Health Assessment and Physical Examination 2022

Health Assessment and Physical Examination 2022 List the five nursing purposes for performing a physical assessment. (5) - Answer- a. Gather baseline data about the patient's health status b. Support or refute subjective data obtained in the nursing history c. Confirm and identify nursing diagnoses d. Make clinical judgments about a patient's changing health status and management e. Evaluate the outcomes of care List the principles related to the nurse performing daily physical examinations. (4) - Answer- a. A head-to-toe assessment is required daily b. Reassessment is performed when the patient's condition changes as it improves or worsens c. The environment, equipment, and patient are properly prepared d. Safety for confused patients should be a priority Proper preparation for examination should include: (5) - Answer- a. Infection control b. Environment c. Equipment d. Physical preparation of the patient e. Psychological preparation of the patient List seven variations in the nurse's individual style that are appropriate when examining children. (7) - Answer- a. Gather all or part of the histories of infants and children from parents b. Perform the examination in a nonthreatening are and provide time for play c. Offer support to the parents during the examination and do not pass judgment d. Call children by their first names and address their parents as Mr. and Mrs. e. Use open-ended questions to allow parents to share more information f. Treat adolescents as adults g. Provide confidentiality for adolescents; speak alone with them List seven variations in the nurse's individual style that are appropriate wen examining older adults. (7) - Answer- a. Do not stereotype about aging patients's level of cognition b. Be sensitive to sensory or physical limitations (more time) c. Adequate space is needed d. use patience, allow for pauses, and observe for details e. Certain types of information may be stressful to give f. Perform the examination near bathroom facilities g. Be alert for signs of increasing fatigue Identify the principles to follow to keep an examination well organized. (7) - Answera. Compare both sides for symmetry b. If a patient is ill, first assess the systems of the body part most at risk c. Offer rest periods if the patient becomes fatigued d. Perform painful procedures near the end of the examination e. Record assessments in specific terms in the record f. Use common and accepted medical terms and abbreviations g. Record quick notes during the examination to avoid delays Define inspection. - Answer- Looking, listening, and smelling to distinguish normal from abnormal findings Identify the guidelines to achieve the best results during inspection. (6) - Answer- a. Adequate lighting is available b. Use direct light source c. Inspect each area for size, shape, color, symmetry, position, and abnormality d. Position and expose body parts as needed, maintaining privacy e. Check for side-to-side symmetry f. Validate findings with the patient Define palpation - Answer- Using the hands to touch body parts. Light palpation - Answer- Pressing inward 1 cm (surperficial) Deep palpation - Answer- Depressing the area 4 cm to assess the conditions of organs. Define auscultation - Answer- Listening to the internal sounds the body makes. Auscultating sounds: Frequency - Answer- Frequency indicates the number of sound wave cycles generated per second by a vibrating object Auscultating sounds: Amplitude - Answer- Loudness, soft to loud Auscultating sounds: Quality - Answer- Sounds of similar frequency and loudness Auscultating sounds: Duration - Answer- Length of time that sound vibrations last List at least 12 specific observations of the patient's general appearance and behavior that should be reviewed. (12) - Answer- a. Gender and race b. Age c. Signs of distress d. Body type e. Posture f. Gait g. Body movements h. Hygiene and grooming i. Dress j. Body odor k. Affect and mood l. Speech Identify some signs of patient abuse. - Answer- Physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising). Also watch for fear of the spouse or partner, caregiver, or parent. Identify the questions related to the following acronym. CAGE - Answer- C: Have you ever felt the need to cut down on your use? A: Have people annoyed you by criticizing your use? G: Have you ever felt bad or guilty about your use? E: Have you ever used or had a drink first thing in the morning as an "eye opener" to steady your nerves or feel normal? List three actions that should be taken to ensure accurate weight measurement of a hospitalized patient. (3) - Answer- a. Weigh patients at the same time of day b. Weigh patients on the same scale c. Weigh patients in the same clothes Assessment of the skin reveals the patient's health status related to: (5) - Answer- a. Oxygenation b. Circulation c. Nutrition d. Local tissue damage e. Hydration List the risks for skin lesions in hospitalized patients. (9) - Answer- A. Exposure to pressure during immobilization b. Various medications c. Neurologic impairment d. Chronic illness e. Orthopedic injury f. Diminished mental status g. Poor tissue oxygenation h. Low cardiac output i. Inadequate nutrition Define pigmentation. - Answer- Pigmentation is skin color. It is usually unifrom over the body Color: Cyanosis Condition: ? Causes: ? Assessment Locations: ? - Answer- Condition: Increased amount of deoxygenated hemoglobin (associated with hypoxia) Causes: Heart or lung disease, cold environment Assessment Locations: Nail beds, lips, mouth, skin (severe cases) Color: Pallor Condition: ? Causes: ? Assessment Locations: ? - Answer- Condition: Reduced amount of oxyhemoglobin resulting from decreased blood flow Causes: Anemia, shock Assessment Locations: Face, lips, conjunctivae, nail beds, palms of hands Color: Loss of pigmentation Condition: ? Causes: ? Assessment Locations: ? - Answer- Condition: Vitiligo Causes: Congenital or autoimmune condition causing lack of pigment Assessment Locations: Patchy areas on skin over face, hands, arms Color: Jaundice Condition: ? Causes: ? Assessment Locations: ? - Answer- Condition: Increased deposit of bilirubin in tissues Causes: Liver disease, destruction of red blood cells Assessment Locations: sclera, mucous membranes, skin Color: Erythema Condition: ? Causes: ? Assessment Locations: ? - Answer- Condition: Increased visibility of oxyhemoglobin caused by dilation or increased blood flow Causes: Fever, direct trauma, blushing, alcohol intake Assessment Locations: Face, area of trauma, sacrum, shoulders, other common sites for pressure ulcers Color: Tan-brown Condition: ? Causes: ? Assessment Locations: ? - Answer- Condition: Increased amount of melanin Causes: Suntan, pregnancy Assessment Locations: Areas exposed to sun: face, arms, areolae, nipples Identify the physical findings of the skin that are indicative of substance abuse. (8) - Answer- a. Diaphoresis b. Spider angiomas c. Burns (especially on fingers) d. Needle marks e. Contusions, abrasions, cuts, scars f. "Homemade" tattoos g. Vasculitis h. Red, dry skin Turgor - Answer- Skin's elasticity Edema - Answer- Areas of the skin that are swollen or edematous from a buildup of fluid in the tissues Senile keratosis - Answer- Thickening of the skin CONTINUES.....