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43 Cards in this Set
- Front
- Back
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objective data |
directly observed or elicited to physical assessment techniques |
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subjective data |
are experienced or known only to the patient (pain or nausea) |
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health assessment involves what actions? |
collecting, validating, and analyzing subjective and objective data to determine the overall level of physical, psychological, sociocultural, developmental, and spiritual health of a patient |
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4 different types of health assessment |
comprehensive assessment, ongoing partial assessment, focused assessment, and emergency assessment |
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comprehensive assessment |
an physical assessment along with health history that is usually conducted when a patient first enters a healthcare setting, with info providing a baseline for comparing later assessments |
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ongoing partial assessent |
an assessment that is conducted at regular intervals ex: (at the beginning of each home health visit or each hospital shift) concentrates on identified health problems to monitor pos. or neg. changes and evaluate effectiveness of interventions |
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focused assessment |
this assessment is conducted to assess a specific problem ex:(a woman coming in with abdominal pain, the nurse ask questions about urinary problems, bowel problems, allergies, menstrual history etc. |
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emergency physical assessment |
a tyro of rapid focused assessment conducted to determine potential fatal situations ex:( assessing the airway, breathing, and circulation before beginning CPR) |
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list techniques used to promote comfort during exam |
-consider and remain sensitive to patients physiologic needs ex:(pain, or decreased stamina b/c of age or illness) and psychological needs like (anxiety about having examination) -explain the procedure and that the first part will involve questions about health concerns, habits, and lifestyle that will only be shared with healthcare providers -explain that drapes will be used for privacy -prepare warm environment with adequate light -maintain cultural sensitivity |
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components of a health history |
-biographical data -reasons for seeking healthcare -history of present health concern -medical history -family history -lifestyle |
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positions for exam include |
-supine -sims position -lithotomy -sitting -dorsal recumbent -prone -knee-chest -standing |
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standing positions |
-patient stands erect -should not be used for patients who are dizzy, weak, or prone to fall -used to asses posture, balance, a gait |
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sitting |
-sitting with head elevated -facilitates lung expansion -used to assess vital signs, head, neck, thorax, lungs, heart, breasts, and upper extremities |
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supine |
-patient lies flat on back -used to asses vital signs, abdomen, head and neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses |
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dorsal recumbent |
-lies on back with legs separated, knees flexed, and soles of feet on bed -used to assess head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses -should not be used for abdominal assess bc it causes abdominal muscle contraction |
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sims postion |
-patient lies on either side with lower arm below body and upper arm flexed at shoulder and elbow. both knees flexed, with upper leg more acutely flexed -used to asses rectum and vagina |
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prone |
-patient lies flat on stomach -used to assess hip joint and posterior thorax |
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lithotomy position |
patient lies in dorsal recumbent position with buttocks at edge of examining table and heels in stirrups -used to assess female genitalia and rectum |
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knee-chest position |
patient kneels with body at 90 degree angle to hips, back straight, arms above head -used to asses anus and rectum |
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general survey includes |
-observing patients overall appearance and behavior -taking vital signs -measuring height and weight |
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different skin color include |
-erythema -cyanosis -jaundice -pailor |
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erythema |
redness of the skin, more seen on face and neck -associated with sunburn, inflammation, fever, trauma, and allergic reaction
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cyanosis |
bluish or grayish discoloration in response to inadequate oxygenation _blue tinge with white patients -dullness in dark patients |
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jaundice |
skin yellowing resulting from liver or gallbladder disease, some types of anemia, and excessive hemolysis (breakdown of blood cells) -easily seem in eyes, oral mucosa and palms
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pailor |
paleness of the skin often results in decrease of amount of circulating blood -easily seen on lips, nail beds, mucous membrane, and eyes for darker people skin seen as ashen gray or yellow tinge |
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ecchymosis |
a collection of blood in the subcutaneous tissues, causing purplish discoloration |
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petechiae |
small hemorrhagic spots caused by capillary bleeding -if present assess location, color, and size |
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primary and secondary lesions |
primary- lesions that may arise from previously normal skin secondary-results from changes in primary lesions ex:(scars) |
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tugor |
the fullness or elasticity of skin
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edema |
excess fluid in tissues, caused by over hydration, heart failure, kidney failure, trauma,or vascular disease -0 (none) +1 (trace 2 mm) +2 (moderate 4 mm) +3 (deep 6 mm) +4 (very deep, 8 mm)
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snellen chart |
visual chart to test eye sight patient stands 20 ft away - numerating is the distance the patient stands from chart -the denominator represents the smallest line read accurately (20/30)
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tuning fork tests |
Weber and Rinne |
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weber test |
-test used to to assess for bone conduction of sound -sound is normally heard in both ears or is located at the center of the head -if have conductive hearing loss the sound will be better heard in affected ear -if sound heard better in ear without a problem it indicates damage to inner ear or nerve disorder |
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Rinne test |
used to compare bone and air conduction of sound -if hearing loss is conductive, sound of bone conduction will be greater than air condution |
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bronchial sounds |
heard over trachea -high pitched, harsh sounds -expiration longer than inspiration |
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bronchovesicular sounds |
heard over the mainstream bronchus -moderate "blowing sounds" -inspiration equal to respiration
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vesicular breath sounds |
heard best over base of lungs during inspiration -soft low pitched sounds -inspiration longer than expiration |
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adventitious breath sounds p.590 |
normally heard in lungs but if present, may be auscultated -stridor can reside here- (harsh, high pitched sounds heard on inspiration when there is narrowing in upper airway) crackles- are fine to coarse crackling sounds made as air move through wet secretions most often heard during inspiration wheezing- continuous sounds that originate in small air passages that are narrowed by secretions, swelling or tumors |
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glasgow coma scale |
standardize assessment tool that assess level of consciousness. three parameters are evaluated: -eye opening -motor response -verbal response a score of 7 or less defines coma
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opthalmoscope |
a lighted instrument used to visualize interior structures of the eye |
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otoscope |
a lightened instrument used to examine external ear canal and tympanic membrane
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nasal speculum |
used to visualize the lower and middle turbinates of the nose |
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tuning fork |
is a two- pronged metal instrument used to test auditory function and vibratory perception |
