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Questions and Answers
What is the primary focus of the general survey in health assessment?
What is the primary focus of the general survey in health assessment?
Which technique should always be performed first during a health assessment?
Which technique should always be performed first during a health assessment?
What is a key action necessary to maintain a safer environment during health assessments?
What is a key action necessary to maintain a safer environment during health assessments?
Which instruments are included in the inspection technique for health assessment?
Which instruments are included in the inspection technique for health assessment?
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What should an assessor do to ensure thorough inspection?
What should an assessor do to ensure thorough inspection?
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Which method uses the sense of touch to confirm observations made during inspection?
Which method uses the sense of touch to confirm observations made during inspection?
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Which part of the hand is best suited for detecting temperature differences during palpation?
Which part of the hand is best suited for detecting temperature differences during palpation?
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What technique involves tapping the skin with short, sharp strokes?
What technique involves tapping the skin with short, sharp strokes?
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Which of the following sounds would typically be assessed using a stethoscope's diaphragm?
Which of the following sounds would typically be assessed using a stethoscope's diaphragm?
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Which percussion sound is characterized by a loud, low-pitched quality?
Which percussion sound is characterized by a loud, low-pitched quality?
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Which technique would best help identify the presence of swelling or a lump?
Which technique would best help identify the presence of swelling or a lump?
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Which quality should be monitored when auscultating sounds from the heart?
Which quality should be monitored when auscultating sounds from the heart?
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What is the primary purpose of using intermittent pressure during palpation?
What is the primary purpose of using intermittent pressure during palpation?
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What is NOT included in a complete health assessment?
What is NOT included in a complete health assessment?
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What is one of the main purposes of a physical examination?
What is one of the main purposes of a physical examination?
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Which principle is crucial for conducting a successful health history interview?
Which principle is crucial for conducting a successful health history interview?
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To develop accurate nursing diagnoses, what must a nurse primarily rely on?
To develop accurate nursing diagnoses, what must a nurse primarily rely on?
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In which type of assessment does a nurse primarily collect comprehensive data about a patient’s condition?
In which type of assessment does a nurse primarily collect comprehensive data about a patient’s condition?
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What do nurses evaluate to demonstrate accountability for their nursing care?
What do nurses evaluate to demonstrate accountability for their nursing care?
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What approach should a nurse take to manage patient problems effectively?
What approach should a nurse take to manage patient problems effectively?
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What does the World Health Organization define as a process to improve health?
What does the World Health Organization define as a process to improve health?
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When should the bed typically be made?
When should the bed typically be made?
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What should be done with bed linens that are wet or soiled?
What should be done with bed linens that are wet or soiled?
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To prevent back injuries, what prior action should be taken when changing linens?
To prevent back injuries, what prior action should be taken when changing linens?
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Which of the following is NOT part of proper body mechanics during bed making?
Which of the following is NOT part of proper body mechanics during bed making?
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How should food particles be handled during bed making?
How should food particles be handled during bed making?
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What is the aim of checking the bed for patient comfort?
What is the aim of checking the bed for patient comfort?
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Which of the following actions is recommended when making an occupied bed?
Which of the following actions is recommended when making an occupied bed?
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What should be done with removed linens during bed making?
What should be done with removed linens during bed making?
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What is one of the primary purposes of conducting a health assessment?
What is one of the primary purposes of conducting a health assessment?
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Which position corresponds to the Fowler's position?
Which position corresponds to the Fowler's position?
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What is a key principle to follow when changing bed linen?
What is a key principle to follow when changing bed linen?
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Which technique can improve patient comfort before a physical examination?
Which technique can improve patient comfort before a physical examination?
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In terms of bed making, what should be done if clean linen touches the floor?
In terms of bed making, what should be done if clean linen touches the floor?
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Which of the following best describes a general survey in health assessment?
Which of the following best describes a general survey in health assessment?
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What should be avoided to prevent transmitting infection when dealing with soiled linen?
What should be avoided to prevent transmitting infection when dealing with soiled linen?
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How often should a nurse check the condition of a patient's bed linens?
How often should a nurse check the condition of a patient's bed linens?
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What is the purpose of using a bell on a stethoscope during auscultation?
What is the purpose of using a bell on a stethoscope during auscultation?
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Which anatomical plane divides the body into equal left and right halves?
Which anatomical plane divides the body into equal left and right halves?
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In anatomical terms, which movement is described as occurring at the articulation of bones?
In anatomical terms, which movement is described as occurring at the articulation of bones?
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Which approach is NOT typically used to describe a patient's body structures or functions?
Which approach is NOT typically used to describe a patient's body structures or functions?
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Which of the following assessments is NOT included in a complete health assessment?
Which of the following assessments is NOT included in a complete health assessment?
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What should be done to minimize artifact sounds during auscultation?
What should be done to minimize artifact sounds during auscultation?
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Which anatomical plane divides the body horizontally at the level of the umbilicus?
Which anatomical plane divides the body horizontally at the level of the umbilicus?
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What does a holistic assessment include?
What does a holistic assessment include?
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Study Notes
Nurse's Role in Health Assessment & Bedmaking
- Objectives: Discuss techniques for making occupied and unoccupied beds. Describe a professional nurse's role in health assessments. Demonstrate understanding of health assessment purposes. Describe components of a General Survey. Demonstrate knowledge of different assessment types and frequencies. Discuss frameworks for collecting health assessment data.
Learning Objectives
- Explain purposes of physical assessment and General Survey.
- Describe cultural diversity, competence, and safety in relation to culturally competent health and physical assessments, improving patient health outcomes.
- Identify data to collect from nursing history prior to physical examinations.
- Explain environmental preparations needed before physical examinations.
- List techniques used for preparing patients physically and psychologically before and during physical examinations.
Bed Making
- Principles: When changing linens, nurses adhere to medical asepsis, keeping soiled linen separate from uniforms. Soiled linens are placed in special bags before disposal in a hamper. Avoid shaking linens to prevent spreading microorganisms. Avoid placing soiled linens on the floor. Discard clean linen if it touches the floor.
Terms to Know
- Fowler's: HOB (head of bed) elevated at least 45 degrees.
- Semi-Fowler's: HOB elevated at 30 degrees.
- Trendelenburg: Entire bed frame tilted, HOB positioned downward.
- Reverse Trendelenburg: Entire bed frame tilted, Foot of Bed positioned downward.
- Flat: Bed and frame horizontal, parallel to the floor.
Bed Making (Continued)
- Daily Maintenance: Beds should be kept clean and comfortable. Regular inspections ensure linens are wrinkle-free. Frequently check for soiled linens if patients frequently sweat, have draining wounds, or are incontinent.
- Routine Procedures: Bed linens are made in the morning, after baths, or while the patient is out of the room for procedures or tests. As needed throughout the day, bed linens should be adjusted and straightened. Check for food particles or any soiling after meals. Change soiled or wet linens.
- Body Mechanics: Proper body mechanics are crucial during bed making to avoid back injuries. Use proper lifting techniques, and adjust the bed height to avoid bending or stretching over the mattress. Change positions when placing linens. Body mechanics are also vital when turning or repositioning patients.
Procedure for Making an Occupied Bed
- Equipment: Assemble equipment, perform hand hygiene.
- Prepare: Use body mechanics to adjust bed height to waist level to accommodate patient. Assess client comfort, including needs for bedpan or privacy.
- Comfort: Provide privacy and offer bedpan/commode if needed.
- Asepsis: Wear gloves when removing/handling bed linens.
- Prepare: Loosen top linens, determine what needs to be changed or laundered, and remove to hamper or table.
- Cover: Place clean linens and blankets/blankets over the patient.
- Dispose: Place soiled linens in the laundry hamper, keeping them away from your uniform.
Procedure for Making an Occupied Bed (Continued)
- Slide Up: Slide the client up the mattress, ensuring proper positioning, and adjusting the pillows.
- Position: Position the client so their side is close to the side rail.
- Make: Make half of the bed, changing the linens on one side.
- Roll: Roll the client onto the other side of the bed, assisting if needed.
- Make: Make the other half of the bed.
- Ask: Ask if the client is comfortable and adjust linens as needed.
- Side Position side rails up securely, and call bell in place.
Procedure for Making an Unoccupied Bed
- Open Beds: Top covers should be folded back, making it easier for the patient to get into the bed.
- Closed Beds: For hospital rooms, beds are typically prepped as closed beds. The top sheets, blankets, and bedspreads are pulled up around the head of the mattress and under the pillows.
- Modified Beds: Surgical, recovery, and postoperative beds are modifications of open beds for patient transfer to the bed from stretchers.
- Transfer: The top linen is arranged for easier transfer from a stretcher. Top sheets are not tucked in the corners but are folded to a side or bottom third for easier maneuvering.
General Survey
- Impressions: Overview of the patient's general health state and obvious physical characteristics.
- Areas: Begins from the first encounter and includes physical appearance, body structure, mobility, and behavior.
A Safer Environment
- Focus: Maintaining cleanliness, using proper equipment, avoiding spread of nosocomial infections, hand hygiene, and use of gloves and standard and transmission-based precautions for patient care.
Assessment Techniques
- Types: Inspection (visual and olfactory), palpation (touch), percussion (tapping), and auscultation (listening).
Cultivating Your Senses (Inspection)
- Overview: Focused observation, comparing right and left sides, and appropriate lighting. Using tools like otoscopes, ophthalmoscopes, and penlights for further examination depending on the body part in question.
Palpation
- Touch: Use various parts of the hand (fingertips, palms) for assessment. Touch can be used to assess skin texture, swelling, lumps, and body organ shape and consistency.
Percussion
- Tapping: Using short, sharp strokes to assess underlying structures and detect sounds like resonance, hyperresonance, tympany, dullness, or flatness. This technique is used to detect abnormalities in organs.
- Direct percussion: Striking the body directly with the hands.
- Indirect percussion: Using a stationary and striking hand to create a sound from which one can predict body structure.
Auscultation
- Listening: Using a stethoscope to detect body sounds from bodily functions like circulatory, respiratory, and digestive system sounds produced by heart, blood vessels, lungs, and abdomen.
Using the Stethoscope
- Diaphragm: Used for high-pitched sounds (e.g., breath, bowel sounds, and normal heart sounds).
- Bell: Best for low-pitched sounds (e.g., heart murmurs and blood pressure).
- Sealing: Proper sealing is crucial for minimizing environmental noise and inaccurate measurements.
Anatomical Terms, Planes and Surfaces
- Purpose: Clarify communication regarding body parts, structures, and their relationship to other body structures. Using anatomical terms is essential for consistent and accurate descriptions.
- Descriptions: Using standardized terms for location and direction.
- Planes: Sagittal, coronal, and transverse/horizontal, median.
Introduction to Health Assessment
- Overview: Holistic assessments encompass the emotional, intellectual, physical, psychosocial, spiritual, and cultural dimensions of a patient. Complete health assessments include a nursing history, behavioural and physical examinations, and cultural assessments
Purposes of Physical Examination
- Data Collection: Gather baseline data, supplementing, confirming, or refuting history data. Confirming and identifying nursing diagnoses. Making clinical judgments of patient's status, management of changing health conditions, and evaluating outcomes of care.
Gathering a Health History
- Principles: Gathering data requires patience and attention to detail, focusing on the patient's perspective, not just the disease. Collecting data to form a comprehensive database about a patient, allowing a more comprehensive understanding of the patient's health status and the reason the patient is seeking help.
Developing Nursing Diagnoses and a Care Plan
- Critical Thinking: The nurse must critically analyze patient information and previous clinical experience to make a definitive nursing or medical diagnosis to form a care plan.
- Database (patient): All collected data forms a database to identify patient's health problems, health needs, and reactions to care.
- Problem-Oriented Approach: A method that nurses can use during assessments.
Managing Patient Problems
- Interventions: Nurses use a range of interventions during patient care, identifying patient status changes and modifying interventions to achieve the best outcomes.
Types of Assessments
- Different Procedures: Different types of assessments (emergent, initial, focused, and comprehensive) are used.
Evaluating Nursing Care
- Accountability: Nurses evaluate the effects of their interventions to demonstrate accountability for care quality.
- Physical Skills: Use physical assessment skills to evaluate patient condition and response to care.
Health Promotion
- Principles: Involves the entire population, social determinants of health, diverse methods, public participation, and care from health providers.
- Focus: Moving from individual behaviors to social and environmental care interventions.
Types of Data
- Primary Sources: Client-gathered information, interviews, narratives, etc.
- Secondary Sources: Data from patient charts, nursing notes, medical reports, lab results, etc.
- Tertiary Sources: Reliable and relevant medical literature or similar data used to supplement the previous sources.
Summary of Assessment Findings
- Comparison: Comparing initial and subsequent assessment findings of patients to reflect patient functional abilities. Inspections compare opposing body parts.
- Palpation: Parts of the hands are used for detailed, consistent, and slow palpations to feel patient characteristics. A variety of touch methods (e.g., fingertips, palms, backs of hands) detect different types of characteristics.
- Auscultation: Stethoscopes are used to identify sounds and organ functions to gain insights into the patient's overall health.
- Nursing Process: A critical thinking system is used to identify, diagnose, treat, and resolve patient health issues.
- Databases: Assessments are used to create a comprehensive database of the patient's perceived health needs, problems, reactions, and responses to care.
- Problem-Oriented Approach: Identifying a patient's health problems is included in the assessment process.
- Diagnostic Cues: Interpretation of gathered data leads to identification of patient issues and problems. Caregivers' and friends' observations are also considered when determining treatment.
Lab this Week
- Required Materials: Full uniform, running shoes, Mohawk ID, pencil/paper, fine-tip dry-erase marker.
- Attendance: Attendance during in-person labs is essential and part of lab engagement marks. Check announcements regularly. Communicate any absences to the professor.
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Description
Test your knowledge on key techniques used in health assessments, including inspection, palpation, and auscultation. This quiz covers essential actions, instruments, and methods healthcare professionals should know to ensure effective assessments and maintain a safe environment for patients. Challenge yourself to remember vital concepts in health evaluation!
