1. Health Assessment

2. Intro Nurses perform assessments regularly in nearly every health care setting ( )care- beginning of shift Nursing home/home care- ( ) or monthly

3. Assessment Techniques 5 basic assessment techniques – Inspection – ( ) – Percussion – Auscultation – ( )

4. Inspection ( ) exam of body parts or areas Important to know what is normal for age before trying to determine abnormal Watch all movements Requires adequate ( )

5. Inspection Requires ( ) exposure of body parts Inspect each area for: – Size, shape, color, symmetry, position, and presence of abnormalities Compare each side of body if possible Ask the ( )

6. Palpation Uses sense of ( ) Detects resistance, resilience, roughness, texture, temperature, and mobility Can be done with ( )

7. Palpation Different parts of hand to detect specific characteristics – Back of hand is sensitive to ( ) – Pads of fingertips detect changes in texture, size, shape, consistency, and pulsation – Palm of hand is sensitive to ( )

8. Palpation Make sure patient is relaxed and comfortable Ask patient to point out sensitive areas Palpate tender areas ( ) Watch for ( ) signs of discomfort Consider the patient’s condition, the area, and the reason for palpation

9. Palpation Light precedes deep Light- apply pressure slowly and gently- ( ) Check tender areas further Deeper- ( )

10. Percussion Tapping the body with ( ) Evaluates size, borders, and consistency of body organs and discover fluid in body cavities Identifies location, size, and density of underlying structures Character of sound depends on density of underlying ( )

11. Auscultation Listening with a ( ) to sounds produced by body Listen in a quiet environment Need to know normal sounds from each body structure

12. Auscultation Need good hearing ( ) Good ( ) Knowledge of how to use stethoscope Need to place directly on skin

13. Auscultation 4 characteristics of sound: – ( )- # of sound wave cycles generated per second; higher the frequency the higher the pitch – Loudness-amplitude of sound wave (loud or soft) – ( )- sounds of similar frequency and loudness from different sources (ex: blowing, gurgling) – Duration- length of time that sound lasts (short, medium, long)

14. Olfaction Sense of ( ) to detect abnormalities

15. OdorSite or SourcePotential Causes AlcoholOral CavityIngestion of alcohol AmmoniaUrineUTI, Renal failure Body odorSkin Wound site Vomit Poor hygiene, excessive perspiration (hyperhidrosis) Abscess; infection Abdominal irritation; contaminated food FecesRectal area Vomit/oral cavity Incontinence; fistula Bowl obstruction Sweet odorTracheostomy or mucus secretions Infection of bronchial tree Foul-smelling stools in infant StoolMalabsorption syndrome HalitosisOral cavityPoor dental and oral hygiene; gum disease; sinus infection Musty odorCasted body partInfection inside cast Stale urineSkinUremic acidosis Sweet, fruity ketonesOral cavityDiabetic acidosis Sweet, heavy, thick odor Draining woundPseudomonas infection

16. Preparation for Assessment Provide ( ) – Close door and pull curtain – In home- examine in bedroom Promote ( ) – Warm, comfortable temperature – Loose-fitting gown or pjs

17. Prep. For assessment Adequate ( ) Control of outside noises Precautions to prevent interruptions Place bed at ( ) level

18. Preparing the Patient Allow patient to empty bowel or bladder Use simple terms and thoroughly explain what will be done, what they will feel, and what the patient can do Provide access to body parts while not exposing others Reduce ( )

19. Preparing Patient Help patient into position Pace assessment according to patient’s physical and ( ) tolerance Encourage to ask questions and report discomfort Have a 3 rd person of patient’s gender in room during assessment of genitalia

20. Skill Guidelines Prioritize assessment based on patient’s presenting S/S Organize the exam- offer ( ) periods Always identify using at least ( ) patient identifiers other than room number Follow standard precautions Record quick notes to facilitate accurate documentation; use appropriate terminology

21. General Survey Includes: – ( ) – Height and weight- recent changes in weight – General behavior- emotional state – Appearance- hygiene, skin and body image

22. Assessment Note any acute distress Review graphic sheet for previous V/S and consider factors that may alter Determine primary ( ) Identify normal height, weight and BMI – How much and how fast have they gained/lost Review past I&O records Assess allergies- esp. ( )

23. Cultural Considerations Mexican American- eye behavior is important; always touch a child when examining him or her ( )- excessive eye contact or touch is offensive African-Americans- dialect requires careful communication to prevent interpretation errors American Indians- eye contact is considered disrespectful

24. General Survey Steps 1.Be sure to note verbal and nonverbal behaviors. Determine LOC and orientation 2.Obtain temp., pulse, respirations, and BP 3.Observe gender, race, and age 4.Always rephrase or ask a similar question if unsure a patient understands 5.If responses are inappropriate, ask short, to- the-point questions that they should know

25. General Survey Steps 6. If unable to respond to questions of orientation, offer simple commands 7. Assess affect and ( ) 8. Watch interaction with caregiver, children, or spouse. 9. Observe for signs of ( )

26. Signs Of Abuse-Child Blood on underclothing Pain in genital area Pain w/ ( ) Vaginal or penile discharge Difficulty sitting or walking Physical injury inconsistent with caregiver’s account of how it occurred

27. Signs of Abuse- Female Injury or trauma inconsistent with reported cause Obvious injuries to face, neck, breasts, abdomen, and genitalia

28. Signs of Abuse-Older Adult Injury or trauma inconsistent w/ reported cause Injuries in unusual locations (neck or genitalia) Pattern injuries Parallel injuries Burns Fractures Poor hygiene Poor nutrition

29. General Survey Steps 10. Assess ( ) (slumped, erect, bent). Note alignment of shoulders and hips. 11. Assess body movements. Purposeful? Tremors? Any body parts immobile? 12. Assess ( )

30. General Survey 13. Observe ( ) and grooming. – Observe color, distribution, quantity, thickness, and texture of hair – Inspect condition of nails – Assess for body odor

31. General Survey 14. Inspect exposed skin and ask if patient has noticed any changes including: – Pruritus, oozing, bleeding – Change in appearance of moles, bumps, nodules – ( ) 15. Inspect color of face, oral mucosa, lips, conjunctivae, sclera, palms of hands and nail beds

32. General Survey 16. Use ungloved fingertips to ( ) skin surfaces. – Use back of hand to palpate temp. – Assess skin turgor by grasping fold of skin on sternum, forearm, or abdomen w/fingertips – Release skin fold and note ease and speed in which in returns

33. General Survey 17. Inspect character of any secretions: note color, odor, amount, and consistency 18. Assess for pressure areas. If see any redness, place fingertip over area, apply gentle pressure and then release. ( )