Chapter 22

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Health Assessment
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1

Health assessment:

a comprehensive assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group or community

2

Nursing assessments focus on:

client's functionl abilities and physical responses to illness and other stressors

3

Physical assessment consists of:

the techniques used to gather objective data about the body.

4

Comprehensive physical assessment is done:

at the initial intake

5

Focused physical assessment is done when:

there is a particular topic, problem, body part or functional ability rather than overall health status

6

Ongoing assessment is performed:

as needed, after the initial database is completed, and ideally at every interaction with the patient

7

System-specific assessment:

a focused assessment limited to one body system

8

Head-to-toe assessment:

starts at the head and neck and progresses down the body, examining the feet last

9

A body systems approach examines:

each system in a predetermined order.

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Inspection:

use of sight to gather data

11

Percussion:

tapping your fingers on the skin using short strokes

12

Auscultation:

the use of hearing to gather data

13

Direct auscultation is:

listening without using an instrument

14

Indirect auscultation:

is listening with the help of a stethoscope

15

Skin lesions:

any lesion, variation in pigment, or break in continuous tissue requires assessment

16

Milia:

white raised areas on the nose, chin and forehead of newbornes

17

Striae:

silver-to-pink stretch marks in pregnant women.

18

Skin lesions considered normal are:

milia, nevi (moles), freckles, brithmarks, skin tags, striae

19

Abnormal skin lesions are:

primary skin lesions, and secondary skin lesions

20

Primary skin lesions:

develop as a result of disease or irritation

21

Secondary skin lesions:

develop from primary lesions as a result of continued illness, exposure, injury or infection, such as the crusts that form from ruptured pustules.

22

Albinism:

lack of pigment

23

Alopecia:

hair loss; normal

24

Alopecia areata:

benign autoimmune disorder or alopecia

25

Hirsutism:

excess facial or trunk hair

26

Pediculosis:

head lice infestation

27

Pink nails with rapid capillary refill:

indicate circulation to the extremities;

28

Pale or cyanotic nail beds are seen in clients with:

circulatory or respiratory disorders that result in anemia or hypoxia