health asssessment
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HEALTH
ASSSESSMENT
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FUNCTIONALLFUNCTIONALL
ASSESSMENT TESTSASSESSMENT TESTSIt is a formalized, comprehensive review of the
older person's daily activities, cognition,
continence, special senses, mobility, andspecific psychosocial issues.
When caring for older adults, health workers
need to be aware of the common age anddisease related disorders that can negatively
affect "functional ability" (e.g., sensory, motor,
and cognitive skills).
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FUNCTIONALLFUNCTIONALL
ASSESSMENT TESTSASSESSMENT TESTSCommon Tests
A. ADULT
I. PHYSICAL A
CTIVITIES OF DAILY LIVING(PADL)
II. INSTRUMENTAL ACTIVITIES OF DAILY
LIVING (IADL)
III. KATZ INDEX OF INDEPENDENCE
IV. BARTHEL INDEXB. NEWBORNS
I. APGAR
C. INFANTS AND CHILDREN
I. MMDS
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PHYSCICAL ACTIVITIES OF DAILYLIVINGPHYSCICAL ACTIVITIES OF DAILYLIVING(PADL)(PADL)
term used in healthcare to refer to daily self-care
activities within an individual's place of residence, inoutdoor environments, or both
"the things we normally do...such as feeding ourselves,
bathing, dressing, grooming, work, homemaking,
and leisure.
refers to six activities: (bathing, dressing, transferring,
using the toilet, eating, and walking) that reflect the
patient's capacity for self-care.
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PHYSCICAL ACTIVITIES OF DAILYLIVINGPHYSCICAL ACTIVITIES OF DAILYLIVING(PADL)(PADL)
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PHYSCICAL ACTIVITIES OF DAILYLIVINGPHYSCICAL ACTIVITIES OF DAILYLIVING(PADL)(PADL)
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INSTRUMENTAL ACTIVITIES OF DAILYLIVINGINSTRUMENTAL ACTIVITIES OF DAILYLIVING(IADL)(IADL)
refers to six daily tasks: (light housework,
preparing meals, taking medications,shopping for groceries or clothes, using the
telephone, and managing money) that
enables the patient to live independently in
the community
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INSTRUMENTAL ACTIVITIES OF DAILYLIVINGINSTRUMENTAL ACTIVITIES OF DAILYLIVING(IADL)(IADL)
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INSTRUMENTAL ACTIVITIES OF DAILYLIVINGINSTRUMENTAL ACTIVITIES OF DAILYLIVING(IADL)(IADL)
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INSTRUMENTAL ACTIVITIES OF DAILYLIVINGINSTRUMENTAL ACTIVITIES OF DAILYLIVING(IADL)(IADL)
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KATZ INDEX OF INDEPENDENCEKATZ INDEX OF INDEPENDENCE
commonly referred to as the Katz ADL, is the most
appropriate instrument to assess functional status as ameasurement of the clients ability to perform activities of
daily living independently.
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KATZ INDEX OF INDEPENDENCEKATZ INDEX OF INDEPENDENCEActivities
Points (1 or 0) (1 Point)
NO supervision, direction or personal
assistance
Dependence
(0 Points)
WITH supervision, direction, personal
assistance or total care
BATHING
Points: __________
(1 POINT) Bathes self completely or
needs help in bathing only a single part
of the body such as the back, genital
area or disabled extremity
(0 POINTS) Need help with bathing more
than one part of the body, getting in or out
of the tub or shower. Requires total bathing
DRESSING
Points: __________
(1 POINT) Get clothes from closets and
drawers and puts on clothes and outer
garments complete with fasteners. Mayhave help tying shoes.
(0 POINTS) Needs help with dressing self
or needs to be completely dressed.
TOILETING
Points: __________
(1 POINT) Goes to toilet, gets on and
off, arranges clothes, cleans genital area
without help.
(0 POINTS) Needs help transferring to the
toilet, cleaning self or uses bedpan or
commode.
TRANSFERRING
Points: __________
(1 POINT) Moves in and out of bed or
chair unassisted. Mechanical transfer
aids are acceptable
(0 POINTS)Needs help in moving from bed
to chair or requires a complete transfer.
CONTINENCE
Points: __________
(1 POINT) Exercises complete self
control over urination and defecation.
(0 POINTS) Is partially or totally
incontinent of bowel or bladder
FEEDING
Points: __________
(1 POINT) Gets food from plate into
mouth without help. Preparation of food
may be done by another person.
(0 POINTS) Needs partial or total help with
feeding or requires parenteral feeding.
Total Points: ________
Score of 6 = High, Patient is independent.
Score of 0 = Low, patient is very dependent
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BARTHEL INDEXBARTHEL INDEX
Consists of 10 items that measure a person's daily functioningspecifically the activities of daily living and mobility.
The assessment can be used to determine a baseline level of
functioning and can be used to monitor improvement in
activities of daily living over time.
The higher the score the more "independent" the person.
Independence means that the person needs no assistance at
any part of the task.
If a persons does about 50% independently then the "middle"
score would apply.
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BARTHEL INDEXBARTHEL INDEX
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BARTHEL INDEXBARTHEL INDEX
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APGARAPGAR
The Apgar score is determined by evaluating the newborn
baby on five simple criteria on a scale from zero to two,
then summing up the five values thus obtained. The
resulting Apgar score ranges from zero to 10.
The five criteria are summarized using words chosen to
form a backronym
(Appearance, Pulse, Grimace, Activity, Respiration.)
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APGARAPGAR
APGAR Score of 0 Score of 1 Score of 2Component of
backronym
Skin color or
Complexion
blue or pale all
over
blue at
extremities
body pink
no cyanosis
body and
extremities pink Appearance
Pulse rateAbsent
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METRO MANILA DEVELOPMENTAL SCREENING TEST
(MMDST)
MMDST is a screening test, not and IQ test
MMDST sought to establish baseline information
on the developmental characteristics of Filipinochildren
MMDST determines what babies and children can
do at certain ages
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MMDSTMMDST
Sectors involved:
-first the personal social (the ability to socialize)
-fine-motor adaptive (the ability to use his hands
to pick up objects and draw)
-language (the ability to hear and to followdirections)
-gross motor (the ability to jump, walk and sit).
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EXAMINATION
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Assessment
Is the systematic gathering of relevant
and important patient information for
use in identifying health problems andplanning and evaluating nursing care.
Purpose of ASSESSMENT:to establish a database
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Assessment
Through the process of data collection,meaningful information, including
health status, actual and potential
health problems, and areas of focus forpriority health promotion, is identified.
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
AssessmentTYPES OF DATA:
SUBJECTIVE DATA ( Symptoms, covert data)
this are information from the clients point of view(e.g. pain, dizziness, nausea, sadness,
happiness)
OBJECTIVE DATA (Signs, overt data) this are
observations or measurements made by the datacollector. The measurement of objective data is
based on accepted standards, like Celsius or
Fahrenheit measure of a temperature.
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
INSPECTION
Observation (see, smell); actually starts during thehealth history and continues throughout the exam;
always comes first (before you touch or listen), but
continues concurrently with PPA as well. Note
General observations and then specifics of eacharea proceeding from the outside to the inside
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
PALPATION
Palpation: Touching; light (1 cm), then deep (4
cm), and rebound (deep with quick release).
Assesses position, texture, size, consistency, fluid,
crepitus, form, structure, vibration, or temperature.
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
PERCUSSION
Tactile sensation and sound (to 5 cm deep); direct
or indirect with fingertip pad or fist; more solid:higher pitch, softer intensity, shorter duration;
more air: lower pitch, louder intensity, longer
duration; expected percussion notes: tympanic
(gastric bubble), hyperresonant (emphysematouslungs), resonant (healthy lung), dull (liver), flat
(muscle)
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
AUSCULTATION
Listening direct (naked ear) and indirect
(acoustical stethoscope or Doppler amplification).
Analyzes intensity, pitch,duration, quality, and
location. The bell analyzes low-pitched soundsand the diaphragm analyzes high-pitched sounds
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
The IPPA organization can be combined by
cephalo-caudal (head-to-toe), general-to-specific,
medial-to-lateral, and external-to-internal
approaches within each category.
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
The nurse must also consider her own
understanding of anatomy and physiology, basicnursing skills, and the nursing process. The
educational preparation and clinical expertise of
the nurse may, therefore, influence the extent to
which the nurse participates in the physicalassessment process.
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
EQUIPMENT NEEDED
Assessment forms or paper to record notations as well as
document findings Growth charts for height and weight
(and head circumference for infants): age, gender, culture,
and sometimes medical condition Well-lit, warm, private room or space
Gown for client privacy and comfort (swimsuits work well
with children and adolescents)
Drape sheet, or blanket for client privacy and comfort
Thermometer: otic or oral/axillary digital preferred
Stethoscope: acoustical with bell and diaphragm; ideal
tubing less than 35 cm in length
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
EQUIPMENT NEEDED Watch with second hand
Sphygmomanometer and blood pressure cuffs twothirds
the size of the client extremity
Ophthalmoscope
Vision charts: Illiterate (matching letters or objects),Snellen (far vision), Rosenbaum (near vision) pocket card,
Ischara (color vision), or Titmus tester (includes all four),
and pupil gauge (in mm)
Otoscope with pneumatic tube
Audio testing equipment: watch, tuning forks (minimum of
one high pitched, 512 Hz, and one low pitched, 128 Hz),
handheld audiometer, tympanometer, or full audiometry
with soundproof room
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
EQUIPMENT NEEDED Nasal speculum with illumination. Optional headlamp
with magnification
Penlight
Tongue depressors
Nonsterile gloves (possibly sterile gloves as well) Glass of water
Marking pen
Measuring tape (with cm and inches), preferably cloth or
plastic Water-soluble lubricant
Guaiac card for occult blood
Specimen cup
Reflex hammer
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION