HEALTH  ASSESSMENT  in  NURSING N 295  Spring 2012 Week 2 Revised January 2012
Preparing for a Physical Exam <ul><li>Setting  </li></ul><ul><li>Oneself </li></ul><ul><li>Client </li></ul>Revised Januar...
General Assessment <ul><li>General Survey </li></ul><ul><li>Vital Signs </li></ul><ul><li>Anthropometric Measures </li></u...
General Sur vey <ul><ul><li>Apparent State of Health </li></ul></ul><ul><ul><li>Appear Stated Age </li></ul></ul><ul><ul><...
Vital Signs <ul><li>Temperature (T) </li></ul><ul><li>Pulse (P) </li></ul><ul><li>Respirations (R) </li></ul><ul><li>Blood...
Temperature <ul><li>Core Temperature  </li></ul><ul><li>Anatomic Sites </li></ul><ul><li>Normal Fluctuation </li></ul>Revi...
Celsius  vs  Fahrenheit <ul><li>Degrees Celsius = 5/9 (F – 32) </li></ul><ul><li>Degrees Fahrenheit = (9/5 x C) + 32 </li>...
Pulse <ul><ul><li>Normal variations </li></ul></ul><ul><ul><li>Rest or exercise </li></ul></ul><ul><ul><li>Oxygen needs </...
Respirations <ul><li>Abnormal Variations </li></ul><ul><ul><li>Tachypnea  </li></ul></ul><ul><ul><li>Bradypnea  </li></ul>...
Normal B/P Fluctuations <ul><li>Time of Day </li></ul><ul><li>Activity </li></ul><ul><li>Age </li></ul><ul><li>Gender </li...
Sample Question <ul><li>Knowledge </li></ul><ul><ul><li>A nurse knows that blood pressure is…. </li></ul></ul><ul><li>Comp...
Types of Anthropometric Measures <ul><li>Height/Weight </li></ul><ul><li>Body Mass Index </li></ul><ul><li>Abdominal Fat <...
BMI Revised January 2012 Weight in pounds * 703 ____________________ Height in inches 2
BMI Categories: <ul><li>Underweight =  <18.5  or < 19 </li></ul><ul><li>  ( varies with source ) </li></ul><ul><li>Normal ...
Ectomorph  Mesomorph Endomorph  Revised January 2012
Parts of the Hand <ul><li>1. </li></ul><ul><li>2. </li></ul><ul><li>3. </li></ul><ul><li>4. </li></ul>Revised January 2012
Types of Palpation <ul><li>Light </li></ul><ul><li>Deep  * </li></ul>Revised January 2012
Percussion <ul><li>Direct   (immediate) </li></ul><ul><li>Indirect  (mediate) </li></ul><ul><li>Blunt  -  Direct </li></ul...
Percussion Notes <ul><li>Flatness * </li></ul><ul><li>Dullness </li></ul><ul><li>Resonance </li></ul><ul><li>Hyper-resonan...
STETHOSCOPE Revised January 2012 *
Documentation <ul><li>Purpose  </li></ul><ul><li>Guidelines </li></ul><ul><li>Types of Assessment Forms </li></ul>Revised ...
Types of Documentation <ul><li>SOAPIE </li></ul><ul><li>PIE </li></ul><ul><li>DAR </li></ul>Revised January 2012
Revised January 2012
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  • September 2009
  • N 295 lecture 2 student copy

    1. 1. HEALTH ASSESSMENT in NURSING N 295 Spring 2012 Week 2 Revised January 2012
    2. 2. Preparing for a Physical Exam <ul><li>Setting </li></ul><ul><li>Oneself </li></ul><ul><li>Client </li></ul>Revised January 2012
    3. 3. General Assessment <ul><li>General Survey </li></ul><ul><li>Vital Signs </li></ul><ul><li>Anthropometric Measures </li></ul>Revised January 2012
    4. 4. General Sur vey <ul><ul><li>Apparent State of Health </li></ul></ul><ul><ul><li>Appear Stated Age </li></ul></ul><ul><ul><li>3. LOC </li></ul></ul><ul><ul><li>4. Behavior / Speech Pattern </li></ul></ul><ul><ul><li>5. Height / Build / Weight </li></ul></ul><ul><ul><li>6. Skin Color </li></ul></ul><ul><ul><li>7. Dress / Grooming / Hygiene </li></ul></ul><ul><ul><li>8. Facial Expression / Behavior </li></ul></ul><ul><ul><li>9. Posture & Gait </li></ul></ul>Revised January 2012
    5. 5. Vital Signs <ul><li>Temperature (T) </li></ul><ul><li>Pulse (P) </li></ul><ul><li>Respirations (R) </li></ul><ul><li>Blood Pressure (B/P) </li></ul><ul><li>TPR </li></ul><ul><li>& </li></ul><ul><li>B/P </li></ul>Revised January 2012
    6. 6. Temperature <ul><li>Core Temperature </li></ul><ul><li>Anatomic Sites </li></ul><ul><li>Normal Fluctuation </li></ul>Revised January 2012
    7. 7. Celsius vs Fahrenheit <ul><li>Degrees Celsius = 5/9 (F – 32) </li></ul><ul><li>Degrees Fahrenheit = (9/5 x C) + 32 </li></ul>Revised January 2012
    8. 8. Pulse <ul><ul><li>Normal variations </li></ul></ul><ul><ul><li>Rest or exercise </li></ul></ul><ul><ul><li>Oxygen needs </li></ul></ul><ul><ul><li>Cardiac output </li></ul></ul><ul><ul><li>Bradycardia (<60) </li></ul></ul><ul><ul><li>Tachycardia (>100) </li></ul></ul><ul><li>Abnormal variations </li></ul><ul><ul><li>Tachycardia (>100) </li></ul></ul><ul><ul><li>Bradycardia (<60) </li></ul></ul><ul><ul><li>Bounding </li></ul></ul><ul><ul><li>Thready, weak </li></ul></ul><ul><ul><li>Pulse deficit </li></ul></ul><ul><ul><li>Asystole </li></ul></ul>Revised January 2012
    9. 9. Respirations <ul><li>Abnormal Variations </li></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Bradypnea </li></ul></ul><ul><ul><li>Cheyne-Stokes </li></ul></ul><ul><ul><li>Biot’s </li></ul></ul><ul><ul><li>Kussmaul’s </li></ul></ul><ul><ul><li>Hyperpnea </li></ul></ul>Revised January 2012
    10. 10. Normal B/P Fluctuations <ul><li>Time of Day </li></ul><ul><li>Activity </li></ul><ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Race </li></ul><ul><li>Weight </li></ul><ul><li>Exercise </li></ul><ul><li>Emotions/Stress </li></ul>Revised January 2012
    11. 11. Sample Question <ul><li>Knowledge </li></ul><ul><ul><li>A nurse knows that blood pressure is…. </li></ul></ul><ul><li>Comprehension: </li></ul><ul><ul><li>A nurse interprets a client’s BP of 140/80 to mean: </li></ul></ul><ul><li>Application: </li></ul><ul><ul><li>A client reports dizziness and fainting episodes that started a week ago. Which vital sign should the nurse assess first ?... </li></ul></ul><ul><li>Analysis: </li></ul><ul><ul><li>A nurse assesses a client’s vital signs and note a BP of 180/90, heart rate 72, respirations of 26/min, temp 98 degrees F. What is the next best action by the nurse?... </li></ul></ul>Revised January 2012
    12. 12. Types of Anthropometric Measures <ul><li>Height/Weight </li></ul><ul><li>Body Mass Index </li></ul><ul><li>Abdominal Fat </li></ul><ul><li>Triceps Skin Fold Thickness (TSF) </li></ul><ul><li>Mid-Arm Circumference (MAC) </li></ul><ul><li>Head/Chest Circumference (infant) </li></ul>Revised January 2012
    13. 13. BMI Revised January 2012 Weight in pounds * 703 ____________________ Height in inches 2
    14. 14. BMI Categories: <ul><li>Underweight = <18.5 or < 19 </li></ul><ul><li> ( varies with source ) </li></ul><ul><li>Normal weight = 18.5-24.9 </li></ul><ul><li>Overweight = 25 -29.9 </li></ul><ul><li>Obesity = ≥30 </li></ul>Revised January 2012
    15. 15. Ectomorph Mesomorph Endomorph Revised January 2012
    16. 16. Parts of the Hand <ul><li>1. </li></ul><ul><li>2. </li></ul><ul><li>3. </li></ul><ul><li>4. </li></ul>Revised January 2012
    17. 17. Types of Palpation <ul><li>Light </li></ul><ul><li>Deep * </li></ul>Revised January 2012
    18. 18. Percussion <ul><li>Direct (immediate) </li></ul><ul><li>Indirect (mediate) </li></ul><ul><li>Blunt - Direct </li></ul><ul><li>Blunt - Indirect </li></ul>Revised January 2012
    19. 19. Percussion Notes <ul><li>Flatness * </li></ul><ul><li>Dullness </li></ul><ul><li>Resonance </li></ul><ul><li>Hyper-resonance </li></ul><ul><li>Tympany </li></ul>Revised January 2012
    20. 20. STETHOSCOPE Revised January 2012 *
    21. 21. Documentation <ul><li>Purpose </li></ul><ul><li>Guidelines </li></ul><ul><li>Types of Assessment Forms </li></ul>Revised January 2012
    22. 22. Types of Documentation <ul><li>SOAPIE </li></ul><ul><li>PIE </li></ul><ul><li>DAR </li></ul>Revised January 2012
    23. 23. Revised January 2012
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