Ch 27 Taylor Health Assess

.docx

School

Jfk Muhlenberg Snyder school of nursing**We aren't endorsed by this school

Course

NURM 141

Subject

Chemistry

Date

Dec 18, 2024

Pages

Uploaded by MajorWorldGazelle27

Health Assessment Ch 27Subjective: based on client experience and perceptions Objective: measurable and directly observed ie: vital signs, i&o’sIncludes two components:1. health history – collection of subjective information about the client’s health status2. physical assessment – collection of objective data about changes in the client’s body systemsTypes of health assessments1.Comprehensive– upon admission – can take an hour, 1.5 hours – interview and physical assessment2.Ongoing partial– conducted at regular intervals3.Focused– conducted to assess a specific problem4.Emergency– conducted t5.Determine life-threatening or unstable conditionsPreparing the client for physical assessment:Consider the physiologic and psychological needs of the clientExplain the process of the clientExplain that physical assessments should not be painful (decrease client fear and anxiety)Explain each procedure in detail as it is conductedExplain that privacy will be maintained using drapesAnswer clients’ questions directly and honestlyconsider: -lifespan considerations – newborn vs. elderly-cultural sensitivity-client prep-environmental nurse’s role:assist before, during and after diagnostic testscomplete testing as prescribedwitness the client’s consentschedule the testprepare the client physically and emotionallyprovide care and teaching after the testdispose of used equipmenttransport specimens

factors to assess during health historybiographical data -- subjective- demographics; client’s name, address and billing and insurance info. Additional biographical info may include biologic sex, sexual orient, gender identity, age and birth date, martial status, occupation, race, ethnic origin, religion, presence of advance directive/living will, client’s pcpreason or seeking health care-subjective: statements in the client’s own words that describes why they are seeking careask open-ended questions; record whatever the person says in their words; avoid paraphrasing or interpretationshistory of present health concernexplore the symptoms(subjective) thoroughly. The description should include info regarding the onset of the problem, location, duration, intensity, quality/description, relieving/exacerbating factors, associated factors, past occurrences, any treatments, and how the problem has affected the client.past health history- may provide insight into current symptoms; alerts the nurse to certain risk factors. Include childhood/adult illnesses, chronic health problems, previous surgeries or hospitalizations. Accidents/injuries, obstetric history, allergies, and the date of most recent immunizations. Health maintenance screenings like mammograms; OTC or prescribed meds, vitamins supplements, herbal (include the name, dose, route, frequency, and purpose for each med)family health history- provides insight into diseases and conditions for which an individual patient may be at increased risk, history of cancer in the familyfunctional health- helps to identify the effects of health or illness on a client’s self-care abilitiesand quality of life; psychosocial factors and lifestyle and health practices can contribute to overall health and well-being ie: smoking modifiable risk factor, can always change this**- level of activity and exercise, sleep and rest, and nutrition. Assess ability to perform activities of daily life or self-care activities eating, bathing, dressing and toileting- assess ability to perform instrumental activities of daily living housekeeping- obtain info related to values, beliefs, spirituality, self-esteem and self-concept, coping and stress management- ask about personal habits, alcohol, drugs-mental health – depression or suicide – screening tools.-sexual health – neutral terms ie: partner; nonjudgmental manner to obtain info about sexual history, activity, gender identity, and sexual orientationpreparing the environment for physical assessmentmake sure client is as free of pain as possibleprepare exam table

provide a gown and drapegather suppliesequipment:thermometer and sphygmomanometerscalestethoscopepenlightruler, metric tapeeye chartwatch with a second handpositions used during a physical assessmentstanding – posture, balance gaitsitting – upper bodysupine – relax absdorsal recumbent – used for clients having difficult maintain supine positionSIMs – rectum/vaginaProne – hip joint and posterior thoraxLithotomy – female genitals rectumKnee-chest – anus and rectumTechniques:1.Inspection – concentrated looking- assessing size, color, shape, position and symmetry2.Palpation – all except abdomen – palpate abdomen last - assessing temp, turgor, texture, moisture, vibrations and shape3.Percussion – assessing location, shape size and density of tissues4.Auscultation – assessing the four characteristics of sound: pitch, loudness, quality, duration** differs by system**Conducting a physical assessment-various organizing structures for conducting a physical assessment – head to toe, body system approach, including all or some of the assessmentsGeneral survey – overall impression of the clientobserving the client’s overall appearance and behavior, taking vital signs, measuring height, weight, and waist circumference, head circumference, calculating BMIinformation obtained from the general survey provides clues to the client’s overall health

Body Mass Index BMI : ratio of weight to height-Used as an initial assessment of nutritional status and is an indicator of obesity or malnutrition-BMI provides an estimation of relative risk for heart disease, HBP, types 2 diabetes, gallstones, breathing problems, certain cancers-BMI <18.5 – underweight-BMI 30-39.9 obese-BMI > 40 extremely obeseDefining mental status:-Emotional and cognitive functioning-Language – can they communicate-Mood and affect (temporary expression of feelings or state of mind)-Orientation – awareness of the objective world in relation to self-Attention – ability to concentrate without distraction-Memory – recent memory, remote memory – ability to store experiences and perceptions for later recall.-Abstract reasoning – deeper meaning beyond the concrete or literal-Thought process – logical train of thought-Thought content – ideals and beliefs-Perception – awareness of an object through the five senseWhen to perform a full mental status exam-Behavior changes-Brain lesions (trauma, tumor, brain attack)-Aphasia (caused by brain damage)-Symptoms of psychiatric mental illnessContributions from health historyKnown illness or health problemCurrent medications known to affect mood or cognitionBaseline educational and behavioral level Personal history; current stress, social habits, sleep habits, drugs and alcohol useAppearance - Behavior – Cognition- Thought processBehavior– level of consciousnessAlert- arousable, oriented, full aware lethargic – not fully alert; drifts off to sleep when stimulated; can be aroused to name when called in normal voice but looks drowsy

obtunded – sleeps most of the time, difficult to arouse, acts confused when aroused,speech may be mumbled and incoherent Abnormal findings with mood or affect:Flat affect (blunted affect) – no expression, lack emotional responsesDepressionDepersonalization (lack of ego boundaries) – feel estranged from the situationElationEuphoriaAnxiety