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ARIZONA COLLEGE NUR 216 - Health Assessment

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Health AssessmentData collection● subjective info - health history provided by patient● objective info - physical exam and diagnostic testsInterviewing techniques● standardized formats - framework to getting info about the client's physical,developmental, emotional, intellectual, social, and spiritual dimensions● therapeutic techniques - foster communication and create environment that promotesoptimal health assessment/data collection experience● therapeutic communication○ encourage trusting relationship with patient■ introduce yourself■ determine what the client wants to be called■ ask for health history, check vitals■ reduce environmental noise and eliminate distractions■ note patients nonverbal communication■ avoid using medical jargon, giving advice, or ignoring feelingsHealth history component● Demographic info○ name, address, contact info○ birth date, age○ gender, race, ethnicity○ relationship status○ occupation, employment status○ Insurance○ emergency contact info● Source of history○ patient, family, medical records● Chief concern○ statement in clients words for why they seek care● History or present illness○ detailed, chronological description of why client seeks care○ details about manifestations, alleviating or aggravating factors● Past health history and Current health status○ childhood illness, surgey's, hospitalizations, immunization records○ current meds, environment, food, prescriptions, vitamins, lifestyle and habits● Psychosocial history○ relationships, support system, living or work situation concerns, financial status,spiritual health● Health promotion behaviors○ exercise, diet, stress prevention, sleep, positive coping measures○ awareness of risk for disease or cancer○ prevention of exposure to harmful substances or excessive sunlightGeneral survey - written summary of overall health● Physical appearance○ age, sex, race, ethnicity, level of consciousness, facial features, indication ofdistress, indication if possible physical abuse or neglect, indecation of substanceuse disorder● Body structure○ body build, stature, height, weight, nutritional status, symmetry, posture, grossabnormalities● Mobility○ gait, movement, range of motion, motor activity● Behavior○ facial expression, mood and affect, speech, dress, hygiene, grooming, and odors● Vital signs○ temperature, pulse, respirations, blood pressure, oxygen saturation, painExamination Sequence● follow the sequence: inspecting, palpating, percussion, and auscultation● except in abdomen: inspect, auscultate, percuss, and palpate○ change order to avoid altering bowel sounds● Inspection○ begins with 1st interaction○ equipment: pen light, otoscope, and ophthalmoscope○ senses: vision, smell, and hearing to detect unexpected findings■ inspect size, shape, color, symmetry, and positioning● Palpation○ use of touch to determine the size, consistency, texture, temperature, location,and tenderness of the skin, underlying tissues, an organ, or body part■ light over most body areas <1 in■ deep to evaluate abdominal organs or masses >1.6in○ various parts of hands detect sensations■ dorsal surface is sensitive to temperature■ palmar surface and base of fingertips are sensitive to vibrations■ fingertips are sensitive to pulsation, position, texture, turgor, size, andconsistency■ fingers and thumb are useful for grasping an organ or mass○ start with light palpation, be systematic and gentle○ proceed with deep uncless contradicted● Percussion○ tapping body parts with fingers, fist, or small instruments to vibrate underlyingtissues to:■ determine size and location■ detect tenderness or abnormalities■ check for presence or absence of fluid or air is tissue● Auscultate○ listening to sounds the body produces, identify unexpected finding○ equipment: stethoscope or doppler○ evaluate for: intensity, frequency, duration, and quality■ diaphragm of stethoscope to listen to high pitched soundseg. heart,bowel, and lung sounds■ bell of stethoscope to listen to low pitched soundseg. unexpected heart sounds, bruitsVital signs● Temperature - reflects balance between heat the body produces and heat lost to theenvironment○ core sites: rectum, tympanic membrane, temporal artery, pulmonary artery,esophagus, and urinary bladder○ surface sites: skin, mouth, and axillae○ heat production - results from increases in basal metabolic rate, muscle activity,thyroxine output, testosterone, and sympathetic stimulation○ heat loss■ conduction - transfer of heat from body to another surfaceeg. immersion into cold water■ convection - dispersion of heat by air currents■ evaporation - dispersion of heat through water vapor■ radiation - transfer of heat from one object to another without contactbetween themeg. body heat loss in a cold room■ diaphoresis - visible perspiration on the skin○ fever becomes harmful at 39C or 102.2F■ hyperthermia - body temp exceeds 40C or 104F■ hypothermia - body temp below 35C or 95F● Pulse - measurement of heart rate and rhythm○ autonomic nervous system - controls HR○ parasympathetic nervous system - lowers HR○ sympathetic nervous system - raises HR○ rate - number of times per min you feel or hear the pulse○ rhythm - regularity of impulses○ strength - reflects volume of blood ejected against the arterial wall with eachheart contraction■ scale of 0 to 4● 0 absent, unable to palpate● 1+ diminished, weaker than expected● 2+ brisk, expected● 3+ increased, strong● 4+ full volume, bounding○ dysrhythmia - irregular heart rhythm, with irregular radial pulse○ pulse deficit - difference between apical and radial rate○ locate apical pulse at 5th intercostal space○ tachycardia - rate >100 bpm■ factors: exercise, fever, meds, pain, anemia, hyperthyroidism, heartfailure, hemorrhage○ bradycardia - rate <100 bpm■ factors: hypothermia, long term physical fitness, meds, chronic severepain, hypothyroidism, relaxation● Respirations - mechanism for exchanging O2 and CO2 between the atmosphere and theblood and cells of the body○ ventilation - exchange of O2 and CO2 in the lungs through inspiration andexpiration○ diffusion - exchange of O2 and CO2 between alveoli and RBC○ perfusion - flow of RBC to and from pulmonary capillaries○ rate - number of full inspirations and expirations in 1min○ depth - amount of chest wall expansion that

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