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Health Assessment

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Title: Health Assessment Author: metro Last modified by: metro Created Date: 7/28/2010 8:51:22 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Health Assessment


1
Health Assessment
  • By Diana Blum MSN
  • NURS 1510

2
Purpose
  • Obtain baseline
  • Evaluate progress/outcomes
  • ID areas for prevention

3
Prepare the client
  • Explain any procedure you need to do

4
Prepare the environment
  • Pick a time that works for both you and the
    client
  • Make sure it is well lit
  • Be organized
  • Make sure the client is warm
  • Provide privacy
  • Take into consideration cultural adaptations
  • Use correct positioning
  • Provide drapes

5
Methods
  • Inspect
  • Palpate
  • Percussion
  • Auscultation

6
General Survey
  • Appearance
  • Mental status
  • VS
  • HT vs WT
  • Posture
  • Hygiene

7
Integument
  • Skin
  • color
  • Turgor
  • Odor
  • lesions
  • Hair
  • dry, brittle, etc
  • Nails
  • Shape
  • Angle
  • Texture
  • Bed color
  • Tissue intactness

8
Head
  • Size
  • Eyes
  • Vision
  • Pupils
  • Ears
  • Drum
  • Wax
  • Acuity
  • Nose
  • Patency
  • Pressure
  • Mouth
  • teeth
  • Symmetry
  • Color
  • Moistness
  • Tongue
  • glands

9
NECK
  • Muscles
  • Lymph nodes
  • Thyroid
  • Trachea

10
Thorax/Lungs
  • Shape/Size
  • Breath sounds
  • Spinal alignment
  • Symmetry

11
Cardio System
  • Heart tones
  • Valve issues
  • Carotids
  • Jugular veins
  • Pulses
  • Edema
  • Color
  • Capillary Refill

12
Breast/Axillae
  • Palpate for lumps
  • Check for discharge

13
Abdomen
  • Inspect contour and symmetry
  • Auscultate bowel tones, bruits
  • Percuss for tympany and dullness
  • Palpate for tenderness, bladder area

14
Musculoskeletal
  • Muscle strength
  • Muscle tone
  • Symmetry between extremities

15
Neuro
  • LOC
  • Language
  • Memory
  • Attention span
  • Reflexes
  • Sensory function
  • Ambulation
  • Balance

16
Genital area
  • Hair distribution, amount
  • Examine for parasites, lesions, inflammation
  • Assess for hernia
  • For men, assess symmetry of scrotum, lumps, etc
  • Rectum/anus inspect only

17
Pain
  • What the patient states
  • Look for verbal and nonverbal cues
  • Assess
  • Location
  • Duration
  • Intensity
  • Type

18
concepts
  • Threshold is the least amount to label it as pain
  • Tolerance is max amount of pain a person will
    withstand before seeking relief
  • Hyperalgesia heightened response to painful
    stimuli
  • Allodynia pain response elicited without painful
    stimuli

19
Nociception
  • Transduction
  • Transmission
  • Modulation
  • perception

20
Gate Control theory
  • If you treat underlying cause, topical therapy,
    guided imagery, massage, help alter mood, etc you
    can elicit a positive response

21
Response to pain
  • Fight or Flight
  • BP increases
  • Short shallow breathing
  • Increase pulse
  • Sleep interference
  • Alters appetite
  • Withdrawl
  • Increase susceptibility of infection
  • Can lead to Chronic pain

22
Factors that affect experience
  • Culture
  • Ex. In some cultures self infliction of pain is a
    sign of grieving, or may signify strength
  • Developmental Stage
  • See table 46-3
  • Environment
  • Noise can increase pain
  • Support system
  • Past experiences
  • Meaning of Pain

23
Assess
  • 5th Vital Sign
  • History
  • Location
  • Intensity
  • Quality
  • Pattern
  • Precipitating factors
  • Alleviating factors
  • Associated symptoms
  • Effect of ADL
  • Coping resources
  • effectiveness

24
  • Have the client keep a pain journal
  • Ineffective airway
  • Anxiety
  • Ineffective coping
  • Self care deficit
  • Knowledge deficit
  • Pain management is key

25
NSAIDS/ NON OPIOD
  • Tylenol
  • Ibuprofen
  • Aspirin

26
Opiods
  • Full MS Contin, Oxycodone, Hydromorphone
  • Mixed Nubain, stadol
  • Partial Buprenex
  • Monitor sedation, respiration

27
Placebos
  • Sugar pills, Saline Injection
  • Use of is fraudulent unless in research

28
routes
  • Oral
  • Nasal
  • Transdermal
  • Rectal
  • IM
  • IV
  • Intraspinal
  • PCA

29
Non pharm interventions
  • Massage
  • Distraction
  • Guided imagery
  • Heat/cold

30
Evaluate
  • Pain should be assessed q2 hours and/or 30min.
    after intervention provided
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