Nursing 251 Health Assessment
Cumulative Final
Initial comprehensive Assessment - ANS occurs when client first presents themselves, and
gives and overall picture of "health"
Ongoing/Partial Assessment - ANS Occurs after comprehensive database is established; is a
reevaluation of problem or baseline looking for Improvement/deterioration
Focused/ Problem Assessment - ANS Occurs in relation to a specific health concern but
doesn't replace comprehensive assessment
Emergency Assessment - ANS Occurs rapidly when life-saving action needs to be taken;
immediate diagnosis needed to begin treatment
Primary Vs. Secondary source - ANS Primary is Patient; secondary is family, medical records,
nurse, doctor
Methods for Validation - ANS -Recheck (repeat)
-clarify (asking client)
-verify (as another physician to listen)
-compare (differences in stories and body language)
Euro-American - ANS -Very time conscious
-Arm's length distance while communicating
-Speaks directly and maintains eye contact
-Productive, prefer action over inaction
-Measure accomplishments by external standards
African-American - ANS -Time orientation is not strict
-Present oriented instead of future
-Avoids eye contact
-May use jargon or slang
-Self-Care and Folk Medicine very prevalent
-Attempts home remedies first
Latin-American (hispanic) - ANS -Very modest
-Time orientation not strict
-Don't like to be questioned
-Politeness is a sign of respect
,-Tends to express emotions openly
-Tends to have a fatalistic outlook on life
-Illness is an imbalance between Hot and Cold
Asian-American - ANS -Privacy, No expression of emotions
-Unlikely to complain about problems
-Physical contact not acceptable
-Do not react well to painful diagnostic work-up
-Goal of therapy is to restore balance of Yin and Yang
Native American - ANS -Respect of the body
-Present oriented
-Respect for the elderly
-All disorders believed to have aspects of the supernatural
-Theology and medicine strongly interwoven
-Fear of witchcraft
Stereotype - ANS A simplified, generally inflexible conception of the members of a group or
subgroup
Ethnocentrism - ANS A tendency to view people unconsciously by using your own group and
your own customs as standards for all judgments
Four Primary Physical examination techniques - ANS 1. inspection
2. palpation
3. percussion
4. Auscultation
Light palpatation - ANS Little to no depression- less than 1 cm; Uses: pulse, skin texture,
temperature, moisture
Moderation palpatation - ANS Depression 1-2 cm using dominant hand in circular motion; uses:
Body organs and masses
Deep palpatation - ANS Depression 2.5-5cm with Two hand technique placing non-dominant
hand over dominant hand; Uses: deep organs
Bimanual - ANS Capture organ between both hands; Uses: breast tissue, spleen, uterus,
ovaries, and masses
Resonance - ANS Air filled lung
Hyperresonance - ANS excess air (emphysematous lung)
, Tympanic - ANS Air in gastric region
Dull - ANS Thud-like, solid organ
Flat - ANS Extreme dullness, bone
What are the 5 vital signs? - ANS 1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Pain
Ways to find temperature - ANS oral
tympanic
axillary
rectal
forehead
Normal Body Temperature ranges:
C - ANS 36.5- 37.7 *C
Normal Body Temperature ranges:
F - ANS 96.9- 99.9* F
Older Adults range - ANS 95.0*- 97.5*F
Normal variations in temperature: - ANS lowest in morning (4-6 AM)
highest in evening (8 PM-midnight)
exercise, stress, ovulation = highest
Oral temp technique - ANS non-mercury glass: hold for 5 minutes
digital: until beeps
Tympanic temperature variation - ANS higher than oral - 0.8 C or 1.4 F
Axillary: use on? technique - ANS babies
10 minutes (glass non-mercury thermometer)
as needed for digital
Axillary temp variation - ANS normally lower than oral - 0.5 C or 1 F
When do you use rectal temperatures - ANS comatose patients, uncooperative, infants
Rectal (red) - ANS insert 1 inch
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