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10 Cards in this Set

  • Front
  • Back
What are the components of the health assessment?
- Nursing interview (biographical data, nursing health history, chief complaint, present illness, past medical history, health patterns, and ROS)
- Behavioral Examination
- Physical Examination (initial and focused)
- Comprehensive (all 3 components)
What is the definition of a physical examination?
- a systemic, orderly process by which the nurse collects objective data about the client's body, mind, and spirit
- critical investigation and evaluation of client's PRESENT status
What is the student nurse's responsibility during the physical examination?
- recognize normal from abnormal
- use proper technique
- identify changes/trends
- validate and analyze
- discuss clinical significance
- communicate significant data
- document within normal limits (WNL)
What is validation?
- comparing data with another source
- knowing normal findings for the client's age, sex, condition in life
What are "fowlers?"
- semi-fowlers: client is supine but bed is lifted at head
- high: anything above 45%
- mid: 45% angle
- most examinations are performed in low fowlers or a sitting positiong
What is the timeframe for a physical examination?
15-20 minutes
What does the inspection technique consist of?
- visual examination, to observe, to look, to notice, to smell
- observe shape, size, color, position, movement, symmetry, equality
What does the palpation technique consist of?
- using the sense of touch
- to feel, to stroke the surface of an area to detect its characteristics such as temperature
- Vibration
- turgor
- texture
- masses
- use of the pads of the fingers to palpate
What are the different types of palpation?
- Light: maintain skin contact while moving in a circle, compressing 1-2 cm
- Deep: not practiced in Basics
What is percussion?
- involves striking the body to elicit sounds that indicate whether tissue is solid, fluid-filled, or air-filled