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Health Assessment Chapter 25. 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

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Competencies for ch 25 health assessment
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


Health assessment
Health Assessment

  • Two components of the health assessment

    • Health History

    • Physical Assessment


What happens during a health assessment between a patient and nurse

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?


General guidelines for physical assessment
General Guidelines for Physical Assessment

  • Instrumentation

  • Positioning

  • Draping

  • Preparation of the environment

  • Patient preparation

  • Techniques of physical assessment


Positioning

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


Draping preparing the environment

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


Techniques for examination

Inspection- keeps the patient warm during the physical exam (P.E.).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


Inspection

Deliberate, purposeful, observations in a systematic manner keeps the patient warm during the physical exam (P.E.).

Nurse use the physical senses: visualizing, hearing, and smelling

Inspection


Instrumentation or equipment used for inspecting

Ophalmoscope- keeps the patient warm during the physical exam (P.E.).

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


Instrumentation or equipment used for vision screening

Snellen chart keeps the patient warm during the physical exam (P.E.).- used to check eye sight

Instrumentation or Equipment used for vision screening


Palpation technique using the sense of touch
Palpation keeps the patient warm during the physical exam (P.E.).technique 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


Percussion the act of striking one object against another to produce a sound

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


Auscultation act of listening with a stethoscope to sounds produced with in the body
Auscultation and density of tissue-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)


General survey

Gather information and density of tissue 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


Vital signs height and weight

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


Physical assessment head to neck

General survey -document

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


Integument structures

Skin -document

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


Health assessment chapter 25

Inspect for color, vascularity, lesions and body odors -document

Color-pinkish white to various shades of brown.

SKIN


Head and neck

Assessment includes -document

Skull

Face

Eyes

Ears

Nose

Sinuses

Mouth

Head and Neck

  • Pharynx

  • Trachea

  • Thyroid glands

  • Lymph nodes


Skull and face

Inspect size and shape -document

Symmetry

Face- examine color

Symmetry

Distribution of facial hair

Assess facial nerve and facial muscles-

Skull and face


Health assessment chapter 25

cellulitis -document


Eye and ears

EYE -document

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



Health assessment chapter 25

Acute Glaucoma -document


Health assessment chapter 25

Healthy Ear -document




Health assessment chapter 25

Cerumen in ear -document


Nose and sinuses

Nose -document

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


Health assessment chapter 25

Hematoma -document


Health assessment chapter 25

Polyp -document


Mouth and pharynx

Composed of many structures -document

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


Health assessment chapter 25

Tonsillitis -document


Health assessment chapter 25

Hairy -documenttongue


Health assessment chapter 25

Trachea- note location -document

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


Assessment part i
ASSESSMENT -documentPart I


Course objectives
COURSE OBJECTIVES -document

  • 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


Health assessment1
HEALTH ASSESSMENT -document

  • Two components of the health assessment

    • Health History

    • Physical Assessment


What happens during the assessment
WHAT HAPPENS DURING THE ASSESSMENT -document

  • 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


General guidelines
GENERAL GUIDELINES -document

  • Instrumentation

  • Positioning

  • Draping

  • Preparation of the environment

  • Patient preparation

  • Assessment techniques


Positioning1

Sitting – use upright chairor dangle of exam table. -document

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



Pulmonary
PULMONARY -document

  • HISTORY

  • INSPECTION

  • PALPATION

  • PERCUSSION

  • AUSCULTATION

  • BREATH SOUNDS


Pulmonary1
PULMONARY -document


Cardiovascular
CARDIOVASCULAR -document

  • History

  • Inspection

  • Palpation

  • Auscultation

  • Heart sounds

  • Peripheral vascular system


Cardiovascular1
CARDIOVASCULAR -document


Breast axilla
BREAST/AXILLA -document

  • History

  • Inspection

  • Palpation


Abdomen
ABDOMEN -document

  • History

  • Inspection

  • Auscultation

  • Percussion

  • Palpation


Genitalia
GENITALIA -document

  • Female

    • History

    • Inspection

  • Male

    • History

    • Inspection


Musculoskeletal
MUSCULOSKELETAL -document

  • History

  • Inspection

  • Palpation

  • Testing

    • Tone

    • Strength

  • Bones and Joints


Neurological
NEUROLOGICAL -document

  • History

  • Mental Status

    • Orientation

    • Level of Consciousness

    • Memory

    • Abstract Reasoning

    • Language


Crainial nerves

Olfactory (I) -document

Optic(II)

Oculmotor (III), Trochlear(IV), Abducens(V)

Trigeminal(VI)

Hypoclosseal (VII)

Facial (VIII)

Acuoustic (IX)

Glossopharyngeal (X)

Vagus (XI)

Accessory (XII)

CRAINIAL NERVES


Sensory motor function
SENSORY MOTOR FUNCTION -document

  • Motor

  • Balance and gait

  • Coordination

  • Sensory


Reflexes
REFLEXES -document

  • Abdominal

  • Babinskis

  • Bicepts

  • Triceps

  • Patellar

  • Achilles Tendon