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31 terms

Health Assessment

STUDY
PLAY
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