal sinusNormally the sinuses are not painful.
34 MOUTH AND PHARYNX Composed of many structures Equipment needed: Lips, tongue, teeth, gums hard and soft palate,salivary gland, tonsillary pillars, and tonsilsEquipment needed:Penlight, tongue blade, 4X4 gauze sponge, and glovesLips should be pink, mosit and smoothTongue and mucous membranse are normally pink in color, moist, and free of swelling or lesionsIF the patient wears dentures, they are removecd for inspection of gums and roof of mouth.The orpharyx is examined when tongue is depressed. Uvula is normmally centered and freely movable. Tonsils are small pink and symmetric in size. Theeth should be regualr and freeof caviites and or dental restoration.Abnormal: pallor cyanosis nor redness and swelling of mucous membranesAbnormal findings: red tonsils (indication of infections, bleeding gums (may be nutrional deficits infammation or infection, poorly fit dentures, or poor oral hygiene.)Tongue: coated poor hygiene, irritaiton or smokingFissured tongue (from dehydration)Bright red tongue (iron deficineces, Vit B12, or naicin, hairy tongue (antibiotic use).
37 Neck Trachea- note location Lymph nodes Generally not palpable Midline at the suprasternal notchThyroid- thyroid is normally not palpable. Palpate for size shape, symmetry tenderness and presence of any nodulesLymph nodesGenerally not palpableIf palpated, should be small mobile, smooth non-tenderAbnormal- enlarged, indicate infection, autoimmune, or metastasis of cancer
39 COURSE OBJECTIVES Students will learn: Components of a health assessmentTo prepare the patient for the examWhat equipment is needed for the examA variety of techniques to obtain patient informationHow to examine the patient head to toe
40 HEALTH ASSESSMENT Two components of the health assessment Health HistoryPhysical Assessment
41 WHAT HAPPENS DURING THE ASSESSMENT Establish the nurse patient relationshipGather data in the following areasPhysiologicalPsychologicalCognitiveSocioculturalDevelopmentalSpiritualIdentify patient strengthsIdentify actual and potential health problemsEstablish base for nursing process
42 GENERAL GUIDELINES Instrumentation Positioning Draping Preparation of the environmentPatient preparationAssessment techniques
43 POSITIONING Sitting – use upright chairor dangle of exam table. Supine – flat on the backDorsal Recumbant – on back with knees bentSim’s – lie on side, lower arm behind back, upper arm bent at the shoulder and elbow, knees both bent
45 PULMONARY HISTORY INSPECTION PALPATION PERCUSSION AUSCULTATION BREATH SOUNDSHistory: trauma, use of pillows,cp w/breathing, cough w/wo production, allergies, freq. Resp infectionsEnvironmental exposure, beauty salons, black lung, smokingFamily hx of lung disease,Inspect for symmetry breathing patterns, color, barrel chest, resp even,Palp for vibrations, fremetis. Posterior, w/ fingers at t-10 or t9. Watch cest movePercussion, flat over bony areas or thick muscle, tympany hollow over the stomachAuscultation. Use to hear air flow in the lungs. patient sitting up. Best hear from back. Demonstrate. Assess lobes.Breath soundsBronchial, high pitched over tracheaBronchiovesicular, bronchus and are moderate blowing insp and exp. EqualVesicular soft low pitched best hear over the base of the lungs. Insp longer than exp..Adventitious stertorous noisiy snoringStridor harshs high pitchedCrackles air moving through fluidWheezes heard w/o stethescope narrowing of small passagesFriction rub like sandpaper
47 CARDIOVASCULAR History Inspection Palpation Auscultation Heart sounds Peripheral vascular systemChest pain , palpitations, dixxinessSwelling in lower extremetiesPillow for sleepMedicationsFamily history, defects,rheumatic fever, surgery,HTNMI, cholesterol, smoking alcohol, birth control pills, HRT,FoodsChanges in color or temp of extremitiesPain in legs when sleeping blood clots or non healing soresInspection: no signs of palpation except at PMI 4-5 intercostal space.Palpation systematic and covet the precordium area, aortc pulmonic tricuspid and apical areas. No pulsationAuscultation use diaphram,Lub-dub lub, s1 best heard at apex pulm aortic valve close squeezeS2 dub vent asystole closure of tricuspid mitralS3 lub dub de. Heard with bell at mitral area pt on left side. Abnormal in middle age to lder adultsS4, abnormal in children adultsMurmers. Valve abmormalityBruits swooshing, best heard over a shunt.Palpation, pulses scale of 1-4 phlebitis pain heat red, inflam of vein use cap refill don’t use allen or bruegerInspect color, temp, turger, lesions, edema
49 BREAST/AXILLA History Inspection Palpation Pain in on or both menstrual periodHx of lumps, swelling redness change insize or dimplingDischargeHx of caUse of hormones of contraceptives oralExposure to radiation or chemicalsBreast self exam, pregnancy, breast feedingInspect for size shape symmetryNipples for discharge or crusting, inversionsPalpate abnormal masses use 1st three fingers pads 4 quads upper outer inner and lower outer inner. Smooth, firm, granularPalpate axilarry area for nodes non papable or tender
50 ABDOMEN History Inspection Auscultation Percussion Palpation Pain, indigestion, n&v constipation, diarrheaAppetite food, fluid intakeHz of gi disorder such as ulcer gb disease, appendicitisUti disordersAbdominal surgeryMedication use including otcsTraumaInspect staie are fine white lines. See frequently in elderly symmetryAuscultate for sounds. Clicks and gurgles. Move clockwisePalpate for masses, and hardened areas . Should be soft and non tender
51 GENITALIA Female Male History Inspection Hx mentration onset last period, character of flow,Sexual hx, stdsContraception, pregnancy, pap smears, prior exams smoking, family hx of disease, discharge pain itchingHx of discharge, std, urinary difficulty, incontinence, erectile dysfunction, occupational exposure to chemicals, radiation, contraceptive use, testicular self exam, digital rectal examUsually role of nurse is to assist md w/exam
52 MUSCULOSKELETAL History Inspection Palpation Testing Bones and Joints ToneStrengthBones and JointsTrauma, arthritis neuro disorderPain or swelling in the jointsPain in bones or musclesExercise historyCalcium in dietSmokingAlcoholHormone replacement therapyPalpate for tone (condition at rest) and strength (assess by asking to move against resistance. Squeeze hand push with hand or feet should be bilat equalAtrophy, wasting, flaccid, no tone assess romBones, abnormal palpation, crepitation, grinding of bone on bone at joint.Changes with age, loss of tone, strength, arthritic changes
53 NEUROLOGICAL History Mental Status Orientation Level of Consciousness MemoryAbstract ReasoningLanguageHistory, numbness tingling seizures, h/a dizziness trauma infections stroke,Changes in senses, loss of eimination controlSmokingHtn, cvd, med hx exposure to environmental hazards
55 SENSORY MOTOR FUNCTION Balance and gaitCoordinationSensoryAbn. Shufling , wide based loss of balanceHolly, speech impact on coordinationSensory distal to proximal.. Eval response to pain, touch, vibration, use of needle or pin.
56 REFLEXES Abdominal Babinskis Bicepts Triceps Patellar Achilles Tendon Abd, light stroke from above to below umbilicus. Muscles contractBabinskis stroke later aspect from heel to soleBiceps see book
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