WGU Health Assessment
Subjective data - Answer: Said by the client (S)
Obejective data - Answer: Observed by the nurse (O)
Assessment Techniques is as follows - Answer: Inspect-Palpation-Percussion-Auscultation
Order of Abdomen Assessment - Answer: Inspect-Auscultation-Percuss-Palapate
Inspection - Answer: *always first*
1. Take time to observe with eyes ear nose
2.Use good lighting
3.Look at color shape symmetry position
4.Observe for odors from skin breath wound
5. Develop and use nursing instincts
6.Inspection is done alone and in combination with other assessment techniuqes
Back of hand - Answer: To assess skin temperature use
Deep Palpation - Answer: 5-8cm or (2-3") deep is considered
Light Paplpation - Answer: 1cm deep is considered
Percussion - Answer: sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
,WGU Health Assessment
Ausculation - Answer: listening to sounds produced by the body
Bell - Answer: picks up low pitched sounds such as heart murmurs
General Survey - Answer: is an overall review or first impression a nurse has of person's well
being.
Appearance - Answer: appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
Body Structure/mobilty - Answer: weight and height WNL BMI guidelines
body parts equal bilaterally
stands erect
sits comfortably
gait is coordinated
walk is smooth and well balanced
full mobility of joints
Behavior - Answer: maintains eye contact with appropriate expressions
comfortable and cooperative
speech clear
clothing is correct for climate
looks cleat and fit
, WGU Health Assessment
appears clean and well groomed
Comprehensive history - Answer: which includes chief complaint or reason for the visit a
complete review of systems and complete past family and social history should be obtained on
the first encounter with a patient regardless of setting and by a RN
Family Health Hx - Answer: Are completed across three generations looking specifically for
patterns in genetic issues that negatively impact quality of life
Health Hx - Answer: gives a picture of patient's current health and documentation must be
completed for each visit and or assessment
How to measure height less than 2 years of age - Answer: Obtain height by measuring the
recumbent length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary
headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are
extended. The foot piece is moved until it is firmly against the child's heels. Read and record the
measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head
should be held by the parent and the knees held so that the hips and knees are extended, mark
the flat surface at the top of the head and tip of the heels. Move child and measure the distance
between the marks with a tape measure. Read and record the measurement to the nearest 1/8
inch
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to
36 months growth chart. When a standing height is obtained for a two year old, plot the finding
on the 2 year to 18 year chart. After plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer according to findings.
Subjective data - Answer: Said by the client (S)
Obejective data - Answer: Observed by the nurse (O)
Assessment Techniques is as follows - Answer: Inspect-Palpation-Percussion-Auscultation
Order of Abdomen Assessment - Answer: Inspect-Auscultation-Percuss-Palapate
Inspection - Answer: *always first*
1. Take time to observe with eyes ear nose
2.Use good lighting
3.Look at color shape symmetry position
4.Observe for odors from skin breath wound
5. Develop and use nursing instincts
6.Inspection is done alone and in combination with other assessment techniuqes
Back of hand - Answer: To assess skin temperature use
Deep Palpation - Answer: 5-8cm or (2-3") deep is considered
Light Paplpation - Answer: 1cm deep is considered
Percussion - Answer: sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
,WGU Health Assessment
Ausculation - Answer: listening to sounds produced by the body
Bell - Answer: picks up low pitched sounds such as heart murmurs
General Survey - Answer: is an overall review or first impression a nurse has of person's well
being.
Appearance - Answer: appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
Body Structure/mobilty - Answer: weight and height WNL BMI guidelines
body parts equal bilaterally
stands erect
sits comfortably
gait is coordinated
walk is smooth and well balanced
full mobility of joints
Behavior - Answer: maintains eye contact with appropriate expressions
comfortable and cooperative
speech clear
clothing is correct for climate
looks cleat and fit
, WGU Health Assessment
appears clean and well groomed
Comprehensive history - Answer: which includes chief complaint or reason for the visit a
complete review of systems and complete past family and social history should be obtained on
the first encounter with a patient regardless of setting and by a RN
Family Health Hx - Answer: Are completed across three generations looking specifically for
patterns in genetic issues that negatively impact quality of life
Health Hx - Answer: gives a picture of patient's current health and documentation must be
completed for each visit and or assessment
How to measure height less than 2 years of age - Answer: Obtain height by measuring the
recumbent length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary
headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are
extended. The foot piece is moved until it is firmly against the child's heels. Read and record the
measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head
should be held by the parent and the knees held so that the hips and knees are extended, mark
the flat surface at the top of the head and tip of the heels. Move child and measure the distance
between the marks with a tape measure. Read and record the measurement to the nearest 1/8
inch
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to
36 months growth chart. When a standing height is obtained for a two year old, plot the finding
on the 2 year to 18 year chart. After plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer according to findings.
