USM Health Assessment Exam 1 Flashcards

Total Health Assessment
Terms Definitions
Nursing Process Components
Assessment; Diagnosis;Planning; Intervention; Evaluation
Techniques for Gathering Objective Data
Inspection;Palpation; Percussion; Auscultation
Concentrating attention; Visualization; Listening and smell;Takes registerin
Light and deep
Listening with stethoscope
Creating sounds and listening to the sound created.
Locate: Determination of size, density and shape.
Components of Sound
Amplitude:Loud or soft
Pitch:# of vibration
Quality:Subjective description
Traps of Interviewing
¨Providing assurance or false reassurance
¨Giving advice
¨Professional jargon
¨Leading/biased questions
¨Talking too much
Types of Data Bases
–Health history and full PE
¨Episodic-problem centered
Health History Categories
¨Biographical Data
¨Source and Reliability
¨Reason for seeking health care
¨Present health or “HPI”
–Well patient
–Ill client
Family History
¨Social Data
–Age related (geriatric)
–Environment (home & work)
Eight Critical Characteristics
¨Aggravating/Relieving Factors
¨Associated Factors
¨Client’s Perception
¨The final summary
Past History
¨Childhood illness
Review of Systems
¨Skin, Hair, Head, Eyes, Ears, Nose, Neurological, Respiratory. Evaluate each system, includes health promotion activities.
¨Avoid normal, no problems, objective
¨General, Overall Health
¨Mental Status
Skin structure and function
•Skin – three layers
1. Epidermis
–Stratum germinativum or basal cell layer
–Stratum corneum or horny cell layer
–Derivation of skin color
2. Dermis
–Connective tissue or collagen
–Elastic tissue
3. Subcutaneous layer
Epidermal appendages
1. Hair
2. Sebaceous glands
3. Sweat glands
–Eccrine glands
–Apocrine glands
4. Nails
Function of the Skin
•Prevents penetration
•Temperature regulation
•Wound repair
•Absorption and excretion
•Production of vitamin D
Healthy People Goals skin
•Reduce the risk of melanoma
–Teach early signs
•Self exam
–Teach protective measures
•Sunscreen, clothing, time in sun, avoid UV
Subjective Data— Health History Questions
•Previous history of skin disease (allergies, hives, psoriasis, or eczema), FH
•Change in mole
•Change in pigmentation (size or color)
•Excessive dryness or moisture
•Excessive bruising Rash or lesion
•Medications (po, topical)
•Hair loss
•Change in nails
•Tattoos, piercings
•Environmental or occupational hazards
•Self-care behaviors
•Change in pigmentation
•Change in mole
•Excessive dryness
•Excessive bruising
•Rash, lesions
•Hair loss
•Change in Nails
•Environmental hazards; insect bites Lyme Disease
•Self-care/protective behaviors
•Past history of skin dx: yours, family (include tattoos and piercing)
•Self Skin Exam
Typical Dermatological Questions
•Location; distribution, arrangement
•Quantity (how many) How far extend?
•Quality-color, raised, fluid, crusty, d/c, odor, borders, effect ADLs
•Alleviating: ice, cover
•Aggravating: scratching, bathing, jewelry, new clothes, new detergent/soap
•Associated issues?
•Family history skin disorders
•What do you think?
Physical Exam skin
•Techniques: Inspection & Palpation…?
•Equipment: ruler, light source, gloves
•Preparation of patient: comfort, warmth, privacy, respect

The Physical Exam inspection
•Skin—Inspect for ??
•Color – where- what?
Objective Data Physical Exam Palpate
•Mobility and turgor
•Vascularity or bruising
Shapes & Configurations
•Annular or circular
•Target or iris
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