Health Assessment EXAM #1 (Communications, Gen. Survey, IPPA, Patient Positioning) – Flashcards
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What is the purpose good communication?
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- Develop a partnership with the patient - Needed to conduct assessments and history
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Therapeutic Communication
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- Effective - Helpful - Builds trust
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Non-Therapeutic Communication
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- Unhelpful - Blocks transfer of information and feelings
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What is the most important category of communication?
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Nonverbal
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What are nonverbal behaviors that affect communication?
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- Physical appearance - Facial expression - Body movements/body language - Physiological reactions
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What are factors that affect interviews?
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- Literacy - Hearing - State of well-being - Attention span - Level of consciousness - Timing - Attitudes - Environmental factors
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How do emotions and self-esteem affect communication?
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People may not hear or interpret information correctly.
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SOLER
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Sit squarely, Open posture, Lean toward patient, Eye contact, Relax
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AIDET
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Acknowledge, Introduce, Duration, Explanation, Thank you
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What are cultural considerations when communicating?
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- Keep terminology unbiased - Use interpreter - Assess literacy
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General Survey
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A quick description of the patient based on an impression.
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What should a nurse observe when surveying a patients physical appearance?
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- Apparent age correlates with stated age - Body size - Manner of dress - Grooming, hygiene
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What should a nurse observe when surveying a patients emotional status?
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- Facial expression - Mood - Behavior
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What should a nurse observe when surveying a patients body movements?
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- Gait - ROM - Posture - Voluntary/Involuntary movements - Deformities
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What should a nurse observe when surveying a patients speech?
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- Quantity - Quality - Organization
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What are the steps to pre-assessment?
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- Knock and introduce self - Identify patient - Wash hands - Explain purpose - Vital signs - Pain rating
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IPPA
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Inspection, Palpation, Percussion, Auscultation
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Inspection
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Begin as soon as you meet the patient. Compare what you see from side to side and look for differences in size, shape, color, symmetry, etc.
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Light Palpation
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Depress the skin about half an inch and assess for pain, tenderness, and pulsations.
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Deep Palpation
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Depress the skin about 1 1/2 to 2 inches and asses for masses, organ size, and contour.
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Percussion
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Consists of tapping the skin with short sharp strokes to produce vibrations. This is used to identify size, location, and density of organs.
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What are the basic principles of Percussion?
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- A structure containing more air produces louder, deeper, and longer sounds because it vibrates freely. - A solid structure gives softer, higher, shorter sounds because it does not vibrate easily.
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Ausculation
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Involves listening to sounds of organs.
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What two questions should I ask myself while auscultating?
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- What should I be hearing in the scope? - What am I actually hearing?
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What are important assessment techniques?
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- Introduction - Inform patient what you are doing - Ask for permission - Summarize
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Bradycardia
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Pulse below 60 beats/min
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Tachycardia
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Pulse above 100 beats/min
