Health Assessment Slides PDF

Assessment Lynne Ordoyne MSN, RN Nursing Instructor Central Piedmont Community Colleg  Learning Objectives Safe and effective Health Promotion and maintenance Physiologic integrity care environment ∙ Prepare the patient...

Assessment Lynne Ordoyne MSN, RN Nursing Instructor Central Piedmont Community Colleg  Learning Objectives Safe and effective Health Promotion and maintenance Physiologic integrity care environment ∙ Prepare the patient and ∙ Discuss the purposes of the ∙ Demonstrate the steps environment for the health assessment used in performing health assessment ∙ Describe the four selected examination ∙ Discuss variations in assessment techniques used procedures assessment techniques in conducting a physical ∙ Discuss expected findings for individuals of varying assessment during the health ages ∙ Describe methods of assessment and ∙ Identify factors affecting assessing vital signs variations across the vital signs (temperature, ∙ Demonstrate knowledge of lifespan. pulse, respirations, blood normal ranges of vital signs ∙ Explain the physiology of pressure) across the lifespan body temperature, pulse, Demonstrate accurate respirations and blood assessment of vital signs pressure Holistic Assessment Physical Psychological Social Spiritual Types of Assessments ○Initial (or baseline) assessment ○Ongoing reassessment ○Problem-focused assessment ○Emergency Assessment Age Considerations Infants Toddlers School Age Children Adolescents Adults Older Adults Cultural Considerations History Review of acute, chronic medical problems Medications Family Health History Disease prevention, health maintenance Disease contact/tracing Functional Assessment Self-care abilities 🞆Continence Risk for falls 🞆Mobility Cognition 🞆Sleep Nutrition and feeding 🞆Skin care  Case Study- Morse Fall Scale History of falling 🞆 Ambulatory aid 🞆 Gait/transferring 🞆 Furniture = Score 30 🞆 Impaired = Score 20 ○ Yes = Score 25 🞆 Crutches, cane, or walker 🞆 Weak = Score 10 ○ No = Score 0 = Score 15 🞆 Normal = Score 0 🞆 None = Score 0 🞆 Secondary 🞆 Mental status (Ask: “Are you 🞆 IV or heparin lock diagnosis able to go to the bathroom alone 🞆 Yes = Score 20 or do you need assistance?”) 🞆 Yes = Score 15 🞆 No = Score 0 🞆 If answer lines up with objective 🞆 No = Score 0 assessment = Score 15 🞆 If not = Score 0 Hester Fall Scale Psychologic Assessment Open ended or closed questions Suicide Prevention Screening Spiritual Assessment Social Assessmen t Physical Assessment Methods of Examination Inspection Palpation Percussion Auscultation Start of Assessment Introduce yourself Infection control Explain purpose of assessment Ask permission Ensure privacy Vital Signs Temperature Pulse Blood Pressure Respirations Oxygen Saturation Pain Environmental Inspection Room Equipment Lines Assess Patients Observe skin color, respiratory effort, and General presence or absence of distress Appearance Evaluate mood and affect Assess posture Observe hygiene, grooming, and dress Check for odor of breath and body Measure height, and weight. Neuro Assessment Sample documentation: normal neurological findings When awake is alert and orientated to person, place and time. Speech is clear, and he is able to follow commands. Appropriate neurologic response to auditory, visual and tactile stimuli. Pupils equal, round and react briskly to light (sometimes abbreviated to PERRLA – pupils equal, round, react to light, accommodation, it is OK for you to use this acronym only if you can explain what it stands for an means  Head Assessment Head Eyes Ears Nose Throat & Mouth Faces and Expressions Sample documentation: normal head assessment Normocephalic, Face symmetrical, No redness, swelling or drainage from the eyes, ears or nose. Mucus membranes moist, all teeth present and well care for Neck Assessment 🞆 Trachea 🞆 Carotid Arteries 🞆 Jugular Vein Distension 🞆 Lymph Nodes 🞆 Thyroid Gland Sample documentation:normal neck assessment Trachea midline. Carotid pulses equal, no JVD, o swelling or painful lymph nodes Skin Assessment Color Temperature Moisture Turgor Edema Lesions Hair Nails Sample documentation: normal skin assessment Skin warm and pink, no lesions or edema. Skin turgor non-tenting. Nails clean well pedicured Cardiac Assessment - Apical Pulse Point of Maximal Impulse (PMI) 5th intercostal space at Midclavicular line  Cardiac Assessment 🞆 Heart Sounds 🞆 Pulses 🞆 Capillary Refill Pulses Pulses Sample documentation: normal CV assessment S1 & S2 heard, pulse rate within normal limits (WNL) and regular. Radial and pedal pulses 3+. Absence of cyanosis, edema, capillary refill less than 2 seconds Respiratory Assessment Shape and symmetry of chest Respiratory Rate Respiratory Effort Cough Breath Sounds Breath Sounds Breath Sounds continued Sample documentation: normal respiratory assessment Respirations regular pattern and depth. Unlabored and symmetrical chest expansion. Clear bilateral breath sounds heard. Pink mucous membranes, No cough, no sputum production Gastrointestinal (GI)/Nutrition Assessment Inspection Auscultation Percussion Palpation Appetite Diet Weight Sample documentation: normal GI assessment No difficulty swallowing or chewing. Abdomen soft, non-tender and non distended. Bowel sounds present in all 4 quadrants. Absence of nausea, vomiting or diarrhea. Last bowel movement (date) Genitourinary(GU) Assessment Bladder Palpation Fluid Intake & Output Assessment of Genitalia Sample documentation: normal GU assessment Continent, Able to empty bladder without difficulty. Urine clear, yellow to amber in color, without odor or sediment. No complaints of frequency, dysuria or hematuria Sample documentation: normal genital assessment Genitalia normal and without redness, swelling or discharge. Breast soft (firm) and non-tender Muscular Skeletal Assessment Inspect posture General body symmetry Muscle Strength Movement Gait normal Muscular Skeletal assessment Full range of motion (ROM) in all extremities. Equal strength bilaterally. Absence of weakness, Steady balanced gait.  Bed in Low Position Side Rails Up Safety Assessmen Call Light t within Reach Personal belongings within reach Restraints