Health Assessment Chapter 25

1. Health AssessmentChapter 25

2. Competencies for Ch 25, Health Assessment • By the end of this unit, the student will: • Demonstrate techniques to obtain patient information • Describe the components of a health assessment • Describe how to prepare the patient for the exam • List the equipment needed for an examination • Demonstrate a brief head to toe physical assessment

3. Health Assessment • Two components of the health assessment • Health History • Physical Assessment

4. Establish the nurse-patient relationship Gather data-physiological, psychological,cognitive, sociocultural, developmental, spiritual Identify patient strengths Identify actual and potential health problems Establish a base for the nursing process (Assessment) What happens during a health assessment between a patient and nurse?

5. General Guidelines for Physical Assessment • Instrumentation • Positioning • Draping • Preparation of the environment • Patient preparation • Techniques of physical assessment

6. Sitting –used in an upright chair or dangling off exam table Supine-lie flat on your back Dorsal recumbent-lie back with knees bent Sims’s-lies on either right or left side lower arm behind the body and the upper arm is bent at the shoulder and elbow and knees are both bent Positioning • Prone-Pt. Lies on abdomen • Lithotomy- patient is in a dorsal recumbent position with buttock at the edge of the examining table and feet support in stirrups. • Knee to Chest-using the knees and chest to bear the weight of body. • Standing

7. Draping prevents unnecessary exposure, provides privacy, and keeps the patient warm during the physical exam (P.E.). Prepare examination table Place a gown and drape on the table Set up any supplies that are needed. -Example: otoscope, tuning fork, ophthalmoscope. Pull curtain around or close door to exam room Draping, preparing the environment

8. Inspection- observing, listening or smelling to gather data Palpation-assessment that uses sense of touch Percussion-act of striking on e object against another to produce a sound Auscultation-act of listening with a stethoscope to sounds produced with in the body. Techniques for examination

9. Deliberate, purposeful, observations in a systematic manner Nurse use the physical senses: visualizing, hearing, and smelling Inspection

10. Ophalmoscope- Exam the eyes Otoscope- examine the ears, mouth and nostrils Tuning fork - hearing Nasal speculum-visualized the turbinates of the nose Stethoscope Instrumentation or Equipment used for inspecting

11. Snellen chart- used to check eye sight Instrumentation or Equipment used for vision screening

12. Palpationtechnique using the sense of touch • The hands and fingers are sensitive tools and assess: • Temperature- use the dorsum of the hand • Turgor • Texture • Moisture • Vibrations • Shape Use the palmer (front side) of the hand

13. Percussion tones are used to assess location, shape, size and density of tissue Percussion Tones Flat Dull Resonance Hyper resonance Tympany Percussion-the act of striking one object against another to produce a sound

14. Auscultation-act of listening with a stethoscope to sounds produced with in the body • Four characteristics assessed by auscultation • Pitch- ranging from high to low • Loudness- ranging from soft to loud • Quality- gurgling or swishing • Duration (short, medium, long)

15. Gather information regarding Patient's appearance, behavior Measuring vitals signs Height, and weight General appearance Gender and race Body build, posture and gait General appearance Hygiene, grooming (note body odor, cleanliness). Signs of illness Affect, mood, attitude (speech and facial expressions) Cognitive process (speech content, patterns, orientation, appropriate verbal responses) General Survey

16. Take Vital signs (VS) and determine normal or abnormal -document Height and weight- document (Check the height and weight table to determine if a patient is under, normal or over weight.) Vital Signs, Height and Weight

17. General survey Height and weight Vital Signs Neck Skin Lymph nodes Muscles Thyroid Trachea Carotid arteries Neck veins Physical Assessment Head to Neck • Head • Skin • Face, skull, scalp, hair • Eyes • Nose and sinuses • Mouth and or pharynx • Cranial nerves

18. Skin Nails Hair Scalp Obtain history of rashes, lesions, changes of color or itching History of bruising or bleeding Exposure to sun Note presence of wounds, abrasions Changes in mole size, shape or color Integument structures

19. Inspect for color, vascularity, lesions and body odors Color-pinkish white to various shades of brown. SKIN

21. Assessment includes Skull Face Eyes Ears Nose Sinuses Mouth Head and Neck • Pharynx • Trachea • Thyroid glands • Lymph nodes

22. Inspect size and shape Symmetry Face- examine color Symmetry Distribution of facial hair Assess facial nerve and facial muscles- Skull and face

23. cellulitis

24. EYE Inspect external structures Pupils and Iris Internal structures Vision Extra ocular movement Peripheral vision EAR Inspect external ear for shape, size, location bilaterally, ear should be smooth Gently palpate ear for pain, edema, or presence of lesions Check hearing Inspect internal ear Eye and Ears

25. Bacteria Conjunctivitis

26. Acute Glaucoma

27. Healthy Ear

28. Acute otitis media

29. Chronic otitis media, stapes extruding

30. Cerumen in ear

31. Nose Inspect size, shape and location Check for patency (open air passageways.) Inspect using otoscope nares and turbinates Sinuses Inspect the sinuses and gently palpate maxillary bone and frontal sinus Normally the sinuses are not painful. Nose and Sinuses

32. Hematoma

33. Polyp

34. Composed of many structures Lips, tongue, teeth, gums hard and soft palate,salivary gland, tonsillary pillars, and tonsils Equipment needed: Penlight, tongue blade, 4X4 gauze sponge, and gloves MOUTH AND PHARYNX

35. Tonsillitis

36. Hairy tongue

37. Trachea- note location Midline at the suprasternal notch Thyroid- thyroid is normally not palpable. Palpate for size shape, symmetry tenderness and presence of any nodules Lymph nodes Generally not palpable If palpated, should be small mobile, smooth non-tender Abnormal- enlarged, indicate infection, autoimmune, or metastasis of cancer Neck

38. ASSESSMENTPart I

39. COURSE OBJECTIVES • Students will learn: • Components of a health assessment • To prepare the patient for the exam • What equipment is needed for the exam • A variety of techniques to obtain patient information • How to examine the patient head to toe

40. HEALTH ASSESSMENT • Two components of the health assessment • Health History • Physical Assessment

41. WHAT HAPPENS DURING THE ASSESSMENT • Establish the nurse patient relationship • Gather data in the following areas • Physiological • Psychological • Cognitive • Sociocultural • Developmental • Spiritual • Identify patient strengths • Identify actual and potential health problems • Establish base for nursing process

42. GENERAL GUIDELINES • Instrumentation • Positioning • Draping • Preparation of the environment • Patient preparation • Assessment techniques

43. Sitting – use upright chairor dangle of exam table. Supine – flat on the back Dorsal Recumbant – on back with knees bent Sim’s – lie on side, lower arm behind back, upper arm bent at the shoulder and elbow, knees both bent POSITIONING

44. ASSESSMENT part 2

45. PULMONARY • HISTORY • INSPECTION • PALPATION • PERCUSSION • AUSCULTATION • BREATH SOUNDS

46. PULMONARY

47. CARDIOVASCULAR • History • Inspection • Palpation • Auscultation • Heart sounds • Peripheral vascular system

48. CARDIOVASCULAR

49. BREAST/AXILLA • History • Inspection • Palpation

50. ABDOMEN • History • Inspection • Auscultation • Percussion • Palpation