WGU Health Assessment

WGU Health Assessment

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HESI 1 -

88 terms Bel Practice questions for this set Learn1 / 7Study using Learn 1. Mixed: (A) Motor: muscles used for facial expressions, close eye and mouth; (B) Sensory (sense of taste in the front 2/3 of tongue; (C) Parasympathetic: saliva and tear secretion

• Sense of taste not usually checked unless specific concerns
• Observe for Any Facial Droop or Asymmetry

a) Ask Patient to do the following, note any lag, weakness, or asymmetry: Raise eyebrows

b) Close both eyes to resistance

c) Smile

d) Frown

e) Show teeth

f) Puff out cheeks

• Test the Corneal Reflex (See C.N. V above)

Choose an answer 1Subjective data2Appearance 3Facial Test4borborygmus Don't know?

Terms in this set (194) Subjective dataSaid by the client (S) Obejective dataObserved by the nurse (O) Assessment Techniques is as followsInspect-Palpation-Percussion-Auscultation Order of Abdomen AssessmentInspect-Auscultation-Percuss-Palapate Inspectionalways first

• Take time to observe with eyes ear nose

2.Use good lighting 3.Look at color shape symmetry position 4.Observe for odors from skin breath wound

• Develop and use nursing instincts

6.Inspection is done alone and in combination with other assessment techniuqes Back of handTo assess skin temperature use Deep Palpation5-8cm or (2-3") deep is considered Light Paplpation1cm deep is considered Percussionsounds produced by striking body surface sounds are dull resonant flat tympanic action is performed in the wrist Ausculationlistening to sounds produced by the body Bellpicks up low pitched sounds such as heart murmurs General Surveyis an overall review or first impression a nurse has of person's well being.Appearanceappears to be reported age sexual development appropriate alert and oriented facial features symmetric no signs of acute distress Body Structure/mobiltyweight and height WNL BMI guidelines body parts equal bilaterally stands erect sits comfortably gait is coordinated walk is smooth and well balanced full mobility of joints

Behaviormaintains eye contact with appropriate expressions comfortable and cooperative speech clear clothing is correct for climate looks cleat and fit appears clean and well groomed Comprehensive historywhich includes chief complaint or reason for the visit a complete review of systems and complete past family and social history should be obtained on the first encounter with a patient regardless of setting and by a RN Family Health HxAre completed across three generations looking specifically for patterns in genetic issues that negatively impact quality of life Health Hxgives a picture of patient's current health and documentation must be completed for each visit and or assessment How to measure height less than 2 years of age Obtain height by measuring the recumbent length of children less than 2 years of age and children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used

a) Lay the child flat against the center of the board. The head should be held

against the headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is moved until it is firmly against the child's heels. Read and record the measurement to the nearest 1/8 inch.

b) A modified technique in home settings is to lay the child flat and straight where

the head should be held by the parent and the knees held so that the hips and knees are extended, mark the flat surface at the top of the head and tip of the heels. Move child and measure the distance between the marks with a tape measure. Read and record the measurement to the nearest 1/8 inch

• When a recumbent length is obtained for a two year old, it should be plotted

on the birth to 36 months growth chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18 year chart. After plotting measurements for children on age and gender specific growth charts, evaluate, educate and refer according to findings.Height children 2-3 and older3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface of the stadiometer is lowered until it touches the crown of the head, compress the hair. A measuring rod attached to a weight scale should not be used.Measuring weight:1. Balance beam or digital scales should be used to weigh patients of all ages.Spring type scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer's instructions.

• Prior to obtaining weight measurements, make sure the scale is "zeroed".

Weight infants, children, and teens and adults3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal clothing.

• Place the patient in the middle of the scale. Read the measurement and record

results immediately. Plot measurements on age and gender specific growth charts and evaluate accordingly Measuring head circumferenceObtain measurement on children from birth to 36 months of age by extending a non stretchable measuring tape around the broadest part of the child's head For greatest accuracy the tape is placed 3 times with a reading taken at the right side at the left side and at the mid forehead and the greatest circumference is plotted.The tape should be pulled adequately compress the hair Should be measured each visit Chest circumferenceThis is measured at the nipple line in a newborn the head circumference with be about 2 cm larger than the chest circumference AS the child ages the chest circumference becomes larger than the head circumference Vital Signsgenerally described as the measurement of temp pulse resp and b/p give an immediate picture of a person's current state of health and well being. Normal and abnormal ranges with management guidelines follow for children and adults Tempertureoral usually 98.6 axillary 97.6 litter lower rectal and aural (ear) 99.6 slightly higher Resperiations1. Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations

• Without letting go of the patients wrist begin to observe the patient's breathing.

Is it normal or labored?

• Count breaths for 15 seconds and multiply this number by 4 to yield the breaths

per minute.

• In adults, normal resting respiratory rate is between 14-20 breaths/minute.
• Rapid respiration is called tachypnea.

PulseCount for 15 seconds multiply x4 Always cont for a full minute if the pulse is irregular Record the rate and rhythm