1B - Health Asssessment

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Created by
Loraine Aguason

Cards (235)

  • Developmental levels

    Across life span using the principles of selected developmental theorists
  • Validation

    Process to confirm that subjective and objective data are reliable and accurate
  • Steps of Validation

    1. Deciding whether data require validation
    2. Determining ways to validate the data
    3. Identifying areas for which or when data are missing
  • Failure to do validation may result in premature closure of the assessment or collection of inaccurate data
  • Provide a basic understanding of the significant contributions made by theorists (psychosexual, psychosocial, cognitive, and moral development of humans) fundamental to performing a holistic nursing assessment
  • Invasive diagnostic test

    Access body tissue, organ, or cavity through some type of instrumentation procedure
  • Non-invasive diagnostic test

    Body is not entered with any type of instrument
  • Errors during the second part of nursing process (analysis of data)
  • Trust vs. Mistrust

    1. Begins at birth and continues to approximately 18 months of age
    2. Infant is uncertain about the world and looks towards primary caregiver for stability and consistency of care
    3. Negative: Fearful and suspicious
    4. Positive: Drive and hope
  • Phases of diagnostic test
    1. Pre-test: Focuses on the client's preparation
    2. Intra-test: Phase focusing on specimen collection, performance or assisting with a certain diagnostic test, nurse uses standard precaution and sterile technique
    3. Post-test: Focus on nursing care of the client, follow-up activities and observation, compares previous and current results, then modify nursing intervention as needed
  • General rule for diagnostic test
    • Verify order
    • Verify identity (at least 2 unique identifiers)
    • Verify client's consent
    • Provide explanation to client and relative (significant others)
    • Explain diagnostic test, purpose, requirement/preparation
    • Adhere to universal precaution/aseptic technique
    • Proper handwashing
    • Proper complete and accurate labelling of specimen
    • Note of proper preservation procedure/transport
    • Proper disposal of supplies and equipment that was used
  • Client teaching for diagnostic test
    • Reason for test and what to expect
    • Estimated time it will take
    • Whether NPO
    • Cathartics or laxatives (dose and frequency)
    • Instructions for specific tests (e.g. sputum collection, urine collection, no jewelry/objects for X-ray, barium and iodine effects)
    • Positioning prior and post test
  • Not every piece of data collected must be verified (no need sometimes to repeat the V/S)
  • Invasive diagnostic tests

    • Laboratory exams
    • Electrocardiogram (ECG)
    • Stress ECG
    • Electroencephalography (EEG)
    • Holter ECG
    • Chest X-ray
    • Cardiac ultrasonography (echocardiography)
  • Non-invasive diagnostic tests

    • Electrocardiogram (ECG)
    • Stress ECG
    • Electroencephalography (EEG)
    • Holter ECG
    • Chest X-ray
    • Cardiac ultrasonography (echocardiography)
  • Assessing Body Temperature
    1. Introduce self and verify client's identity
    2. Explain procedure to client and discuss how results will be used
    3. Gather appropriate equipment
    4. Perform hand hygiene and observe other appropriate infection prevention procedures
    5. Provide for client privacy
    6. Place the client in the appropriate position
    7. Place the thermometer
    8. Wait the appropriate amount of time
    9. Remove the thermometer and discard the cover or wipe with a tissue if necessary
    10. Read the temperature and record it on worksheet
    11. Wash the thermometer and return it to storage location
    12. Use effective body mechanics throughout procedure
    13. Communicate appropriately with the client
    14. Document all relevant information
  • Purpose of the 4 phases of the client's interview
    • Pre-introductory: Nurse reviews the medical record before meeting with the client
    • Introductory: Introduce self to the client, explain the purpose of interview
    • Working Phase: Elicit client's comments and information
    • Summary and Closing Phase: Summarize information, provide goals, discuss plan
  • Assessing an Apical Pulse
    1. Introduce self and verify client's identity
    2. Explain procedure to client and discuss how results will be used
    3. Gather appropriate equipment
    4. Perform hand hygiene and observe other appropriate infection prevention procedures
    5. Provide for client privacy
    6. Position the client appropriately in comfortable supine position or sitting position. Expose area of the chest over the apex of the heart
    7. Locate apical pulse
    8. Auscultate and counted heartbeats
    9. Assess the rhythm and strength of heartbeat
    10. Use effective body mechanics throughout procedure
    11. Communicate appropriately with the client
    12. Document all relevant information
  • Assessing an Apical-Radial Pulse
    1. Introduce self and verify client's identity
    2. Explain procedure to client and discuss how results will be used
    3. Gather appropriate equipment
    4. Perform hand hygiene and observe other appropriate infection prevention procedures
    5. Provide for client privacy
    6. Position the client appropriately in comfortable supine position or sitting position. Expose area of the chest over the apex of the heart
    7. Locate apical pulse
    8. Count the apical and radial pulse rates for 60 seconds
    9. Use effective body mechanics throughout procedure
    10. Communicate appropriately with the client
    11. Document all relevant information
  • Documentation of diagnostic procedures
    • Who performed the procedure
    • Reason for the procedure
    • Type of anesthesia, dye, or other medications administered
    • Type of specimen obtained and where it was delivered
    • Vital signs and other assessment data, such as the client's tolerance of the procedure or pain and discomfort level
    • Any symptoms of complications
    • Who transported the client to another area (designate the names of persons who provided transport and place of destination)
  • Effective verbal communication Techniques
    • Open ended questions
    • Closed ended questions
    • Laundry list
    • Rephrasing
    • Well-phrased phrases
    • Inferring
    • Providing information
  • Assessing Respirations

    1. Introduce self and verify client's identity
    2. Explain procedure to client and discuss how results will be used
    3. Gather appropriate equipment
    4. Perform hand hygiene and observed other appropriate infection prevention procedures
    5. Provide for client privacy
    6. Observe or palpate and count respiratory rate
    7. Observe depth, rhythm, and character of respirations
    8. Use effective body mechanics throughout procedure
    9. Communicate appropriately with the client
    10. Document all relevant information
  • MORNING PRAYER
  • Effective nonverbal communication Techniques
    • Appearance
    • Demeanor
    • Facial expression
    • Attitude
    • Silence
    • Listening
    • Smile/appropriate facial expression
    • Maintain open position
  • PHYSICAL EXAMINATION
  • Autonomy vs. Shame and Doubt
    1. Occurs between 18 months to 3 years
    2. Children focused on developing a sense of personal control over physical skills and a sense of independence
    3. If encouraged and supported, they become more confident and secure in their ability to survive
  • Health Assessment

    An essential nursing function that provides the foundation for quality nursing care and intervention, helps to identify client needs or clinical problems, identify patient strengths, and evaluate response to health management
  • HEALTH ASSESSMENT PREPARED BY: RHANILYN R. BRUL,RN Clinical Instructor
  • Assessing the skull and face
    Inspection and palpation of the skull and face; and also measuring the skull circumference, in which the presence of deviation and changes of facial shape may indicate a disorder or certain condition
  • Before to proceed with the assessment: Don't forget! Always ask first the client history
  • Inspection

    • For size, contour, shape and evidence of trauma
  • Palpation

    • For lumps or bumps, lesions and any evidence of trauma
  • Size, shape and symmetry of skull
    NORMAL: Rounded (normocephalic and symmetric, with frontal, parietal, and occipital prominences); smooth skull contour
  • Size, shape and symmetry of skull
    DEVIATION FROM NORMAL: Lack of symmetry; increased skull size with more prominent nose and forehead; longer mandible (may indicate excessive growth hormone or increased bone thickness)
  • Assessing for nodules, massess and depression
    NORMAL: normally hard and smooth uniform. consistency Absence of nodule or masses and depressions
  • Assessing for nodules, massess and depression

    DEVIATIONS FROM NORMAL: Presence of nodule or masses and depressions
  • How to palpate the skull for any nodules, masses and depression?
    Use gentle rotating motion with fingertips. Begin at the front and palpate down the midline, then palpate each side of the head
  • Facial features

    • Inspect the symmetry of structures and of the distribution of hair
  • Eyes

    • Inspect for edema or hollowness
  • Facial movements

    • Note symmetry of facial movements