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    ISPN 复习要点提示 11 健康和体格评估
    日期:2020-03-17 19:52:21    
    Tips On How To Review For ISPN Examinations
     
    11
    Health and Physical Assessment of the Adult Client
    成份的健康和身体评估
     
    Health assessment – 健康评估Health assessment involves collecting, validating, and analyzing subjective data (also called symptoms) and objective data (also called signs) to determine the overall level of physical, psychological, sociocultural, developmental, and spiritual health of a patient.
    Health history – 健康史A health history is a collection of subjective data that provides a detailed profile of the patient’s health status.
    Physical assessment – 身体评估A physical assessment is the systematic collection of objective information. It is usually conducted in a head-to-toe sequence or a system sequence but can be adapted to meet the needs of the patient. Components of a comprehensive physical assessment include general survey (observing general appearance, hygiene, posture, gait, etc), integument, head and neck, thorax and lungs, etc.
    Techniques of physical assessment – 身体评估技术The four primary assessment techniques are inspection 视诊, palpation触诊, percussion扣诊, and auscultation听诊. These techniques are most often used in the sequence listed. Bilateral body parts are always compared; for example, the assessment findings of one leg are compared with those of the other leg. Bilateral body parts are normally symmetric; that is, they have the same size and shape as well as the same characteristics, such as movement or pulses.
    Positioning – 体位A variety of positions are used during a physical assessment. During positioning, it is important to consider the patient’s age, culture, health status, mobility, physical condition, energy level, and privacy. Uncomfortable or embarrassing positions should not be maintained for long periods.
    Signs and Symptoms – 症状体征Signs are objective data. They are directly observed or elicited through physical examination techniques. Symptoms are subjective data. They are experienced or known only by the patient (e.g., pain and nausea) and are gathered by verbal report during the health history.
    Quite some of the assessments are usually carried out by healthcare providers with advanced education (such as an internal eye examination, a vaginal examination, or a rectal examination). However, nurses need to be familiar with all parts of a physical assessment so they can assist as necessary and also can explain the techniques and rationale for the assessment to patients. That means, what we are reviewing concerning health assessment is the general ideas, concepts, and knowledge that the nurse are asked to know, rather than the specific advanced techniques. Therefore, our focus will be on the general state of health including the normal and abnormal findings, the overall characteristics of the systems, the techniques used in assessment, and patient and family teaching after completing the assessment. As usual, they will be summarized in three parts: (1) general assessment基本情况评估; (2) techniques of physical assessment身体评估所采用的技术; and (3) systems assessment身体各系统的评估.
     



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