New User Special Price Expires in

Let's log you in.

Sign in with Facebook


Don't have a StudySoup account? Create one here!


Create a StudySoup account

Be part of our community, it's free to join!

Sign up with Facebook


Create your account
By creating an account you agree to StudySoup's terms and conditions and privacy policy

Already have a StudySoup account? Login here

NU 220, Session 1 Notes

by: Jessie G

NU 220, Session 1 Notes NU 220

Jessie G
View Full Document for 0 Karma

View Full Document


Unlock These Notes for FREE

Enter your email below and we will instantly email you these Notes for Health Assessment

(Limited time offer)

Unlock Notes

Already have a StudySoup account? Login here

Unlock FREE Class Notes

Enter your email below to receive Health Assessment notes

Everyone needs better class notes. Enter your email and we will send you notes for this class for free.

Unlock FREE notes

About this Document

These notes cover the lecture material from session 1 on September 7.
Health Assessment
Dr. Teresa Roberts
Class Notes
Nursing, #HealthAssessment, #GeneralSurvey, #AnatomicalNomenclature




Popular in Health Assessment

Popular in NURSING

This 9 page Class Notes was uploaded by Jessie G on Tuesday September 13, 2016. The Class Notes belongs to NU 220 at University of Massachusetts Boston taught by Dr. Teresa Roberts in Fall 2016. Since its upload, it has received 4 views. For similar materials see Health Assessment in NURSING at University of Massachusetts Boston.


Reviews for NU 220, Session 1 Notes


Report this Material


What is Karma?


Karma is the currency of StudySoup.

You can buy or earn more Karma at anytime and redeem it for class notes, study guides, flashcards, and more!

Date Created: 09/13/16
Health Assessment Session 1 Notes Introduction to Health Assessment  The Nursing Process o Assessment o Nursing Diagnosis o Planning o Implementation o Evaluation  Health Assessment o HA is a point of entry, collection of data to formulate a database  HA = Health Assessment o This database is used to:  Form diagnoses  Plan interventions  Measure evaluations o Health Assessment follows a pathway of steps  Gather data  Diagnose  Intervene  Evaluate o Example: Your patient, Ms. Wilson, has an area of redness on her coccyx.  Gather data (who, what, where, when, etc)  How long has she been on her back?  Is she moving often?  Has anything been recently applied to that area?  Is it itchy or painful?  When did it start?  What is her nutritional status?  The spot: o Size: 7cm x 5cm o Color: pale, pink/red o Texture: nothing notable  Possible diagnosis (use the data gathered to determine the problem)  Pressure sore?  Intervene (create a plan of care for patient to treat the health problem)  Change bedding  Make sure Ms. Wilson is turned often  Hydrate & give a healthy diet  Get a new mattress for Ms. Wilson  Increase social interaction  Encourage movement  Evaluate (recheck patient to see if plan of care has proven effective)  After a few hours  Check spot, note any differences/ changes Report findings!!!! o If you didn’t report it, you didn’t do it!!! Forms of Documentation o Narrative format  Information provided in sentences, usually time sequenced. o SOAP notes o PIE o FOCUS o Charting by Exception o Clinical Pathways SOAP o Subjective  Subjective notes are what the patient/client says  A symptom is a subjective piece of information  HPI History of the present illness o Ex. If Ms. Wilson has redness, asking questions such as “does it hurt?” or “has it changed?” is finding the history of the present illness.  ROS Review of Systems Asking questions such as “have you eaten?” or “Do you feel nauseous?” reviews the other body systems that can help rule out or lead to a diagnosis; finding how other systems in the patient’s body are effected. o Objective  What the nurse or health care professional observes  A sign of an illness is an objective piece of information Exam o Vitals! o Size o Color o Raised/flat o Temperature Lab studies Diagnostics o Assessment o Plan Organization of a SOAP note o Information should be in order from general to specific  Ex. Ms. Wilson is unconscious = general information, listed earlier in the note.  Ex. Mark on coccyx is 5cm x 7cm = specific information, later in the note. o Information should be noted with remarkable information before unremarkable.  Remarkable observations are abnormal findings Ex. Redness on coccyx is remarkable or not usually present. Stating that there is no redness present on the rest of the body is unremarkable information but still important! Redness is confined to one area, it is important to note the unremarkable! o Example of report: “Ms. Wilson has redness on her coccyx but nowhere else on her body.” Example of a correct SOAP note: o S – “My head hurts right in the back of my eyes.” Client describes pain being worse when bending over, like sinus headaches in past. o O – Eyes closed, lights dim, hesitant to move head when questioned. HR: 80 RR: 20 BP: 140/90 T: 98.6 o A – HA probable 2 to sinus pressure o P – 1. Decongestant pm as ordered; 2. Warm wash cloth to eyes; 3. Monitor temp q 4; 4. Assess pain after medication Example of an incorrect SOAP note: o S – my head hurts  Should be in quotations if patient words o O – Hx diarrhea, decreased appetite, ambulating with walker, heart rate regular “it hurts”  Hx is history of diarrhea, this is subjective information, as it is a symptom usually reported by a patient and not a sign typically observed by the nurse  Decreased appetite is also subjective, as it is something only the patient would be able to report, and not often something seen by the nurse.  Heart rate regular is not an acceptable report of vitals.  “it hurts” is a quote from patient, should be in subjective information not objective. o A – headache  Headache is not a diagnosis or assessment. o P – contact physician for further orders  Nurse’s job is to create a plan of care, this is not a correct plan of care. Relative Importance o Importance of subjective vs. objective generally depends on the situation  At times, subjective can provide more key information however in other cases objective information can be more important. o Among the objective methods, exam generally yields the most data. Exam o 4 components  Inspection: what you see  Palpation: what you feel through touch  Percussion: what you feel or hear through vibration  Auscultate: what you hear o Inspection:  General  Detailed  Good lighting  Other tools include: pen light, magnifying glass, measuring tape, ruler, ophthalmoscope, otoscope, specula o Palpation:  Temperature (use dorsa of hands)  Tenderness (pain to touch or palpation/pressure)  Texture (what does the area feel like)  Moisture  Rigidity/flaccidity  Strength  Masses  Crepitation (creaking/cracking) o Percussion  Helps to assess: Shape Location Size Density Tenderness Reflex  Indirect percussion  Direct percussion  Blunt percussion o Auscultation  Need: stethoscope with 2 heads Bell Diaphragm  Stethoscope use Hints to improve conduction: o Ear tips should point towards your nose o Check to make sure the canal is twisted toward the head that you are using to allow sound to travel o Don’t touch the lumen o Clench your jaw Types of databases (Situational) o Complete (annually, new patient information, admittance to hospital) o Episodic (one particular problem) o Follow-up (following up on an episodic database) o Emergency (vitals, immediate status, medications and allergies if possible) Anatomical Nomenclature  Directions & Orientation o Superior: Above, towards the top half of the body o Cranial: Towards the head o Inferior: Below/underneath, towards the lower half of the body. o Anterior: front o Posterior: back o Ventral: front o Dorsal: back o Superficial: on or closer to the surface of the body o Deep: below or farther from the surface of the body o Proximal: closer to the point of attachment or closer to the trunk, only in reference to appendages o Distal: farther from the point of attachment or trunk, only in reference to appendages/extremities. o Medial: comparison term; closer to midline of the body than something else is. o Lateral: comparison term; farther from the midline of the body than something else is.  Regions of the Body o Cephalic: in reference to the head o Thoracic: in reference to the chest o Abdominal: in reference to the abdomen or belly o UE: upper extremities o LE: lower extremities o Cervical: in reference to the neck, area of cervical vertebrae o Thoracic: in reference to the upper back, area of thoracic vertebrae o Lumbar: in reference to lower back, area of lumbar vertebrae o Sacral: in reference to the tailbone or coccyx o Gluteal: in reference to the derriere or bottom o Midsternal: area surrounding the midsternal line, or the center of the sternum o Midclavicular: area surrounding the middle of the clavicle, or following the nipple line o Axillary: in line with the armpit and the outer side of the trunk o Palmar surface: palm of hand o Dorsal surface: back of hand o Ventral surface: top of foot o Plantar surface: sole of foot  Motions of the Body o Abduction: movement of the extremity away from the midline o Adduction: movement of the extremity towards the midline o Pronation: movement of the hand or foot so the plantar surface or palmar surface is up o Supination: movement of hand/foot so the dorsal surface or ventral surface is down o Flexion: movement generally toward the flexor (anterior) surface or toward the body o Extension: movement generally out straight or away from the body. o Hyperextension: an exaggerated or greater extension movement. General Survey  The basics o Where we start:  General survey: how does the pt seem?  Vital signs: basic measurements of pt’s condition  Apparent state of health o Observations made by the nurse and subjective information from patient  Physical appearance  Body habitus/structure  Mobility  Behavior  Physical appearance o Age  Does the patient appear the stated age? Older? Younger? o Gender  Is the sexual development appropriate for the age and sex?  Does the patient appear male, female or transgender? o LOC (level of consciousness)  Are they alert?  Is the patient oriented to person, place, time, and situation? o Skin  What is the tone/coloration of the skin  Is the skin intact?  Well perfused? o Position  Is the patient sitting, standing or lying?  Body Structure o Stature  Is the patient’s height in normal range for the genetic background? o Nutrition  Is the patient’s weight and fat distribution in a healthy range? o Symmetry  Are sides equal in size and position? o Posture  Comfortably erect?  Even plumb line?  Stooped? o Body build  Are proportions in normal range?  Any notable, unique features?  Mobility o Gait  Shoulder width?  Does the patient walk smoothly?  Is movement voluntary for the patient? o Speech  Are they articulate?  Can the patient communicate well? o ROM  Range of Movement  Is movement full and easy for the patient?  Is movement limited or difficult?  Behavior o Facial expression  Does the patient’s facial expression match the conversation?  i.e. loss of loved one, patient not sad or grieving but smiling instead o Affect  Affect is when a nurse observes the apparent emotional state of a patient  What is the patient’s apparent mood?  Are the cooperative? o Speech  Is the patient’s speech logical?  Is the patient coherent? o Grooming  Is the patient clean?  Are they unkempt??  Is the patient dressed bizzarely? o Odor  Does the patient have a foul body or breath odor?  Is a tobacco or ETOH (alcohol) odor present?  Example of a health assessment: G.M. o G. M. is a 27 year old white male who appears stated age, WDWN, A&Ox4, sitting and pleasantly engaged in interview. Upright posture, coordinated with FRQM, articulate, coherent, well groomed. Abbreviations to Note HA = Health Assessment LE = Lower Extremities ETOH = Alcohol HPI = History of present illness LOC = Level of Consciousness Pt = Patient ROS = Review of Systems ROM = Range of Movement Hx = History of … UE = Upper Extremities WDWN = Well developed, well nourished A&Ox4 = Alert & oriented to person, place, time, event


Buy Material

Are you sure you want to buy this material for

0 Karma

Buy Material

BOOM! Enjoy Your Free Notes!

We've added these Notes to your profile, click here to view them now.


You're already Subscribed!

Looks like you've already subscribed to StudySoup, you won't need to purchase another subscription to get this material. To access this material simply click 'View Full Document'

Why people love StudySoup

Bentley McCaw University of Florida

"I was shooting for a perfect 4.0 GPA this semester. Having StudySoup as a study aid was critical to helping me achieve my goal...and I nailed it!"

Jennifer McGill UCSF Med School

"Selling my MCAT study guides and notes has been a great source of side revenue while I'm in school. Some months I'm making over $500! Plus, it makes me happy knowing that I'm helping future med students with their MCAT."

Bentley McCaw University of Florida

"I was shooting for a perfect 4.0 GPA this semester. Having StudySoup as a study aid was critical to helping me achieve my goal...and I nailed it!"

Parker Thompson 500 Startups

"It's a great way for students to improve their educational experience and it seemed like a product that everybody wants, so all the people participating are winning."

Become an Elite Notetaker and start selling your notes online!

Refund Policy


All subscriptions to StudySoup are paid in full at the time of subscribing. To change your credit card information or to cancel your subscription, go to "Edit Settings". All credit card information will be available there. If you should decide to cancel your subscription, it will continue to be valid until the next payment period, as all payments for the current period were made in advance. For special circumstances, please email


StudySoup has more than 1 million course-specific study resources to help students study smarter. If you’re having trouble finding what you’re looking for, our customer support team can help you find what you need! Feel free to contact them here:

Recurring Subscriptions: If you have canceled your recurring subscription on the day of renewal and have not downloaded any documents, you may request a refund by submitting an email to

Satisfaction Guarantee: If you’re not satisfied with your subscription, you can contact us for further help. Contact must be made within 3 business days of your subscription purchase and your refund request will be subject for review.

Please Note: Refunds can never be provided more than 30 days after the initial purchase date regardless of your activity on the site.