Podcast
Questions and Answers
Which assessment technique is used to touch and feel tissues in order to gather information about the patient?
Which assessment technique is used to touch and feel tissues in order to gather information about the patient?
What is the purpose of the Morse Fall Scale during a health assessment?
What is the purpose of the Morse Fall Scale during a health assessment?
Which vital sign is NOT typically measured in a routine health assessment?
Which vital sign is NOT typically measured in a routine health assessment?
How should a nurse begin the health assessment process?
How should a nurse begin the health assessment process?
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What does a problem-focused assessment primarily involve?
What does a problem-focused assessment primarily involve?
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Which assessment category includes evaluating self-care abilities and risk for falls?
Which assessment category includes evaluating self-care abilities and risk for falls?
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When assessing vital signs, what is typically considered the normal range for adult resting heart rate?
When assessing vital signs, what is typically considered the normal range for adult resting heart rate?
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Which assessment technique involves listening to the sounds made by internal organs?
Which assessment technique involves listening to the sounds made by internal organs?
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What type of assessment would be conducted immediately in response to a patient's sudden decline in health?
What type of assessment would be conducted immediately in response to a patient's sudden decline in health?
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During a spiritual assessment, which approach is most appropriate for a nurse to take?
During a spiritual assessment, which approach is most appropriate for a nurse to take?
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What does PERRLA stand for in a neurological assessment?
What does PERRLA stand for in a neurological assessment?
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Which sign indicates normal neck assessment regarding the trachea?
Which sign indicates normal neck assessment regarding the trachea?
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What is considered a normal finding in a skin assessment?
What is considered a normal finding in a skin assessment?
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Which respiratory assessment finding indicates normal respiratory function?
Which respiratory assessment finding indicates normal respiratory function?
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In a normal cardiovascular assessment, what is the appropriate finding for capillary refill?
In a normal cardiovascular assessment, what is the appropriate finding for capillary refill?
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What finding would indicate a normal gastrointestinal assessment?
What finding would indicate a normal gastrointestinal assessment?
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Which of the following reflects normal findings in a head assessment?
Which of the following reflects normal findings in a head assessment?
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Which statement is true regarding normal pulse assessment?
Which statement is true regarding normal pulse assessment?
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Study Notes
Assessment Learning Objectives
- Prepare the patient and environment for a health assessment, considering age-related variations in techniques.
- Identify factors affecting vital signs (temperature, pulse, respirations, blood pressure).
- Discuss the purposes of health assessments.
- Describe four assessment techniques used in physical assessments, including methods for measuring vital signs.
- Demonstrate knowledge of normal vital sign ranges across the lifespan.
- Demonstrate accurate vital sign assessment.
- Demonstrate steps in performing selected examination procedures, including expected findings and lifespan variations.
- Explain the physiology of body temperature, pulse, respirations, and blood pressure.
Holistic Assessment
- Physical
- Psychological
- Social
- Spiritual
Types of Assessments
- Initial (baseline) assessment
- Ongoing reassessment
- Problem-focused assessment
- Emergency assessment
Age Considerations
- Infants
- Toddlers
- School Age Children
- Adolescents
- Adults
- Older Adults
Cultural Considerations
- (No details provided)
History
- Review of acute and chronic medical problems
- Medications
- Family Health History
- Disease prevention and health maintenance
- Disease contact tracing
Functional Assessment
- Self-care abilities
- Risk for falls
- Cognition
- Nutrition and feeding
- Continence
- Mobility
- Sleep
- Skin care
Case Study - Morse Fall Scale
- History of falling (Yes = 25 points, No = 0 points)
- Ambulatory aid (Furniture = 30, Crutches/cane/walker = 15, None = 0)
- Gait/transferring (Impaired = 20, Weak = 10, Normal = 0)
- Secondary diagnosis (Yes = 15, No = 0)
- IV or Heparin lock (Yes = 20, No = 0)
- Mental status (Ask about bathroom use; score 15 if consistent with objective assessment, otherwise 0)
Hester Fall Scale
- 9-factor scale (scores range from 0-77; Hester et al., 2013).
- Each factor is scored 0-4 (except Age, 0-3).
- Factors include: Age, Last known fall, Mobility, Toileting, Mental status/LOC/awareness, Communication/sensory, Behavior, Medication, Volume/electrolyte status
Psychologic Assessment
- Open-ended or closed questions
- Suicide Prevention Screening
Spiritual Assessment
- (No details provided)
Social Support Network
- Community member
- Partner
- Neighbor
- Friend
- Family member
- Co-worker
Physical Assessment Methods
- Inspection
- Palpation
- Percussion
- Auscultation
Starting an Assessment
- Introduce yourself
- Implement infection control
- Explain the purpose of the assessment
- Obtain permission
- Ensure privacy
Vital Signs
- Temperature
- Pulse
- Blood Pressure
- Respirations
- Oxygen Saturation
- Pain
Environmental Inspection
- Room
- Equipment
- Lines
Assessing Patient General Appearance
- Observe skin color, respiratory effort, and distress.
- Evaluate mood and affect.
- Assess posture.
- Observe hygiene, grooming, and dress.
- Check for odor of breath and body.
- Measure height and weight.
Neuro Assessment (Glasgow Coma Scale)
- Eye opening (spontaneous, to loud voice, to pain, none)
- Verbal response (oriented, confused/disoriented, inappropriate words, incomprehensible sounds, none)
- Best motor response (obeys, localizes, withdraws, abnormal flexion posturing, extension posturing, none)
- Pupillary response
Sample Documentation: Normal Neurological Findings
- Alert, oriented to person, place, and time.
- Clear speech; follows commands.
- Normal neurological response to stimuli (auditory, visual, tactile).
- Pupils equal, round, and react to light (PERRLA) (sometimes abbreviated to PERRLA, accommodation).
Head Assessment
- Head
- Eyes
- Ears
- Nose & Mouth
- Throat
- Facial expressions
Sample Documentation: Normal Head Assessment
- Normocephalic (normal head size), face symmetrical, no redness or swelling. No drainage from eyes, ears, or nose. Moist mucous membranes. All teeth present and well-cared for.
Neck Assessment
- Trachea
- Carotid arteries
- Jugular vein distention
- Lymph nodes
- Thyroid gland
Sample Documentation: Normal Neck Assessment
- Trachea midline. Carotid pulses equal. No jugular vein distention (JVD). No swelling or painful lymph nodes.
Skin Assessment
- Color
- Temperature
- Moisture
- Turgor
- Edema
- Lesions
- Hair
- Nails
Sample Documentation: Normal Skin Assessment
- Skin is warm, pink, no lesions or edema. Skin turgor is non-tenting. Nails are clean and well-manicured.
Cardiac Assessment - Apical Pulse
- (Diagram of heart and related vessels)
Cardiac Assessment
- Heart sounds (Lub Dub) including location of S1 and S2.
Pulses
- Temporal
- Carotid
- Apical
- Brachial
- Radial
- Femoral
- Popliteal
- Posterior tibial
- Dorsalis pedis
Sample Documentation: Normal CV Assessment
- S1 and S2 present, pulse rate within normal limits (WNL) and regular. Radial and pedal pulses are 3+. Absence of cyanosis, edema, and capillary refill <2 seconds.
Respiratory Assessment
- Shape and symmetry of chest
- Respiratory rate
- Respiratory effort
- Cough
- Breath sounds
Breath Sounds - Descriptions and Causes
- Wheezes
- Crackles (fine, coarse)
- Rhonchi
- Stridor
Sample Documentation: Normal Respiratory Assessment
- Respirations regular, unlabored, and symmetrical. Bilateral clear breath sounds, pink mucous membranes. No cough, no sputum production.
Gastrointestinal (GI)/Nutritional Assessment
- Inspection
- Auscultation
- Percussion
- Palpation
- Appetite
- Diet
- Weight
Sample Documentation: Normal GI Assessment
- No difficulty swallowing or chewing. Abdomen is soft, non-tender, and non-distended. Bowel sounds present in all four quadrants. No nausea, vomiting, or diarrhea. Last bowel movement [date].
Genitourinary (GU) Assessment
- Bladder palpation
- Fluid intake and output
- Assessment of genitalia
Sample Documentation: Normal GU Assessment
- Continent, able to empty bladder without difficulty. Urine clear, yellow to amber in color, no odor or sediment. No complaints of frequency, dysuria, or hematuria.
Sample Documentation: Normal Genital Assessment
- Genitalia normal, without redness, swelling, or discharge. Breasts are soft (firm) and non-tender.
Musculoskeletal Assessment
- Posture (general body symmetry, sway back, lumbar lordosis, thoracic kyphosis, forward head posture, good posture)
- Muscle strength
- Movement (gait)
Sample Documentation: Normal Musculoskeletal Assessment
- Full range of motion (ROM) in all extremities. Equal strength bilaterally. Absence of weakness. Steady balanced gait.
Safety Assessment
- Bed in low position
- Side rails up
- Call light within reach
- Personal belongings within reach
- Restraints
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Description
Test your knowledge on health assessment techniques and vital sign measurements. This quiz covers various assessment types, considers age-related variations, and discusses the holistic approach to patient evaluation. Prepare for a comprehensive understanding of physical, psychological, social, and spiritual assessments.
