health assessment student copy.ppt

7/23/2019 Health Assessment student copy.ppt

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A comprehensive health assessmentencompasses the physical, psychological,

social, and spiritual dimensions of living. RuthCraven EDD, RN


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Health Historythe nurse gathers

subjective data bytalking to the client.

Subjective data is what theclient tells you

Subjective data are clientsperceptions about theirhealth problems

Physical Examthe nurse gathers

objective datathrough the physical

exam

Objective data areobservations ormeasurements made bythe nurse


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Establish the client-nurse relationship Obtain inormation about all aspects o the

clients health

!dentiy client strengths !dentiy actual and potential health

problems"o establish a data base rom which the

subse#uent phases o the nursing processevolve


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$ssessment % a collection o data about anindividuals health state

&ata includes' Subjective data

Objective data' (data gained through physical examand rom the clients record) including lab anddiagnostic tests*

"hese elements orm the data base. "he nurse

makes a judgment or diagnosis about the clientshealth state. "hus) the purpose o the assessment isto make a nursing diagnosis.


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What is spoken of as a clinical picture isnot !ust a photograph of a sick man in "ed#it is an impressionistic painting of the

patient surrounded "y his home, his $ork,his relations, his friends, his !oys, sorro$s,hopes, fears. %rancis &ea"ody Weld, '((' ) '*+


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See Potter & Perry Chapter 16, pp. 214-216 * +iographical data ,hie complaint (reason or visit* PQRST ! (history o present illness*

ast history also called health history Environmental history /amily history o illness 0ie-style sychosocial &ata Spiritual ealth

1OS (review o systems* atterns o health care oes the !atient have an advanced

directive"


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On admission) the nurse asks the client 2hatcaused you to come to the hospital34 "he clientresponds we were on a cruise and ! caught a

cold and was not eeling well. 5y husband toldme to go to the hospital when ! began to coughand have chest pain.4 2hich o the ollowingwould be considered the chie complaint43

$. ! caught a cold4 +. ! was not eeling well4 ,. 5y husband told me to go to the hospital4

&. ! began to cough and have chest pain4


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6oals' "o obtain baseline data about theclients health) unctional ability

"o identiy variations rom normal) $nd to gain objective data to support

inormation given during the interview. &ata gained will help the nurse ormulate

nursing diagnoses and establish a plan o

care.


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"he nurse must look calm) con7dent) andorgani8ed

9tili8e principles o inection control 6ather all necessary e#uipment $void expressions o alarm or disgust +e sensitive to the clients needs

ave a #uiet) well-lit room withoutinterruptions


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Eyes) ears) nose)hands:7ngers

6loves

,otton balls enlight Stethoscope +lood pressure cu;"hermometer"ongue blade See p. or complete list


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Explain the procedure and assist the client inappropriate positioning % (see chart) p. ?*

9se a head-to-toe approach 5ove rom external to internal Examine normal or una;ected side 7rst Observe or symmetry) comparing one side to

the other

Per#orm the !hysical exam $hilestanding on the client%s right side. (thishelps to better identiy anatomic landmarks*.


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!nspectionalpationercussion$uscultation


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,oncentrated watching4)a thorough and unhurriedvisuali8ation) and noteany odors.

$de#uate lighting is

essential osition and expose bodyparts so that all suracescan be viewed

!nspect or si8e) shape)color) symmetry)

position) andabnormalities ,ompare to opposite side

o body


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"apping the skin suraceto create vibrations ounderlying structuresthat produce sound.

9sed to determine the

si8e and shape ointernal organs

-direct percussion

-indirect percussion

- 7st percussion


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/latness &ullness 1esonance@@

yperresonance"ympany

Sot intensity such as soundheard over muscle or bone

5edium Athudlike over liver:heart

0oud intensity) low in pitch)hollow sounding normal lung4

Bery loud intensity heard overhyperinCated lung tissue(emphysema*

0oud) hollow sounding heard overair-7lled organ such as emptystomach or large distended colon

rom gas


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/eeling:touching"ouch is used to determine the extent o

tenderness) tremor) spasm) to elicit crepitus(o bones*) and to determine variations othe skin

$lso use to determine si8e) shape)consistency) and mobility o structures) andto evaluate abnormal Cuid collections


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ave warm hands) well-trimmed nails) andwear gloves when necessary

/eel or temperature) turgor) texture)moisture) vibration) and shape

0ight palpation % involves slight pressure) dobeore deep palpation

&eep palpation % done to assess si8e andcontour o organs

&se dorsum o# hand to assesstem!erature o# s'in (l$ays !al!ate !ain#ul area )(ST*


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Listening for sounds produced by the body

Usually use stethoscope to block out

environmental sounds and increase

Transmission to ears

Bell of stethoscope low frequency

sounds such as vascular sounds

Diaphragm higher pitched sound such

as lung sounds and peristalsis

Listen for: pitch, loudness, quality, duration, location,

and timing


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$. Observation

+. alpation

,. ercussion

&. $uscultation


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!n order to elicit inormation about thepatients chie complaint) the nurse usesthe D1S"4 ormat as a guide or urther

#uestioning. 2hich o the ollowing#uestions will elicit inormation regardingthe 4 o the D1S"43

$. ,an you point to where it hurts34 +. !s the pain constant34 ,. ,an you describe the pain34

&. 2hat did you do to relieve the pain34


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ealth assessment begins with a generalsurvey that involves observation o theclients general appearance and mentalstatus (p. *

5easurement o vital signs) height) andweight are also included


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"he best way to proceed is in a head-to-toe4 manner

Fou will become aster) more eGcient) and

more thorough and competent with1$,"!,EH

$t the end o this semester) you will be a

beginning expert4 in putting it alltogether4H


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$ssessment o the skin uses the skills oins!ection and !al!ation

+egin by inspecting the hands and nails +ns!ection , note color) vascularity or

bruising) evidence o perspiration) edema(swelling*) hygiene) injury) or lesions

Pal!ation , note temperature) turgor)

texture) thickness) moisture) and edema


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,yanosis % +luish discoloration due to low oxygenlevels

Iaundiced % yellow-orange color due to increased

amounts o bilirubin in the skin Erythema % redness o the skin due to increased

vascularity"an-brown % due to increased amounts o melanin

allor -decrease in color


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$. Jotiy the physician o the 7ndings

+. "ake the patients blood pressure

,. old all medications until urther notice

&. &on a gown and gloves

E. $pply lotion to the lesions

/. 5ove the patient to a private room

6. $ssess the patient or pain rom thelesions


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$ K $symmetric lesion + K +order irregularity , K ,olor o lesion varies with shades o

tan) brown) or black) and possibly red) blue)or white

& K &iameter greater than L mm

E K Elevated or enlarging lesion


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&ecreased elasticity 2rinkling ,olor changes !ncreased translucence &ryness &ecreased turgor air' thins) grays) texture changes


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"he home care nurse is visiting a new client. erhospital records stated that she has !etechiaeon her arms and legs. ow would the nurse

expect the clients extremities to appear uponassessment3

$. urplish-blue lesions with areas ading togreen-yellow

+. /lat) round M-Nmm lesions that are reddishpurple

,. Spiderlike lesions o varying si8e that arebluish in color

&. urple blotches varying rom ?.-Mcm in si8e


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+ns!ection , note angle) shape) contour)ridges) symmetry) cleanliness) color

Jail changes may result rom illness:disease

Pal!ation ,palpate or texture)consistency) thickness) adherence to nailbed

-lanch test #or ca!illary rell / See !. 012 client teaching R3T nail

care


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+ns!ection , note symmetry and shape oeyes) eyebrows) nasolabial olds) andmouth) note any abnormal movements)edema) pallor) sweating) lack o expression)

lesions) or pigment changes.

Pal!ation , palpate the skull or si8e)shape) tenderness) depressions) or swelling


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0ook or redness) edema) inCammation) orlesions on the lids

"he irises should be the same si8e) color)and shape

"he conjunctiva should be clear and shiny.Jote excessive redness or exudate. "hesclerae should be white or bu;


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Jote thepatients pupilsas they respond

to light


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irect res!onse , the illuminated pupilconstricts in response to light directed intothat eye

4onsensual res!onse ,the opposite pupil

constricts in response to the light ( direct and consensual res!onse is a

normal nding

PERR)( 5( 6 accommodation7 need toassess this7 other$ise chart onlyPERR)8


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$ssessing visual 7elds% this is a check operipheral vision

$ssessing EO5s(extra-ocularmovements*

this is a check o eyemovements in the sixcardinal 7elds o ga8e

(p. M?*http'::www.youtube.com:watch3vK$or>26P/


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$. upillary dilation when looking at a arobject

+. upillary constriction when looking at anear object

,. !nvoluntary blinking in the presence obright light

&. ,hanges in peripheral vision in responseto light


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eripheral vision diminishes Bisual acuity decreases as the lens becomes

opa#ue and loses elasticity 5!resbyo!ia8"he ability to accommodate to darkness

and dim light decreases Jear vision decreases ,olor vision declines older people are less

able to perceive purple color anddiscriminate pastel colors


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$. "he eye ocuses the image in the centero the pupil

+. "he eyes converge to ocus on the light ,. ,onstriction o both pupils occurs in

response to bright light &. 0ight is reCected at the same spot in

both eyes


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Observe or position Qsymmetry

"he ears should line up withthe outer corner o the eye

Jote any lesions) nodules)

drainage) or redness Jote any discharge) redness)

or odor at the opening o theear canal

ull the helix back and noteany tenderness (may indicate

otitis externa* atients wearing oxygen %

inspect the top crease o theear or skin breakdown


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Skin o the ear becomes dry and less resilient !ncrease hair along the ear and in the ear inna increases in both width and length and

ear lobes enlongates Earwax is drier Sensorineural hearing loss occurs 6enerali8ed hearing loss on all re#uencies

occurs 5!resbycusis8. "he 7rst symptom isloss o high re#uency sounds' the 4) s4)sh4 and ph4 sounds.

$ NM ld li t t ll th t h h


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$ NM-year-old client tells you that he hasnoticed pain in his let ear when peoplespeak loudly to him. 2hat would be an

appropriate response3

$. ! would just cover my ear to prevent thepain.4

+. "his is normal or people o your age.4 ,. ave you noticed any change in your

ability to hear34

&. ! will check your ear or a middle earinection.4


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enlight) gloves) tongueblade

+ns!ection , lips orcolor) moisture) texture)lesions. "eeth or tartar)

decay) and gums orgingivitis. Jote anylesions) masses)discolorations) si8e anddischarge o tonsils

Pal!ation , palpate anylesions) nodules) ormasses or si8e)tenderness) consistency


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,andida o the tongue $phthous lesion


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"ake N minutes to discuss the ollowingbrain twister with your partner

2hen assessing the pupils o a patientwho is blind in their right eye) what willthe nurse assess3

2hat i the patient has a prosthetic eye3 (aka ake eye or glass eye3*


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1eer to &otter - &erry for these self)eams

BSE on starting on page 53

!a"e genita" e#a$ starting on page 54

/he nurse has a pivotal role in health

promotionand these + self eams areimportant in the promotion of health.

health assessment student copy.ppt

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