HEALTH ASSESSMENT

• Health assessment is the first step of nursing classes and it directs the rest of the process
• Nursing process is a systematic, organized method of planning in providing quality and individualized nursing care
• Subjective data is the symptoms or the covert data and it is apparent only to the person that is affected
• Objective data is the sign or the overt data which is detectable by an observer and it can be measured or tested
• Interview is a planned communication or conversation with a purpose
• Pre-introductory phase is where nurse reviews the medical record before meeting the client
• Introductory phase is where the nurse explains the purpose of the interview, discusses the types of questions that will be asked, and explain the reasons for taking notes and assure confidential info will remain
• Direct interview is highly structured, use directive questions and its controlled by the nurse
• Non-directive interview are interviewed that is controlled by the client. It is a raport building interview
• Close questions are used in directive interview. It's answerable by yes or no and it is often begin with where, who, what, do, is
• Open ended question is used in non-directive interview. Its answerable by more than one word and it begins with how, why, tell me about
• Neutral questions is where client can answer without direction or pressure from the nurse
• Physical examination is carried out systematically from head to toe


  Cephalocaudal approach
• Screen examination is the review of systems.


  It is brief review of essential functioning of various body parts or systems
• History taking is done first because it provides information on the patient’s health status.
• Physical examination is used to obtain physical data about the client's functional abilities
• Standing is for assessment of posture gate and balance of the patient


  Patients who are weak disabled or paralyzed may need assistance
• Sitting is a seated position that is unsupported and legs are hanging freely


  It is for head neck posterior and anterior thorax breast axillae, heart, vital signs, upper and lower extremities
• Dorsal Recumbent is used for head neck posterior and anterior thorax, breast , axillae, heart, vital signs,vagina, etc.


  Its not for patient with cardio pulmonary problems and its not used for abdominal testing
• Lithotomy is used for assessment of female rectum and vagina


  Patient is lying on the back with hips and knees flexed at right angle and feet in stirrups
• Knee chest is for assessment of rectal area
• Prone is used for assessment of lumbar spine sacrum buttocks and thighs
• Palpation

  use hand to touch and feel patient skin organs mass and other delineated structures in the body
• Percussion is striking of the body surface with short and sharp strokes


  It is used to detect the presence of air and fluid in a body space
• Auscultation is used for listening to sounds produce within the body
• General survey is the first part of physical examination that begins the moment the nurse meets the client
• Vital sign is the common non-invasive physical assessment procedure that most clients are accustomed to
• Temperature is a core body temperature that is maintained by the body
• Pulse is a shockwave produced by the contraction of the heart and forceful pumping of blood out of the ventricles into the aorta
• Respiration is the act of breathing. Rate and character are additional clues to the clients overall health status
• Alterations in body temperature:

  • Pyrexia/Hyperthermia/Febrile: body temperature above the usual range
  • Hyperpyrexia: response to prolonged exposure to cold or need for oxygen in the body
  • Hypothermia: sensor probe shaped like an otoscope in the external opening of the ear canal
• Onset/chill is the set point from normal to higher than normal
• Course/plateau symptoms includes absence of chills, skin that feels warm, increase in PR, RR, thirst. Loss of appetite
• Defervescence symptoms includes sweating, decreased shivering, flushed skin, and possible dehydration
• Eupnea is normal breathing
• Apnea is absence of breathing
• Orthopnea refers to a need to sit up/upright position in order to breath
• Dyspnea describes difficult & labored breathing
• Stridor is a shrill harsh sound during inspiration - laryngeal obstruction
• Wheeze is a high pitched musical squeak on expiration (asthma)