General Health Assessment Guide PDF

 OFFICIAL  Set priorities for assessment based on signs and symptoms  Use head to toe approach (A-I)  Allow active participation by the client  Record quick notes to facilitate accurate documentation  Consider cultural background  Integrate health pr...

 OFFICIAL  Set priorities for assessment based on signs and symptoms  Use head to toe approach (A-I)  Allow active participation by the client  Record quick notes to facilitate accurate documentation  Consider cultural background  Integrate health promotion and education OFFICIAL  OFFICIAL  Explain to patient the type of assessment you will perform  Empty bladder/bowel before assessment (if required)  Provide privacy  Positioning  Gather equipment required  Explain how long this may take to patient  Watch video TDC: HLTAAP002 Lesson 3 (Collecting Patient information)  Clinical Skills Patient Communication And Assessment (TAFE NSW, 4:27 min) OFFICIAL  OFFICIAL  Provide physical and emotional support  Assist with changes in position  Assist with changes in vitals or condition  Accurate and timely documentation and recording/reporting OFFICIAL  OFFICIAL  Assist patient into comfortable position  Clean and remove equipment  Send specimens if applicable  Report to RN or other team of any concerns OFFICIAL  OFFICIAL 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 5. Olfaction OFFICIAL  OFFICIAL  Rest and activity needs  Nutritional, fluid and electrolyte needs  Safety and security  Hygiene and grooming  Oxygenation and circulation needs  Psychosocial needs  Elimination OFFICIAL  OFFICIAL  Detects resistance, resilence, roughness, texture, temperature, and mobility  Examples: 1. Back of the hand is sensitive to temperature 2. fingertips to detect texture, shape, size and pulsation 3. Palm to sense vibration OFFICIAL OFFICIAL OFFICIAL  OFFICIAL  Examiner strikes a body surface to produce vibration and sound OFFICIAL  OFFICIAL  Listening with a stethoscope to sounds produced by the body  Examples 1. Breath sounds-wheeze, crackles 2. Heart sounds 3. Bowel sounds (hypoactive or hyperactive) OFFICIAL OFFICIAL OFFICIAL OFFICIAL OFFICIAL  OFFICIAL  Utilize sense of smell to detect odors that are characteristic of certain conditions  Examples: 1. Fishy smelling urine 2. Offensive rotting odor of wound 3. Acetone breath 4. Halitosis 5. Fecal odor of vomitus 6. Smoke and alcohol OFFICIAL  OFFICIAL  Assess patient’s condition  Identify problems and needs  Evaluate effectiveness of care given  Recognise the onset of complications or another condition OFFICIAL  OFFICIAL  Interviewing  Observing and examining the patient  Using equipment  Evaluating diagnostic and laboratory test results OFFICIAL  OFFICIAL  Skin  Weight  Height  Body Mass Index [BMI]  Psychological/emotional state OFFICIAL  OFFICIAL  What do you see?  What do you hear?  What do you feel?  What do you smell? OFFICIAL  OFFICIAL  Appearance, behaviour  Pain versus comfortable  Eyes, limbs, abnormalities of the skin  Color (skin, nails, feet, hands, teeth,mouth, ears)  Expression (emotions, mood)  Body posture, gait, height, weight  The ability to perform ADL’s  Degree of independence  The ability to interact with others  Excretions and secretions OFFICIAL  OFFICIAL  Abnormalities of breathing (wheezing)  Abnormalities of heart sounds, blood pressure, bowel sounds  Manifestation of patient’s distress (coughing)  Listening to speech and sounds  Change of the sound of the technical equipment OFFICIAL  OFFICIAL  Skin textures (smooth, rough)  Temperature of skin / dry/moist  Rapid, slow or irregular pulse  Rigid or flaccid muscles  Swelling  Assessing pain  Assessing response/reflexes OFFICIAL  OFFICIAL  Odours are characteristics of certain conditions ◦ Mouth ◦ Fishy smell; infected urine ◦ Ammonia: concentrated ◦ Offensive odour: infected wound ◦ Alcohol – breath ◦ Melaena : blood in stool ◦ Personal hygiene/body odour OFFICIAL  OFFICIAL  Thermometer  Sphygmomanometer/Stethoscope  Scales  Urine testing equipment  Tapemeasure OFFICIAL  OFFICIAL  Colour.  Integrity.  Turgor.  Temperature  Dry/wet OFFICIAL  OFFICIAL Jaundice  Yellowish discolouration of skin and sclera due to excess bilirubin in the blood. OFFICIAL  OFFICIAL Erythema  Redness of the skin produced by congestion of the capillaries. Pallor  Paleness of the skin. OFFICIAL  OFFICIAL Cyanosis  Bluish discolouration of the skin and mucous membranes due to low oxygen in the blood. OFFICIAL OFFICIAL Ecchymosis  Bleeding into tissue under the skin, leaving small bruises. OFFICIAL OFFICIAL Petechiae  Pinpoint sized red dots under the surface of the skin OFFICIAL OFFICIAL Purpura  Purple coloured spots and patches that occur on the skin OFFICIAL  OFFICIAL  Abnormal accumulation of fluid in the bodies tissues.  Can occur in any part of the body; common areas are the feet and ankles. Caused by kidney or heart failure or excessive salt intake OFFICIAL  OFFICIAL  Symptoms ◦ weight gain ◦ swelling of feet, ankles, hands, fingers, face ◦ decreased urine output ◦ shortness of breath ◦ collection of fluid in abdomen (ascites) OFFICIAL  OFFICIAL  Behaviour- position, being noncompliant  Emotional state - crying  Mood or expression OFFICIAL  OFFICIAL  Baseline data on admission  Calculation of drug dosage  Measure of loss or gain in body mass  Measure of fluid retention or loss OFFICIAL  OFFICIAL  Height measurements ◦ Feet ◦ Inches ◦ Centimeters  Weight measurements ◦ Pounds ◦ Ounces ◦ Kilograms OFFICIAL  OFFICIAL  Guidelines for weighing residents ◦ Use same scale each time ◦ Have resident void, remove shoes and outer clothing ◦ Weigh at same time each day ◦ Scales remain accurate if moved as little as possible OFFICIAL  OFFICIAL  Floor scales  Weigh chair  Baby scales  Weight bed OFFICIAL  OFFICIAL  BMI is an indicator of acceptable weight for the height of a person  BMI = weight in kilograms Height in meters²  Indicates if a person is within an acceptable weight range for their height. OFFICIAL  OFFICIAL  A healthy BMI range is from 20-25  30 is obese  > 40 indicates morbid obesity OFFICIAL  OFFICIAL  Alert  Response to voice  Response to pain  Unconscious OFFICIAL OFFICIAL OFFICIAL  OFFICIAL  Resources General Health Assessment:TDC HLTENN037 Lesson 2  Chapter 19: Health assessment frameworks: Initial and ongoing in Tabbner's Nursing Care. OFFICIAL