Health Assessment Portfolio | Lecture Note

University:
High School
Course:
High School Medicine
Academic year:

2025
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114
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Health Assessment Portfolio Discipline: BSN(G)2nd Year Student Covering Letter TO Principal, College of Nursing, Victoria Hospital Bahawalpur, Respected Madam, I would like to submit my portfolio for your kind guidelines. From the assessment techniques were helpful regarding ... . I have also included a variety of prices in order to display wide breadth of my practice and interests. The second piece I added in the portfolio is written in response to the events. Thanking you for your special attention, Yours affectionately, Asia Parveen BSN(G) 2nd year Roll No: Seven INDEX 1- Physical examination. 2- Assessment of 1 lungs and thorax 3- Assessment of Breast 4- Assessment of female genitalia 5- Assessment of Nervous system 6- Assessment of Cardio vascular system 7- Assessment of abdomen Objectives After physical examination of patient I will be able to: Define Data and its types. Types of assessment Sign and Syptoms Equipments of physical examination Techniques of examination DEFINITION It is a systematic delibrate and interactive proems by which nurses use critical thinking to colbet, validate, analyze and synthesise the collected Information in order to make judgment about the health status and life processess of indi viduals, families and communities -(Nursing council of Hongkong 2006)- TYPES: Types of assessment are following: 1. Initial comprehensive assessment 2. Ongang or partial assessement 3- Focused or problem orriented assessmont 4. Emorgency assessment 5- Time lapsed assessment TYPES OF DATA: There are two types of data. 1-Objective data 2. Subjective data Objective Data Obtained through observation, standerd assessment technique, Laboratory and diagnostic tests. Roffered to as signs as it can be seen or heared or felt by Someone other than patient or client. SUBTETIVE Data Oblained through interviewing patient reffered to as syptoms (feelings, perception cand concerns) that can't be observed by others. SYPTOMS: Repeated by palient erdiscussed in medical history example: Shortness of breath, cough chest pain. SIGH Noted by examiner(signs) discussed in physical examination Example cyanosis Clubbing Wheeze. Onset Location 0 Duration Characterstics Allevating factors Radiations Timing Components of Health History: Components of health history as belows Ichenh lang dala - Kamply history Relatbrisky Personal arid social ntabiry Chief complbind Renew of system pod bistory Equipments Of Physical Examinaton An opliharemosape * longue depresser An closcaupe Ruler A flash Bight or perlight -Flexible tape measure the murater Watch a sphegmomanometer a sthethoscope a visual auity card a reffers hammer Tunning fork both 128,512 Hz Cotton swabs Safety pins -Two test tube for losting temperature "Lubricant for anal, vagina and rectal examinations gloves paper vaginal spetula pen and penicil laptop or computer. Cardinal Techniques OF Examination) Cardinal techniques of examination are as following: INSPECTION Close observation of the details of patient appearance,behaviour and movement such as fascial expression, mood. skin condition, contour. PALPATION Tectile pressure from palmar fingers or finger pad to access a raise of skin ie elevation , depression, warmth, tenderness, lymph nodes, pulses and size of organs and crepitus of Fingers PERCUSSION Lise sticking or plexer finger usually the third to deliver a rapid a blow against distal pleximeter finger wave generales tectile vibration against pleximeter finger. This sound ASCULTATION List of diaphram and bell of stethoscope are used for to detect characterstics of heart lungs and bowel sounds. Ascultation also permits detection of bruits Vessels. or Turbulence over arterial Table 47.1 AVPU-the patient's response Alert Eyes are already open or they open in response to the ruse's voice. The patient is onenated to time and place and recalis own name Volce Eyes may or may not be open, but the patient does not always give correct answers to questions lae 'Do you know where you are? Pain Eyes may or may not be open, but there is no response to the nurse's voice or being genity shaken. May localise, flex or extend to trapezus pinch Unnssponsive Eyes are closed and there is no response to voice being gently shaken or to bapezius pinch or supraorbital nage presture Figure 47.1 Testing for pain Trapezius pinch applying pressure to the trapez muscle Applying pressure to the supraorbital ridge: this is manual manipulation of the supraorbital nerve in order to elicit a pain response. This test should not be performed facial Fractures are present With both tests, start by applying soft pressure and then increase. Apply pressure for no more than 10 Figure 47.2 Face, arm, speech, time (FAST) test for stroke Face Has The patent's face fallen on one side? Can the patent smie? Arm Can the patent saise both arms and imp Speech Is the patient's speech shumed? Time to call 999 or medical emergency team in hospital if you see any one of these sight Figure 47.3 Pupil assessment shape, size, symmetry and reaction 1mm 2m 3mm 4mm 5mm 0mm Examine the shape, size and symmetry of the pupils they should te round equal and about 25 Shine bright light into each eye one at a time, from the outer aspect, and look for pupe constriction in both eyes (consensual mactioni Table 47.2 Glasgow coma scale Eyes opening: E Verbal response: V 4: Spontaneously 5c Onertated, communicating normally 6: Obeys commands 3. Orly to voice 4: Disorientaten conversation 2: Orly to pan 2 Incoherent words or incomprehensible sounds None 2 Sounds only 1: None Motor response: M 5: Locaises-brrige hand to the source of pan & Withdraws to pain patent bendis arm to the source of the pan but can't locate 2. Decorticate posture flexion to pan 2: Decerebrate posture extension to pain 1: None Sock your tongue out and now put it back an Lit your as and now put down Pan (supraorbital pressure Types of motor response Flexed Plantar lesed Internally rotated Flexed Adducted Decorticate rigidity Extended Adducted V M For example: 5 615 Total score Any drop in OGS she be reported immediately Plantar flexed Flexed Pronated Decerebrate rigidity