Health Assessment General Survey Quiz

Nurse's Role in Health Assessment & Bedmaking

• Objectives:
  • To explain the process of making occupied and unoccupied beds.
  • To outline the role of a nurse in health assessments.
  • To describe the components of a general survey.
  • To outline the differences in assessment types and frequencies.
  • To discuss frameworks for collecting health assessment data.
  • To explain the purposes of physical assessment & a General Survey.
  • To describe cultural diversity, cultural competency, and cultural safety relating these to culturally competent health assessments and improved patient outcomes.
  • To identify the data to collect from the nursing history before a physical examination.
  • To describe the necessary environmental preparations prior to a physical examination.
  • To list techniques needed to prepare a patient physically and psychologically before and during an examination.

Bedmaking

• Principles of medical asepsis:
  • Keep soiled linen away from uniforms.
  • Place soiled linen in special bags before discarding it.
  • Avoid shaking bed linens to prevent the spread of microorganisms.
  • Do not place soiled linen on the floor.
  • Immediately discard clean linen that touches the floor.

Bedmaking - Occupied Bed Procedures

• Equipment: Assemble all required equipment.
• Prepare: Hand hygiene, body mechanics, adjust bed height.
• Bed: Position client according to needs, and adjust pillow and ensure comfort.
• Comfort: Offer necessary items (bedpan, privacy).
• Asepsis: Apply gloves before handling any dirty linens, remove linens carefully.
• Prepare: Loosen top linens, assess what is clean and dirty, remove dirty linens and place into the hamper or beside table.
• Cover: Cover client with a clean sheet or blanket, making sure to tuck correctly and provide cleanliness and comfort.
• Dispose: Place soiled linen in the laundry hamper.

Bedmaking - Occupied Bed - Continued

• Slide up: Instruct on placing the soiled linen correctly under the client and replacing with a new one while sliding up.
• Position: Positioning client, ensuring comfort.
• Be/Gloves: Gloves removal, and comfort checks.
• Make: Make half the bed, tuck dirty linen under, put clean linen on the side and fold correctly.
• Roll: Roll client to other side and readjust side rails, pillow, etc
• Make (full bed): Make other half of the bed, apply appropriate covers/pillows and ensure comfort.
• Ask: Ask client if they are comfortable, ensuring a pleasant experience.
• Side: Side rails up and call bell in position

Bedmaking - Unoccupied Beds

• Open bed: Fold back top coverings to allow easy entry.
• Closed bed: Draw top sheet, blanket, and bedspread up to the head of the mattress and under pillows.

Terms you should know

• Fowler's: HOB elevated at least 45 degrees
• Semi-Fowler's: HOB elevated at 30 degrees
• Trendelenburg: Entire frame tilted, HOB down
• Reverse Trendelenburg: Entire frame tilted, FOB down
• Flat: Bed & frame horizontal and parallel to floor

General Survey

• General health state: Observe and document any obvious physical characteristics.
• General impression: Provide an overarching impression of the patient's overall state.
• First encounter: Start the general survey as soon as you encounter the patient.
• Four areas: Focus on physical appearance, body structure, mobility, and behaviour.

Assessment Techniques

• Inspection: -Using sight and smell to observe body systems, be thorough and systematic. -Compare right with left sides; check for symmetry. -Ensure adequate lighting and patient exposure. -Use instruments like otoscopes, ophthalmoscopes, and penlights when required.

• Palpation: -Use specific parts of the hand to detect texture, swelling, pulsation, lumps, or the position, shape, and consistency of an organ or mass. -Use different parts of hands for assessing different aspects like the dorsa (back) for temperature, the base of fingers for vibration, etc.

• Percussion: -Use short, sharp strokes to assess underlying structures and get sounds like resonance, hyperresonance, tympany, dullness, or flatness. -Distinguish between direct and indirect percussion techniques.

• Auscultation: -Use a stethoscope to detect sounds from the body, including heart, blood vessels, lungs and abdomen. -Pay attention to the quality, pitch, and intensity of sounds. -Ensure proper stethoscope fit and seal.

Types of Assessments

• Emergent: Quick assessment of immediate needs.
• Initial: Comprehensive assessment to understand the overall health status.
• Focused: Assessment for a particular problem or injury.
• Comprehensive: Detailed overview of the patient's medical history.

Purposes of Physical Examination

• Baseline data: Collect starting data.
• Supplementary/confirming data: Aid in confirming or refuting data from the medical history.
• Identifying nursing diagnoses: Confirm or identify potential nursing problems based on examination findings.
• Assessing changing health: Regularly evaluating ongoing shifts in the patient's health.
• Evaluating care outcomes: Evaluate the effectiveness of previous treatment and interventions.

Gathering Health History

• Comprehensive data collection: Ensuring thoroughness and accuracy.
• Relational practice: Establishing a caring and respectful relationship.
• Patient-centred approach: Prioritising the patient's concerns rather than solely focusing on the disease itself.

Developing Nursing Diagnoses

• Critical thinking: Employ critical thinking skills about the patient's condition and history.
• Clinical experience: Apply previous knowledge of similar cases to the current situation.
• Objective database: Create a clear picture of the patient's health status based on collected data.
• Form a diagnosis: Form a definitive nursing diagnosis requiring all aspects to be understood and reviewed.

Managing Patient Problems

• Assessing and intervening: Performing a range of interventions in response to the patient's issues.
• Achieving outcomes: Recognizing change in status and making necessary adjustments in interventions, aiming to achieve the most desirable outcomes.

Evaluating Nursing Care

• Accountability: Showing responsibility for care provided by confirming the results of nursing interventions.
• Physical assessment: Utilizing physical assessment skills to evaluate the patient's response to treatment.

Health Promotion

• World Health Organization (WHO) definition: The process of enabling people to increase control over, and improve, their health.
• Five principles:
  • Involves the population as a whole;
  • Directed toward action on the social determinants of health;
  • Combines diverse complementary methods;
  • Seeks to achieve effective and concrete public participation;
  • Nurtured and enabled by health care providers, particularly in primary care.

Types of Data

• Primary sources: Information collected directly from the patient.
• Secondary sources: Information from patient charts, nursing notes, diagnostic reports, laboratory data and so forth.
• Tertiary sources: Relevant literature and nurse experience.

Summary of Findings and Assessment

• Baseline summary: Baseline assessment findings are important for comparisons in subsequent assessments.
• Inspection: Careful observation using sight and smell to evaluate health status.
• Palpation: Using parts of the hand to assess physical characteristics like lumps, swelling and texture.
• Auscultation: Using a stethoscope to listen to sounds within the body for a variety of conditions.
• History & Body Systems: Patient history aids in understanding areas needing additional evaluation.
• Nursing Process: Critical thinking steps involved in diagnosis and treatment of patient problems.
• Database Formation: Creating a comprehensive database using a variety of data collection methods.

Lab Requirements

• Uniform: Full uniform (scrubs, running shoes, ID, Marker)
• Announcements: Regular check for announcements.
• Lab groups: Check lab groups for details.
• Attendance: Weekly in-person lab attendance.
• Absence: Contact Professor; if required.

Test your knowledge on the components of a general survey in health assessment. This quiz covers critical topics such as safety during assessments, techniques of inspection, and principles of health promotion. Enhance your understanding of nursing practices and cultural competency.