NUR 3029 NUR 3029: Health Assessment Final Exam: Study Guide

Introduction to Health Assessment  Understanding the components of the Nursing Process  Nurse’s role in environmental assessment  Communication for assessment of multiple populations (adult/elderly)  Cultural sensitivity in Health Assessment Health History  Communication during the physical examination and obtaining health history  Obtaining subjective and objective information during the health history  Components of the Health History Assessment Techniques > Parts of the stethoscope and assessment of sounds (bell vs diaphragm)- the bell is used for soft, low pitched sounds such as extra heart sounds or murmurs and diaphragm used for high-pitched sounds such as, breathe, bowel, and normal heart sounds. > Inspection, palpation, percussion, auscultation (order changes in abdominal assessment. > Appropriate sequence of assessment (infant, child, adult)- the same for each- head to toe General Survey Assessment of vital signs (normal vs abnormal, routes & locations of vital signs) 1) Temperature- > normal oral temp: 96.8 degrees F; normal range: 35.8 to 37.3 degrees C (96.4-99.1 degrees F)- most accurate and convenient > normal rectal temp: 0.4 to 0.5 degrees C higher (0.7 to 1 degree F)- only used when other routes are not practical > TMT- temperature checked by ear (used mostly in children) 2) Pulse- palpating the peripheral pulse gives the rate and rhythm of the heartbeat, as well as local data on the condition of the artery; counting for 30 seconds and multiplying by 2 is the most accurate but if rhythm is irregular, count for the full minute; assess for rate, rhythm, and force > bradycardia- rate less than 50 bpm > tachycardia- rate greater than 90 bpm > 3+ full, bounding; 2+ normal; 1+ weak, thready; 0 absent. 3) Respirations- for a neonate 30-40 breaths per min is normal; for an adult 10-20 is considered normal but 10 should be a concern. 4) Blood pressure- Can be checked in the arm or the thigh (brachial pulse, popliteal pulse) > Normal: 120/80 or less > Prehypertension: 120-139/80-89 JOUBERT/HAMMACK Page 1 NUR 3029: Health Assessment Final Exam: Study Guide > Stage 1 hypertensio