...Health History and Examination Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client. |Student Name: xx |Date: 03/22/2015 | |Client/Patient Initials: I.F |Sex: Female |Age: 76 | |Occupation of Client/Patient: Stay at home | | |Health History/Review of Systems | | |(Complete and systematic review of systems) | | |Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, | | |difficulty swallowing, etc., medications): | | |dizziness once in a while. ...
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...PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Nursing Assessment 1. Part of Nursing Process 2. Nurses use physical assessment skills to: a) Obtain baseline data and expand the data base from which subsequent phases of the nursing process can evolve b) To identify and manage a variety of patient problems (actual and potential) c) Evaluate the effectiveness of nursing care d) Enhance the nurse-patient relationship e) Make clinical judgments Gathering Data Subjective data - Said by the client (S) Objective data - Observed by the nurse (O) Document: SOAPIER Assessment Techniques: The order of techniques is as follows (Inspect – Palpation – Percussion - Auscultation) except for the abdomen which is Inspect – Auscultation – Percuss – Palpate. A. Inspection – critical observation *always first* 1. Take time to “observe” with eyes, ears, nose (all senses) 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 techniques B. Palpation – light and deep touch 1. Back of hand (dorsal aspect) to assess skin temperature 2. Fingers to assess texture, moisture, areas of tenderness 3. Assess size, shape, and consistency of lesions and organs 4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep C. Percussion – sounds produced by striking body surface 1. Produces different notes depending on underlying mass (dull...
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...Health History and Examination Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client. Student Name: | Date: | Client/Patient Initials: | Sex: | Age: | Occupation of Client/Patient: | Health History/Review of Systems(Complete and systematic review of systems) | Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Patient is oriented x3. No major memory deificit was noted or reported. Patient if forgetful at times due to the aging. Has BLE muscle weakness and pain due to the disease process. No history of tremors or seizures was reported. No numbness or tingling was reported. Patient speech is clear; no difficulty in swallowing was reported or observed. Patient takes Aspirin 81mg PO daily prophylactically. | Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): Per patient “I get occasional headaches but is relived with the pain medication. I have LBP less often then daily but is relieved with the...
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...ASSESSMENT OF THE PATIENT Why do we assess the pt? · To evaluate the client’s current physical condition · To detect early signs of developing health problems · · Gather General Data information….The Data Base 1. Personal Data 2. Chief Complaint = 3. Past Health History = the past health problems, treatments, & outcomes. A. Surgical history…..type & date of surgery. B. Medical Illnesses 4. Family History= 5. Allergies = 6. Current Meds 7. Prosthesis= Pacemaker, Hearing Aid, Dentures, False Eye, False Limb 8. ADL’S @ home….hygiene, bladder & bowel elimination, hygiene, activity level, diet habits. 9. Health Practices 10. Lifestyle Habits Vital Signs: Must be taken Height/Weight: Always take the pt’s weight on the hospital scale 1. Compare the weight with 2. Determine if See Guidelines of Wgt/Height measurement pg. 188. Before you begin your assessment, ask the pt how he/she feels? · Note any Signs & Symptoms = warning that something is wrong. A. sign= B. symptom = C. local sign= D. systemic sign = one that’s produced by the effect of disease on the whole body · Does the pt c/o any pain or discomfort? Where? · How much pain? · use Make your assessment give a mental picture of the patient: · don’t use critical or judgmental words · don’t use the words: Good or Bad, Well, or Normal · Instead describe why you think it’s normal, good, or bad! 4...
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...Tinnitus can intrude with listening to but doesn’t cause listening to loss Tinnitus is a symptom associated with many ear disorders. A common purpose of tinnitus is inner ear damage. Tiny, sensitive hairs for your inner ear pass with the stress of sound waves. That movement triggers the cells in your ear to release an electrical sign. The sign travels from your ear, via the auditory nerve and into your brain. Your mind interprets the sign as sound. If the hair cells interior your inner ear are broken, bent or otherwise damaged, they may spark random electrical impulses in your brain, inflicting tinnitus. some of the ear conditions that may cause tinnitus consist of exposure to loud sound, age-related listening to loss, earwax buildup and adjustments...
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...Health Assessment Physical Assessment Documentation Form Date: __3/3/16 Patient Information Patient Initials | LD | Age | 30 | Sex | Female | General Survey Does patient appear to be their stated age? | Yes | Level of consciousness | Alert and Oriented x3 | Skin color | Caucasain | Nutritional status | No malnurishment noted, pt she eats three meals a day | Posture and position | Patient maintains good posture and position | Obvious physical deformities | No physical deformities noted | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet, ankles, and arms, no Involuntary twitches or movements noted | Facial expression | No abnormal facial expressions noted, pt has nice smile | Mood and affect | patient appears to be in good spirits, patient has smile on face, pt cooperative and answers questions when prompted | Speech: articulation, pattern, content and appropriate, native language | patient speaks English appropriately, patient articulates and enunciates well, all content related to pt’s health | Hearing | patient denies hearing problems, patient able to hear and follow commands when directed | Personal hygiene | patient appears clean, no dirty skin visible, no foul smells noted | | | | | Measurements and Vital Signs Height | 5 foot...
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...The Silent Society: Being Deaf Deafhood and Epistemology When considering the epistemology of deafness, one must consider the history of how deafness has evolved. The history of deafness comes from the ignorance of those who could not understand how people who had a disability were different from them. It was easier to place these types of “folks” in intuitions and not deal with their needs. Understanding the deaf community comes through understanding the culture and the history that allows the deaf to have a “voice” and provide them with the necessary services that make the deaf more human. Through mental health, hearing assessments, and trauma, there is an understanding that even though they may not live in the hearing world, there are still apart of society. How they function as a community is important, as they too have a voice. Deafhood is described as “static”, not a medical condition; however, it is a process-a struggle that is endured by every child, adult, and family to explain themselves, and each other their own existence within their world (Hauser, O’Hearn, Steider, &Thew, 2010). Epistemology can be defined as the philosophy that investigates the origin, nature, methods, and limits to human knowledge. When dealing with deaf epistemology, there are many facets to which it can be understood and misunderstood. The authors discuss the visual learning process that a Deaf child goes through by being raised by either a Deaf parent or a hearing parent....
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...sore on the wrong pillows.” Patient denies taking medication. Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): Patient states she has a history of dry macular degeneration and it is being well controlled. Patient uses special eye drops for her eye disease. Patient wears corrective lenses at all times for both reading and sighting with blurred vision occasionally. Negative glaucoma testing 02/15/2014Eye surgery in relation to the macular degeneration 08/13/2013 Ears (Earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): Patient denies any ear problems Last eye infection was over 10 years ago. No discharge noted from ears Nose, Mouth, and Throat (Discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Lips pink, mucous membranes pink and moist No discharge or foul odor noted No history of nosebleeds, bleeding gums, allergies or...
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...Health Assessment Physical Assessment Documentation Form Date: __3/1/16________ Patient Information Patient Initials BR Age 30 Sex Female General Survey Does patient appear to be their stated age? Yes Level of consciousness Alert and Oriented to person, place and time. Skin color Pinkish tan Nutritional status Well nourished Posture and position Good posture, sitting upright Obvious physical deformities None noted Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Steady gait, no assistive devices, no involuntary movement Facial expression Symmetrical Mood and affect appears to be in good mood Speech: articulation, pattern, content and appropriate, native language Speech appropriate clear, English Hearing No difficulty hearing Personal hygiene Clean, Good hygiene Measurements and Vital Signs Height 5’7” Weight 144 BMI 22.6 Radial pulse: • Rate • Rhythm 62 bpm, Regular rhythm Respirations: • Rate • Depth 12 breaths per min, regular Blood pressure (indicate if sitting or lying) 118/76 Pain assessment 0/10 Physical Assessment Skin Hands and nails no clubbing biting or discolorations Color and pigmentation Uniformly pinkish tan in color. Warm, dry, intact, good turgor. No lesions, birthmarks, edema. Moles noted, al round shape and circular borders. Presence of lesions? none Temperature warm Moisture dry Texture smooth, firm...
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...Health Assessment Physical Assessment Techniques Evaluation Form Assessment Area | Individual Items to AssessDemonstrate the correct technique for assessing the following: | Points/Points Possible | Measurement and Vital Signs | * The candidate asks the patient their weight. * The student takes the vital signs (pulse, respirations, and blood pressure). | /2 | Skin – | * Hands and nails * Color and pigmentation * Temperature * Moisture * Texture * Turgor * Any lesions | /7 | Head and Face | * Scalp, hair, cranium * Face (cranial nerve VII) * Temporal artery * Temporomandibular joint * Maxillary sinuses * Frontal sinuses | /6 | Eyes – describe in your video how you would use the ophthalmoscope to find the corneal light reflex. | * Visual fields (cranial nerve II) * Extraocular muscles (cranial nerves III, IV, VI) * Corneal light reflex * Cardinal positions of gaze * External structures * Conjunctivae * Pupils | /7 | Ears – Describe in your video how you would perform the Weber and Rinne tests for hearing. | * External ear * Any tenderness * Conduct the voice test (cranial nerve VIII) | /3 | Nose – Describe in your video how you would use a speculum to evaluate the nasal mucosa, septum and turbinates. | * External nose * Patency of nostrils | /2 | Mouth and Throat | * Lips and buccal mucosa * Teeth and gums * Tongue Hard/soft palate * Tonsils * Uvula (cranial nerves IX, X)...
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...OrientationWARD 17Pediatric WardBSN Clinical Practice VI AN 3320 * Clinical Learning Objective: 1. Provide individualized quality care to all assigned clients following the nursing process 2. Perform management and organizational ability during the provision of nursing care 3. Apply critical appraisal skills to evaluate the available evidence which underpins practice 4. Plan health promotion activities for clients and family to maintain appropriate behaviors to attain or maintain health 5. Integrate significance of research in clinical practice to achieve best patient outcomesSpecific Objectives: * Plan timely execution of nursing task in the ward * Perform independent learning through self-study and reflective practice * Effectively use up to date information through electronic access of literature and searching database * Critically evaluate an aspect of service delivery that can influence the quality of healthcare system * Utilize assessment, benchmarking audit and quality assurance tools effectively * Incorporate evidence based interventions in healthcare delivery and meeting health inequalities...
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...Gloves Cotton Balls/Cotton Tipped Applicator Cup of Water Lemon Juice, Sugar, Salt TECHNIQUES OF PHYSICAL ASSESSMENT Inspection Palpation Percussion Auscultation #2 GENERAL SURVEY GENERAL SURVEY Visible skin Facial expression/Mood (Grimace, Flat Affect, Pleasant, Distress, SOB) Nutritional Status (Cachexia, Obesity, Well-nourished) Grooming/Hygiene (UnKempt, Neat, Poor Hygiene) Gross Anatomical Deformities EXAMPLES #3 SKIN SKIN • Integument • Color Pigmentation Cyanosis Jaundice Erythema • • • • Moisture Temperature Texture Turgor SKIN (CONT’D) Vascularity Edema Lesions ABCD: Asymmetry Border irregularity Color Diameter HAIR AND SCALP Hair: Color Distribution Quantity Thickness Texture Lubrication NAILS Condition of nails reflects: General health State of nutrition Occupation Level of self-care Age #4 NEUROLOGICAL SYSTEM ““ SMILE FOR ME” NEUROLOGICAL ASSESSMENT Orientation (person, place, time, purpose) 12 Cranial Nerves/Sensation Glascow Coma Scale 12 CRANIAL NERVES Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Auditory Glossopharngeal Vagus Spinal Accessory Hypoglossal #5 HEAD & NECK COMPONENTS OF HEAD & NECK • • • • • • Ears Nose Eyes Throat Neck Lymph Nodes EYES Inspect • Anterior Eyes • Eyelashes • Conjunctivae • Tear...
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...Adult Health History and Examination RN Health Assessment and Screening NRS 434-V Health History and Examinati Client/Patienton Initials: LH Sex: F Age: 47 Occupation: Registered Nurse Health History/Review of Systems Neurological System headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, and difficulty swallowing etc., medication): Neurologically JP is intact. Alert ox3 clear speech with no hesitations, c/o headaches and dizziness occasionally, upon arising in the am. She admits being “little stressed to family situations” and rotating shifts (DAYS/NIGHTS). Suggested to seek EAP (Employee Assistance Program) at work Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications: LH has full ROM to neck and head, closes her eyes and able to hold her arms and hands out without swaying. LH takes Motrin 800mg for headaches. Motrin (ibuprofen) is a no steroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. This medicine may also cause serious effects on the stomach or intestines, including bleeding or perforation (forming of a hole). These conditions can be fatal and can occur without warning while you are taking Motrin, especially in older adults. Nursing Drug Handbook (2013) Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to...
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...HEALTH HISTORY AND EXAMINATION OF AN OLDER ADULT HEALTH HISTORY AND EXAMINATION OF AN OLDER ADULT On March 1, 2016, with the permission of Mr. P.F. henceforth known as the client, a health history assessment and physical examination was conducted and the detailed results dictated within the appropriate assessment templates which are attached for review. In an effort to summarize the health history assessment and physical examination, the summarized assessment findings will be henceforth reported in SBAR format. Situation The client is a Caucasian 64 year old male, whom is alert and oriented to person, place and time whom presents as a well-groomed, well- rested, and well-nourished man that looks his age. English is spoken fluently by the client and is reported as his first language therefore interpreter services were not required. The client states that he worked and supported his family over forty years as a truck driver however has been retired since 2012. Additionally he reports living alone in a single story home which he has owned for over forty years. His plans are to continue to live in his home as long as he is able to care for himself and continue to maintain the home independently. He further states that he is able to complete all his activities of daily living independently, routinely cooks for himself three cardiac meals per day, and takes walks daily for exercise. Client does not report to currently be in a relationship or sexuality active, however did...
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...TOPIC 1 NUTRITIONAL ASSESSMENT 1. Techniques used to assess nutritional status FOOD RECALL METHODS 24-hour food recall Recall of food and fluid intake Information may be collected by interview or self-administered questionnaire Advantages: quick, only short-term memory required, establishes a recent food pattern, easy to obtain a mean intake of large group Limitations: information is based only on one day, not usual intake Diet history Involves an interview to determine usual food and fluid patterns of individual over 2-3month periods Frequently used in adults to establish a basis for dietary modification Advantages: useful measure of usual intake Limitations: time consuming, difficult to standardise, relies on memory, believed to have insufficient quantitative value Food Frequency Questionnaire Self administered questionnaire to ascertain how frequently common foods are consumed Advantages: standardised method, cheap, don’t require trained personnel Limitations: limited number of foods included, reliability of the respondent FOOD RECORDS Involves clients recording current intake over a period of time (1-7 days) Weighed records provide accurate descriptions of food consumed Limitations: time consuming, requires cooperation of individual, may show only the actual intake which may be different from the usual intake, individuals may eat differently because they are recording their intake for a purpose EVALUATING DIETARY...
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