Health assessment mid

• General Survey


  First step in a Head to Toe Assessment
• Components of the General Survey

  • Overall impression of the client
  • Mental status
  • Vital signs
• Overall impression of the client

  • Client's appearance, dress & hygiene, posture and gait, LOC, behaviors, body movements, gender and sexual development, apparent age, skin condition and color, facial expressions and speech
• Mental status


  Refers to a client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviours, stability)
• Mental health


  An essential part of one's total health and is more than just the absence of mental disabilities or disorders
• Mental Status Exam


  Determine clients emotional and cognitive functional status
• Vital Signs


  • Pulse
  • Respiratory Rate
  • Blood Pressure
  • Temperature
  • Pain
• Pain is the 5th vital sign
• General Survey


  • Observes the client and environment before interacting, notes any abnormalities in the client's skin color, dress, hygiene, posture, and body build
• Biographical Data


  • Name, Address, Age, Date of Birth, Birthplace, Gender, Marital Status, Race, Ethnic Identity/Culture, Religion and Spirituality, Occupation
• Source of Information/Reliability


  The usual source of information and the most reliable is the patient who is the primary source. Secondary sources include family members, healthcare professionals and others
• Present Health or Illness

  • Reason for seeking care, symptoms, characteristics (location, radiation, character, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, patient's perception)
• Past History


  • Childhood illnesses, Accidents or injuries, Serious or chronic illnesses, Hospitalizations, Operations, Obstetric history, Immunizations, Last examination date, Allergies, Current medication
• Family History


  To identify the presence of genetics and highlight those diseases and conditions for which a patient may be at increased risk
• Psychosocial History


  Includes information about the patient's occupational history, educational level, financial background, roles and relationships, ethnicity and culture, family, spirituality and self-concept
• Components of the General Survey

  • Physical appearance, Mental status, Mobility, Patient behaviour

  
• Measuring Height


  Patient stands straight with heels together and shoulders back, nurse raises height attachment rod above patient's head until it rests on the crown
• Measuring Weight


  Patient weighed at same time of day in same clothing, without shoes, nurse moves weights until balance beam is level
• Body Mass Index (BMI)

  Calculated as weight (kg) / height^2 (m), used to assess appropriate weight for height
• Mental Health Status


  • Appearance/clothing, Motor behaviour, Speech, Mood, Affect, Orientation, Judgement, Attitude, Perceptual disturbance, Thought and process/form, Thought content, Insight

  
• Preparing the Client


  • Client in comfortable sitting position, explain purpose of examination, explain vital signs will be taken
• Equipment

  • Thermometer, Aneroid and Mercury sphygmomanometer, Stethoscope, Disposable gloves
• Physical Assessment Deviations


  • Malnourished and Obesity, Dwarfism and Gigantism, Acromegaly and Marfan's Syndrome, Cushing's Syndrome, Skin Color, Kyphosis and Lordosis, Scoliosis
• Decorticate posturing


  Abnormal posturing with bent arms, clenched fists, and legs held out straight, can be caused by traumatic brain injury, bleeding, tumor, stroke, drug use, etc.
• Decerebrate posture


  Abnormal posture with arms and legs held straight out, toes pointed down, head and neck arched back, indicates severe brain damage
• Glasgow Coma Scale (GCS)


  Scoring system to describe level of consciousness after brain injury, assesses eye, verbal, and motor responses, ranges from 3 (unresponsive) to 15 (fully responsive)

  
• Vital Signs


  • Body temperature, Pulse rate, Respiratory rate, Blood pressure
• Purpose of Assessing Vital Signs

  Establish baseline data, assess patient response, determine treatment protocols, make life-saving decisions, confirm treatment feedback, monitor patient condition
• Core body temperature


  36.5 °C – 37.7 °C
• Types of Temperature Measurement

  • Core temperature (tympanic, rectal), Surface temperature (oral, axillary)
• Thermometer Types

  • Electronic/Digital, Infrared, Chemical-dot disposable, Temperature-sensitive tape, Mercury-in-glass (no longer used)
• Assessing Body Temperature


  • Assess appropriate site, clinical signs of fever/hypothermia, factors altering temperature, assemble equipment
• Sensor


  Senses the body temperature in the form of infrared energy given off by a heat source
• Chemical-dot disposable thermometer


  • Uses liquid crystal dots or bars or heat sensitive tapes or patches applied to the forehead
  • For reading result, note the highest reading of dots that had colour changes
• Temperature-sensitive tape


  • Tape is applied to skin, forehead, or abdomen
  • Inside the tape is liquid crystals that change colour according to temperature
  • Obtains only body surface temperature
• Mercury-in-glass thermometer

  No longer use in health care settings because it is very hazardous (made of glass and mercury is a toxic chemical)
• Factors to assess when measuring body temperature

  • Site most appropriate for measurement
  • Clinical signs of fever
  • Clinical signs of hypothermia
  • Factors that might alter core body temperature
• Equipment to assemble for measuring body temperature

  • Digital thermometer (infrared if to measure tympanic temperature)
  • Thermometer sheath or cover
  • Tissue and alcohol wipes
  • Container with cool water
  • Small towel (for axillary temperature)
  • Water-soluble lubricant (for rectal temperature)
  • Disposable gloves (for rectal temperature)
  • Waste receptacle
• Must be taken when the client is conscious and can hold the thermometer securely under his tongue and can breathe through his nose
• If the client has just taken a hot or cold drink or food, allow 15-30 minutes to lapse before taking the temperature