Foundations Chapter 25 (Health assessment) JERSEY COLLEGE Questions and Answers

Foundations Chapter 25 (Health assessment) JERSEY COLLEGE Questions and Answers Subjective data Symptoms, data that are experienced or known only by the patient and are gathered by verbal report during the health history. Objective data signs, directly observed or elicited through physical examination techniques. Health History collection of subjective information that provides information about the patient's health status. Physical assessment collection of objective data that provides information about changes in the patient's body systems. Comprehensive assessment conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments. Ongoing partial assessment follow-up assessment, conducted at regular intervals during care of the patient. Focused assessment conducted to assess a specific problem Emergency assessment rapid focused assessment conducted when addressing a life-threatening or unstable situation. Components of the health history Biographical data Reason for seeking health care Hx of present health concern Past health Hx Family Hx Functional health assessment Psychosocial and lifestyle factors Review of systems Series of questions about all body systems that helps to reveal concerns or problems as part of the health history. Techniques of physical assessment Inspection, Auscultation, Palpation , Percussion Inspection process of performing deliberate, purposeful observations in a systemic manner. Auscultation act of listening with a stethoscope to sounds produced within the body. 4 characteristics of sounds assessed by auscultation 1) pitch (ranging from high to low) 2) Loudness (ranging from soft to loud) 3) Quality (gurgling or swishing) 4) Duration (short, medium or long) Palpation sense of touch Percussion striking one object against another to produce sound. Supine Pt lies flat on back with legs extended and knees slightly flexed. Used to assess vital signs and head, neck, anterior thorax, lings, heart, breasts, abdomen, extremities, and peripheral pulses. Lithotomy buttocks at the edge of exam table and heels in stirrups. Used to assess female genitalia, and rectum Ecchymosis collection of blood in the subcutaneous tissues, causing purplish discoloration. Petechiae small hemorrhagic sports caused by capillary bleeding. Performing a general survey overall impression of the pt. Includes observing pt's overall appearance and behavior, taking vital signs, measuring height, weight, waist circumference, calculating BMI Precordium potion of the body over the heart and lower thorax, ecompassing the aortic, pulmonic, tricuspid, and apical areas, and Erb's point. Auscultating heart sounds begin at the aortic area, moving to the pulmonic area, then to Erb's point, then tricuspid area and finally to the mitral area. Common cardiovascular and peripheral vascular variations in newborns and children: -visible cardiac pulsation of the chest wall is thin -sinus dysrhythmia (the rate increases with inspiration and decreases with expiration) -Presence of S3 -more rapid heart rate Common cardiovascular and peripheral vascular variations in older adults include: -difficult-to-palpate apical pulse -difficult-to-palpate distal arteries -dilated proximal arteries -more prominent and tortuous blood vessels; varicosities common -increased systolic and diastolic pressure -widening pulse pressure Palpating the Breasts and Axillae Upper outer quadrant, lower outer quadrant, upper inner quadrant, lower inner quadrant. Assessing the abdomen make sure the pt empties the bladder prior. Sequence of assessing the abdomen inspection, auscultation, percussion, palpation. Common abdominal variations in newborns and children: -Umbilical cord in newborns; dries and falls off within the first few weeks of life. -"pot belly" under 5 years of age -visible peristaltic waves Common abdominal variations in older adults include: -decreased bowel sounds -decreased abdominal tone -fat accumulation on the abdomen and hips Common Genitalia variations in newborns and children include: -enlarged labia and clitoris -breast enlargement in both boys and girls -vaginal discharge in girls, called pseudomenstruation -pubic hair and breast development occur at puberty and follow a regular sequence of development -menstruation begins about 2.5 years after puberty begins -irregular menstrual cycle for first 2 years Common genitalia variations in older women include: -decrease size of labia and clitoris -decreased amount of pubic hair -decreased vaginal secretions -pale, thing, and dry vaginal mucosa.