Health Assessment In Nursing

Collection of subjective and objective data

Analysis of subjective and objective data to make a professional nursing judgement

Developing a plan of nursing care and outcome criteria

Carrying out the plan of care

Assessing whether outcome criteria have been met and revising the plan of care if necessary

Clinical judgement about individual, family or community responses to actual or potential health problems and life processes

Sensations or symptoms that can be verified only by the client (ex. pain)

Findings directly observed or indirectly observed through measurements (ex. body temperature)

Physiologic complications that nurses monitor to detect their onset or changes in status

Problem that requires the attention or assistance of other health care professionals

Physiologic status

Formulation of nursing diagnoses

Continuous

Comprehensive

Includes a brief reassessment of the client's normal body system

Arrive at conclusions about the client's health

Closed-ended

Rephrasing the client's statements

Working phase

Provide structure and set limits

Identify risk factors to the client and his or her significant others

Character, Onset, Location, Duration, Severity, Pattern, Associated factors, how it Affects the client

Side-lying position used during the rectal examination

Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

Back-lying position used for examination of the abdomen (with one small pillow under the head and another under the knees); this position also allows easy access for palpation of peripheral pulses

Position used to examine male genitalia and to assess gait, posture, and balance

Client lies on abdomen with head turned to the side; may be used to assess back and mobility of hip joint

Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum

Fingerpads

Ulnar surface or palm of hand

Dorsal surface of hand

Bell of stethoscope

Diaphragm of stethoscope

Inspection, palpation, percussion, auscultation

Assessment, diagnosis, planning, implementation and evaluation

History of present health concern, past health history, family history and lifestyle and health practices

Initial comprehensive assessment, ongoing or partial assessment, focused or problem oriented assessment and emergency assessment

Collection of subjective data, collection of objective data, validation of data and documentation data

The client's culture, family, community and spirituality all affect their overall health

Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information and to gather information on the client's developmental, psychological, physiologic, sociocultural and spiritual statuses

Introductory phase, working phase, summary and closing phase

Gerontologic, cultural and emotional

Biographic data, reasons for seeking health care, history of present health concern, past health history, family health history, review of body systems (ROS) for current health problems, lifestyle and health practices profile, developmental level

To obtain objective data

Necessary equipment and how to use it, preparing the setting, onself and the client for examination and how to perform the four basic assessment techniques

Failure to validate data may result in premature closure of the assessment or collection of inaccurate data

Recheck objective data through reassessment, clarify with client by asking additional questions and compare your objective findings with subjective findings for discrepencies

To provide the nurse with an overall impression of the client's whole being.

Physical development and body build, gender and sexual development, apparent age vs reported age, skin condition and color, dress and hygiene, posture and gait, LOC, behavior, body movements and affect, facial expression, speech and vital signs

Temperature, pulse, respiration, blood pressure and pain

96-99.9 F orally 36.5-37C

60-100 beats per minute

Pulse rate of greater than 100 beats per minute

Pulse rate of less than 60 beats per minute

Rate, rhythm, amplituded and contour

12-20 per minute

Rate, rhythm and depth

120/80

Isolated systolic hypertension 140/90

Pain is whatever the client says it is, directly quote description of pain use COLDSPA mneumonic

Use of pain assessment tools

Visual analog scale (VAS), numeric pain intensity scale (NRS) and simple descriptive pain intensity scale (VDS)

Acute pain, chronic nonmalignant pain and cancer pain

Acute pain

Chronic nonmalignant pain

Cancer pain

Multiply by 2.54

Divide by 2.2

Client's level of cognitive and emotional functioning and stability reflected in their speech, appearance and thought patterns

Client is alert, awake and orientated to time, place, date and purpose. Responds to questions and answers appropriately

Client opens eyes, answers questions and falls back asleep

Client opens eyes to loud voice, responds slowly with confusion and seems unaware of environment

Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep

Client remains unresponsive to all stimuli, eyes stay closed

aka Abnormal flexor posture, client with lesions of the corticospinal tract draws hands up to chest when stimulated

aka Abnormal extensor posture, client with lesions of the diencephalon, midbrain or pons extends arms and legs arches neck and rotates hands and arms internally when stimulated

Client interview which may include a 24 hour dietary recall

Anthropometric measurements are used to evaluate the client's physical growth, development and nutritional status as well as physical examination and hydration assessment

Triceps skinfold (TSF), Mid upper arm circumference (MUAC), Arm muscle circumference (AMC)

Alert, energetic, good endurance, good posture, good attention span, psychological stability, weight within range for height, age and body type, no skeletal changes, eyes bright and clear, shiny hair, skin glowing, elastic, good turgor, smooth, healthy reflexes

Withdrawn, apathetic, easily fatigued, stooped posture, inattentive, irritable, overweight or underweight, flaccid muscles, wasted appearance, diminished reflexes, skin dull, pasty, scaly, dry, bruised, eyes dull, hair brittle, skeletal malformations

Lower socioeconomic status, long working hours and fast food consumption, poor food choices, chronic dieting, chronic diseases, dental issues, limited access to sufficient food, eating disorders, illness or trauma

30-34.9

35 inches or greater for women and 40 inches or greater for men

Weight in kg/height in meters squared

One's search for life's meaning and purpose

Shared practices and rituals used to express one's faith

An assessment used to determine a client's spiritual needs

Actions used to assist the client in meeting spiritual needs

Bronchial, bronchovesicular and vesicular

In the trachea and thorax

Over the major bronchi: between the scapulae, around the upper sternum in the first and second ICS

In the peripheral lung fields

High pitched

Moderate pitch

Low pitched

Pitch, quality and amplitude

B-loud, BV-moderate, V-soft

Bronchial

Bronchovesicular

Vesicular

Right upper lobe

Horizontal fissure

From the 4th rib at the right sternal border to the 5th rib at the midaxillary line to the 6th rib at the midclavicular line

Oblique fissure

Right lower lobe

From 3cm above the medial 1/3 of the clavicle to the 6th rib at the MCL to the 5th rib at the MAL to T3-T1

From the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL

At the apex of the heart

At the base of the heart

Aortic area, pulmonic area, erb's point, tricuspid area and mitral (apical) area

Bilateral palpation of the carotid arteries can result in reduced cerebral blood flow

60 seconds

2nd ICS right

2nd ICS left

3rd ICS left

4th ICS left

5th-6th ICS midclavicular

LUB

DUB

Systole

Diastole

Murmur

Pulse deficit

Abnormal breath sounds heard during auscultation of the lung fields which may include crackles, wheezes or pleural friction rubs

Abnormally increased forward curvature of the upper spine

Loss of elasticity, fewer functional capillaries and loss of lung resiliency

C7

Vibrations of air in the bronchial tubes transmitted to the chest wall

Crackling sensation like bones or hairs rubbing against eachother

The abnormal accumulation of fluid in interstitial spaces of tissues

Elevated mass with transient borders size and color may vary. ex hives or insect bites

aka a mole, is a flat or raised tan/brownish marking up to 6mm wide

A pus-filled vesicle or bulla ex. acne or impetigo

An encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis

Skin-loss extending past epidermis, necrotic tissue ex. pressure ulcer

A scar, a skin mark left after healing wound or lesion

A linear crack in the skin ex. chapped lips and athlete's foot

A blue-green color

Tests the client's equilibrium, client stands with feet together and arms at sides eyes open and then closed. Client should be able to maintain the position for 20 secs with minimal or no swaying

The Snellen chart or E chart results are expressed as 20/20 representing the distance from the chart and the last line the client was able to read

The Jaeger reading card results are expressed as 14/14 representing the distance in inches from the chart and the last line the client was able to read

The confrontation test

The reflection of light on the corneas should be in the exact same spot on each eye which indicates parallel alignment

Deviation in alignment or strength and slight deviations in eye movement

The uncovered eye should remain fixed straight ahead, the covered eye should remain fixed and straight ahead after being uncovered

An inward turn of the eye

An outward turn of the eye

Testing the six cardinal positions of gaze to assess for extraocular muscle weakness or dysfunction of the cranial nerve

Pupils should constrict in both eyes

Pupils constrict and eyes converge

Tenderness, mobility, size and shape

No