Part of the nursing process providing important infos

comparisaon info between pt current health vs normal health

Health history

physical aassessment documentation of data

Subjective=data from. Pt

objective= a nursing assessment

Comprehensive

problem based/focussed

episodic/follow uup screening assessment

Comprehensive assessment

3 level of health promotion

and health protection ?

Desease prevention

sreening

minimizing disability

2 primary component of health assessment?

Heath history

physical examination

Introductory phase

discussion base

summary phase

Appearance

interpersonal skills

Non verbal behaviors

Age

physical

mental

emotional status 

pt not ready save question for later

Clearly, 

define,

avoid medical jargon adapt question rt client

Encourage client to be sspecific one question at the ttime be attentive

Active llistening

open ended questions

clarification

restatement

reflexion

confrontation

interpretation

summary

Using medical terminology

expressing judgement

interrupting pt

being authoritarian or paternalistic

asking why questions might make pt to defensive

Brief direct answers

sharing experiences supporting cclients

enhancing relationships increasing credibility

silence

display of emotion

Overly details problem

re focusinterview 

redirect cconversations

othere in room

langauge barriers

cultural differences 

 Comprehensive

 problem based

episodic

History of Present Illness: a chronological record or summary of the symptoms and events leading up to the event/hospitalization.

Client conditions 

acute vs chronic

duration and impact on live

medication 

dx

allergies

Define 

medicare vs Medicaid 

Medicare resource for people over 65

medicaid is for poor

Pst and present health of each body  

conduct symptom analysis when clients indicate s.s

medical terms define to client llevel

avoid repeting review system if present health stas enoughs enough

Not organize by body ssystem health is based on functional health ppattern

data organize on 11

Health perception 

nutrition

elimination

activity exercise

cognitive pperception

sleep rests

self perception self concept

role relationship

reproduction

coping/ stress values beliefs

1-Establishes a therapeutic relationship with the client

2-Provided snapshot of client and identifies problems mentioned by client that can be confirmed or refuted during exam

3-Data must be organized, synthesized, and documented

4-Organized collection of data makes documentation easier

Inspection

Palpation

Percussion

auxcultaion

visual exam of body, mv,posture, smell

examination of all body system

use of hand to feel texture,size, shape, consistency, location and identification of painful or tender area

be careful rt invasive touch, prevent pt before and recognize importance of cultural/ethnic beliefs

True of false?

Palmar surface of fingers and fingers pads are more sensitive than fingertips?

True of false?

Ulnar surface of hand to fifth finger is most sensitive to vibration?

True of false?

Dorsal surface is better for assessing Temp

using palmar suface of finger small/deep controll pressure 1cm assessing skin, pulsation and tenderness

Deep palpation 4cm with one to 2 hands used to determine organ size and contour

What comes first?

Light palpation vs Deep palpation

Evaluating size, border, consistency of internal organs

Detect tenderness

determine extend of fluid in cavity

Direct:

use finger or hand directly against client body>evaluate tenderness over kidney

Indirect:

Requiere both hands

Non dominant hand palm down with fingers together and strike with lateral aspect of fist of dominant hand

producing vibration

Tympany is loud>high pitch sound over abd

Resonance is heard over lung

Hyperresonance is heard in overinflated lungs

Dullness is heard over liver

Flatness is heard over bones and muscles

What is auscultation?

Intensity

pitch

duration

quality

Sound may be transitory of suble>closed eyes might help listening better

T or False

During auscultation is the stetoscope can be on top of clothes?

T or F?

Is positioning important during auscutation?

yes>Sitting and supine most common

appropriate drapping

Thermometers

stethoscope/Fetoscope (fetus)

BP

Pulsometer

Scales

Visual acuity and screening>Ophtalmoscope

Otoscope>Hear

Penlight

Ruler and tape mesure

Nasal speculum

tuning forg

percussion or reflex hammer

doppler

Goniometer>determines degree of flexion/extension of join

Calipers for skinfold thickness>thickness of skin

Vaginal speculum

Audioscope

Monofilament>test lower extremity sensation

Transilluminator>differentiate tissue characteristic

Woods lamp>detect fungal infection

magnigication device>increase size

General pt survey,

Physical appearance>atn to details

body structure and position>rt age, social status, nutritional status, body symetry, position posture(guarding, fetal position)

Body mvt

General and mental status and behavior

rt pain

Variation of temp T F?

0.5F-1F during ovulation?

Exercise increase T?

Po>delay 15min if pt just drank

Tympanic

Ax>less acurate

Rectal>sim position

Radial artery

finger over arm determine HR and rythm

Document irr pulse of rythm

Radial artery

brachial artery

carotid

apical pulse>1min over heart

with client unaware

note rythm, depth(excursion, mvt of chest wall, symetry), effort(normal, shallow)

Force of blood against arterial walls

Cardiac output vs peripheral resistance

Cardiac output>volumeof blood ejected from heart each minute

Peripheral resistance> is force that opposes flow of blood through vessels. Narrowing of arteries increase peripheral resistance therefore increase BP.

Velocity of blood

intravascular Blood volume

elasticity of vessel walls

what systolic BP?

Diastolic?

Systolic BP > maximum pressure exerted to arteries when ventricles ejected blood from heart.

Diatolic BP is the minimun of pressure exerted on vessels when ventricles of heart relax

BP mesure MM hg

Direct>BP manually

Indirect>machine

IF Bp appears abnormal less accurate always double check with manual cuff

Thigh>sytoslic BP 10/40 higher

wrist>overestimate BP

Always note the location of BP

Mechanism of blood pressure

Different sounds?

unpleasant sensory and emotional exp rt actual and emotional tissue damage

Pain is complex, multidimentional, subjective

Always note Location, quality, quantity

T F

Correlation between amount of tissue damage and pain?

arises from stimulation of somatic or visceral structures

Nociceptive pain is caused when special nerve endings—called nociceptors—are irritated exp burning your hands

occurs dur to abnormal processing of sensory input by CNS or PNS

Neuropathic pain is a type of pain which is caused by damage to or dysfunction of the nervous system

Referred pain

Pain intensity instruments

WOng baker faces

Numeric rating scale

Flacc scale>kids

Comfort scale>kids

Cries pain scale>kids

check list of non verbal indicators

Description of pain?

location,

quality

quantity

pain instruments

Chronology>when does the pain occur?

Setting>where, environment factors

Associtated manifestations

Alleviating factors

Aggravating factors

aSSESS FOR RESPONSE TO PAIN

Neonate responses link to HR, pallor, global

Young children>basic ability to describe pain and location

School age children>better understand

P: provocative or palliative

Q: quality or quantity

R: region and radiation

S: severity

T: timing

U: understanding the patient's perspective