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What is the purpose of a health assessment?

to collect subjective and objective data about a patient to obtain info about his physical, psychological, sociocultural, developmental, and spiritual health

What is subjective data?

information perceived only by the affected person;
what the patient reports

What is objective data?

observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them;
data the nurse obtains

Name the types of assessments?

Comprehensive
Ongoing Partial
Focused
Emergency

What is a comprehensive assessment?

Health history and complete physical

What is a ongoing partial assessment?

Performed at specific intervals focusing on specific health problems

What is a focused assessment?

Performed to assess a specific problem

What is an emergency assessment?

A quick focused assessment in an emergency situation to identify life-threatening problems

How do you prepare the patient and the environment for a health assessment?

Preparing the patient: explanation of health concerns, habits, lifestyle; explain privacy and confidentiality

Preparing the environment: examination room, table, instruments, lighting

Maintain cultural sensitivity

What is health history?

A collection of subjective data that provides a detailed profile of the patient's health status

The primary source of data comes from:

The patient

What are the components of health history?

Biographical
Chief Complaint
History of Present Health Concerns
Medical History
Family History
Lifestyle

Biographical data includes:

Name, address, gender, marital status, occupation, religion, insurance/payment source, healthcare provider

Document the patients chief complaint in the ______ _________ ________.

patient's own words

When obtaining the history of a patient's present health concern, what information do you need to ask for?

Location
Duration
Quality
Quantity
Setting
Aggravating factors
Associating factors
Alleviating factors
Patient perception

What does medical history entail?

Past illness, chronic health problems, treatment received, previous surgery, hospitals

Family history is obtained to establish _______ links.

genetic

Lifestyle includes:

Habits, alcohol, drugs, typical day, sleep, exercise, resources/support

Physical assessment is a ____________.

A systematic collection of objective data

What equipment is needed for a physical assessment?

Stethoscope
Ophthalmoscope
Otoscope
Snellen chart (eye chart)
Nasal Speculum
Vaginal Speculum
Tuning Fork
Percussion hammer
Other: timing device, bp cuff

What are the techniques for assessment?

inspection, palpation, percussion, and auscultation

Explain the inspection technique.

observations, inspect symmetry, size, color, shape, position, deviations, normal v. abnormal findings

How is the palpation technique performed?

Hands and fingers are used to assess (feel) temperature, turgor, moisture, vibrations, and shape.

What are the 3 palpation techniques and when are they used for assessment?

Dorsum (back) of hand used for temperature assessment.
Palm of hand used to assess vibrations.
Palmar (front) of fingers and finger pads used to assess texture, shape, fluid, size, consistency, and pulsations.

What are the types of palpations?

Light palpation- less than 1 cm/ 0.5 inch
Moderate palpation- 1 to 2 cm/ 0.5 to 0.75 inch
Deep palpation- approximately 2 cm/ 1 inch

Area of ______________is palpated last.

tenderness

What characteristics can you identify with palpations?

Shape
Size
Consistency
Surface
Mobility
Tenderness
Pulsatile

What is the percussion technique?

Striking one object against another to produce sound;
Use your hands

What is the auscultation technique?

Listening to sounds of the body with a stethoscope

What characteristics are identified with auscultations?

Pitch
Loudness
Quality
Duration

What are the general survey components?

Observation of the patient's appearance and behavior
Vital signs
Height and weight

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