Health Assessment braden scale – Flashcards
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Braden Scale
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A scale which evaluates a person for pressure ulcer risk; Range of pts from 6-23. Lower score means increase risk for pressure ulcer development
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Symptom Analysis
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Systematic way to collect data about the history and status of symptoms. Uses the acronym PQRSTUA
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What does P stand for in PQRSTUA?
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Provocative/Palliative. What cause the symptom? What make it better or worse?
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What does Q stand for in PQRSTUA?
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Quality. How would you describe the symptom?
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What does R stand for in PQRSTUA?
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Region/Radiation. Where is the symptom located? How does it radiate?
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What does S stand for in PQRSTUA?
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Severity. How does the symptom rate on a scale of 0-10 with 10 being the most extreme?
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What does T stand for in PQRSTUA?
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Timing. When did the symptom begin? Is it sudden or graduate onset? How often does it occur?
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What does U stand for in PQRSTUA?
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Understanding. What do you think it means?
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What does A stand for in PQRSTUA?
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Associated symptoms. Are there any associated symptoms? For example, like fever, headache, nausea, fatigue, etc.
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What is health assessment defined as?
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Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgements about nursing interventions based on the findings and evaluating patient care outcomes.
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What are the 3 basic types of assessments?
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1. Emergency Assessment 2. Focused Assessment 3. Comprehensive Assessment
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Emergency Assessment
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Utilized in a life threatening or unstable situation in an emergency department. Triage is ulilized to determin acuity based on: A-Airway B-Breathing C-Circulation D-Disability
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Focused Assessment
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Based on specific issues identified by the client or abnormal findings discerned in the comprehensive assessment. Usually limited to 1 or 2 body systems. Focuses on the symptoms associated with the clients chief complaint.
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Comprehensive Assessment
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Includes complete history and physical exam. Consists of 4 components: 1. Interview 2. Physical Assessment 3. Interpretation/Analysis of findings-critical thinking 4. Documentation
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Subjective data
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What the patient say about self.
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Objective data
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Info that is measurable and that the health pro gathers during the assessment of the client
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Components of lifesyyle
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Activities of Daily Living (ADL's)-Self care activities-grooming, eating, dressing, home maintenance-meal prep, laundry, shopping, driving, management of finances; Mobility- balance, walking, stairs, use of walking aids. -Exercise -Nutrition -Sleep -Personal habits-tobacco use, ETOH consumption, drug use
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Basic techniques to obtain objective data during health assessment
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1. Inspection 2. Palpation 3. Percussion 4. Auscultation
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Inspection
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General observation of the client including hygiene, level of anxiety or discomfort, level of alertness, skin, musculoskeletal structures, lesions, scars, etc. Note: Color, size, shape, contour, location, movement, behavior, SYMMETRY, odors, and sounds.
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Palpation
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Texture-rough or smooth. Temp-warm, hot or cold. Moisture-dry, wet or moist. Motion or mobility-fixed, moveable, still, vibrating. Consistency of structures-soft, hard, fluid filled. Size-small, medium, large. Shape-well defined, irregular. Degree of tenderness. Edema (swelling).
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Palpation-purpose and technique
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1. Light palpation (finger tips)-depth 1 cm, assess for surface characteristics. 2. Moderate to deep palpation (palmer surface of fingers)-approx 1-2 cm, assess underlying organs
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Percussion
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Direct-direct contact of fingertips to pts skin eg.sinuses. Indirect-non-dominant hand on clients skin and tap with your dominant hand. Blunt (or fist)-to percuss organs below the surface such as kidneys, liver or gallbladder.
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Percussion sounds
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Resonance. Hyper-resonance. Tympany. Dullness. Flatness.
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Resonance
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Intensity-Loud. Pitch-Low. Quality/duration-clear; hollow/long. Location-Normal lungs
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Hyper-resonance
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Intensity-Very loud. Pitch-Very low. Quality/duration-booming, longer than resonance. Location-Hyper inflated lungs (COPD).
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Tympany
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Intensity-Loud. Pitch-High. Quality/duration-drumlike/medium. Location-Gastric bubble in stomach.
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Flatness
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Intensity-Very soft. Pitch-High. Quality/duration-Flat/very soft. Location-Muscle.
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Dullness
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Intensity-Soft. Pitch-High. Quality/duration-Thudlike/short. Location-solid, dense organs/bones (liver).
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Pulse Range
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60-100 beats per minute
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Pulse Description
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Rate + Range, Regular, Force 2+, Smooth, straight and resilient
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Breathing Range for Adult <65
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12-20 breaths/minute
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Breathing Range for Adult >65
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12-24 breaths/minute
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Systolic Blood Pressure Range
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100-139 mm/Hg
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Diastolic Blood Pressure Range
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60-89 mm/Hg
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Description of Breaths
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Eupnea OR relaxed, regular, symmetrical, no distress noted, no shortness of breath, no accessory muscles used
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Temperature Range (oral)
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36.5 - 37.5 degrees Celsius
