Upgrade to remove ads
My Health Assessment
Terms in this set (34)
The nursing assessment is
2. a collection of data
3. information that you gather you validate
4. a collection of data that is used to form a database about the patient
5. gathering subjective and objective data
6. The focus of the nursing assessment is different than the focus of a physicians assessment. Nurses focus on THE FUNCTIONAL ABILITY OR RESPONSE TO A HEALTH ISSUE as opposed to pathology.
What are the 4 types of assessments?
Comprehensive (complete) assessment
Comprehensive (complete) assessment
Performed after patient is admitted to a health care facility
Purpose is to establish a database for problems, identification, and care planning.
Is limited to the chief complaint (the systems involved and issues related)
Type of focused, identifies LIFE THREATENING problems
Regular intervals throughout shift. To see if what has been done to patient has resulted in any changes or is effective. Medications? Treatments?
What does ABC's mean
Stands for Airway, Breathing, and Circulation. 3 things to look for while assessing an emergency assessment.
2 types of data
Subjective (Pain felt only by patient) and Objective (can be verified by another person).
What is the nursing process?
you assess the patient to diagnose their problem then create a plan of action and teach it to the patient so it can be implemented and then evaluate to see if the process was successful.
What is a health history?
* The first interaction you'll have with a patient
* Only provides subjective data
* look for patients strengths, problems and potential problems by using effective communication skills and decoding all patients verbal and non verbal communications.
What data do you look for while taking a health history?
Biographical data (name, address, sex, dob)
History of present illness
what are the components of a health history?
review of systems
psycho-social history=health, activity, lifestyle, habits, nutrition, relationships,
what is a physical assessment?
the part of the nursing process that gives you objective data
what are the 4 components of the nursing physical assessment?
inspection - no touching, only using senses
palpation - light palpation = 1/2-1 inch, palpate areas of tenderness last
percussion - tapping for sounds on body
auscultation - listening
what parts of your hands are good for doing what as far as palpation goes?
fingertips down your fingers = shape, texture, fluid, size, pulsation (sensitive things)
dorsal surface (back of fingers) = temp
palm of hand = vibration
what are the percussion tones you hear?
flatness, dullness, resonance, hyper resonance, tympany
What is flatness?
over dense tissue such as bone or muscle
thud like over solid tissue such as liver, spleen, or heart
Hollow sound-heard over normal lungs
booming over air, or over inflated lung such as lung with emphysema
loud drum like noise over air filled structure or organ
what are the 4 sound characteristics you check for during auscultation?
intensity - loud/soft?
pitch - high, medium, low
quality - harsh, gurgling,
duration - how long was the sound heard?
Before you start your assessment what 2 things should you be sure to do?
1. Have all necessary equipment.
2. Be sure that you take care of all the clients needs (pain, explanations, privacy, positioning (make sure they are in least embarrassing/uncomfortable positions as little as possible))
What do you look for in the skin during physical assessment?
color, vascularity, lesions, tempurature, edema, turgor, hair, nails, scalp,
what are possible problems in color?
erythema - redness in skin (rash)
cyanosis - not enough oxygen, blue or purple in darker people
jaundice - yellowing in skin starts in the white of the eye (sclera) caused by accumulating bilirubin in the skin usually because of liver and gallbladder disorders.
pallor - paleness, whiteness, or dark people will look yellowish or brown because of poor perfusion in the blood
what are possible problems in vascularity
petechia - little tiny red dots associated with low platelet count
ecchymosis - bruising
Rash - raised area
ulcerations - erosion of skin
what is diaphoresis?
very moist, wet. Skin is supposed to be dry, not have diaphoresis.
what is edema, pitting edema? how is pitting edema rated?
fluid sitting outside of intravascular volume into the interstitual (or tissue). pitting edema means you can push the edema and it'll leave an indentation. pitting edema is rated between +1 (trace) and +4. It can be assessed by either pushing into with pinky (first joint = +4) or how much time it takes to come back.
what is turgor?
the elasticity in your skin. it measures the hydration in your skin. you pinch and pull the back of your hand normal hand will return immediately. in elderly do not use hand but use on sternum, under clavicle or over scapula.
hair, nails, scalp, what are possible problems?
clubbing - long term hypoxia finders are rounded at end., lice - will show with nits in hair, alopecia - loss of hair. terchosis - excessive hair growth
what is capillary refill time?
the time it takes for color to return to nails after you push down on the nail. should be immediate, shows healthy or poor perfusion.
what do you look for in the head while assessing the head?
symmetry, teeth, ears, hearing (wisper test touch outside of ear or brush outside of ear with hair), nose for drainage, lymph nodes - palpate.
what does PERRLA mean?
pupils equal round react to light and accommodation.
pupils need to be equal in size, round, react to light, and accommodate.
bring light in from side look for constriction 7-8 mm down to 3-4 mm.
consentual reflex - both sides respond to just 1 light.
accomodation - item is close pupils constrict, far away object eyes dilate.
convergency - eyes come together when they follow the pen light.
extra occular movement - when following a pen light to different corners (make a bow in the air) look for eye movement (called mastalgia, like an eye wiggle)
YOU MIGHT ALSO LIKE...
Mod 4 Normal and Abnormal Physical Assessment
Test 1 Outline - HA
CH. 12 NURSING ASSESSMENT & CH. 17 HEALTH ASSESSME…
OTHER SETS BY THIS CREATOR
class 7, unit 2, activity, safety, rest/sleep
Assessment 1 Physical full