主页 > 国际资格 > 美国护士 > 备考资料 > 正文

美国护士NCLEX-RN备考完整的身体评估指南

2024-04-12 16:42:10来源: admin阅读量: 271

评估是美国护士NCLEX-RN备考,护理过程的第一个也是最关键的阶段。不正确的护理判断源于数据收集不足,并可能对护理过程的其余阶段产生不利影响:诊断、计划、实施和评估。通过这份全面的从头到脚的身体评估指南,全面了解患者的健康状况。

评估技巧

为了使您从头到脚的评估系统化,您需要了解四种基本评估技术。这些技术是视诊、触诊、叩诊和听诊。

检查涉及使用视觉、嗅觉和听觉来观察和检测任何正常或异常的发现。
触诊包括使用手的某些部分来触摸和感觉以下特征:质地、温度、湿度、流动性、稠度、脉搏强度、大小、形状和压痛程度。
敲击涉及敲击身体部位以产生声波。这些声波或振动使检查者能够评估底层结构。
听诊涉及使用听诊器听心音、心血管系统的血液运动、肠道的运动以及呼吸道的空气运动。
使用COLDSPA助记符

COLDSPA 助记符是一种有用的记忆辅助工具,有助于探索每种健康问题的症状。

Mnemonic    General Question
Character    Describe the sign or symptom (appearance, feeling, sound, smell, or taste)
Onset    When did it begin?
Location    Where is it? Does it radiate? Does it occur anywhere else?
Duration    How long does it last? Does it recur?
Severity    How bad is it? How much does it bother you?
Pattern    What makes it better or worse?
Associated factors    What other symptoms occur with it? How doe it affect you?

当前健康问题的历史

本节考虑健康问题的几个方面,并提出问题,其答案可以提供问题的详细描述。

既往健康史

这些问题旨在引出与客户的过去、健康史的优势和劣势相关的数据。

家族健康史

家族史应包括客户能回忆起的尽可能多的一般亲属;除了遗传倾向之外,了解客户因在家庭中长大并接触到这些问题而可能影响的其他健康问题也很有帮助。

生活方式和健康习惯

这些问题用于评估客户如何管理自己的生活、健康意识以及不健康的生活模式。这些通常是开放式问题,以促进与客户的对话。

Physical Assessment Guide
This section is where we’ll start the head-to-toe assessment. We’ll start with the general survey and identify the patient’s chief complaint, then the assessment of each body system.


1. General Appearance/Survey
The general appearance or general survey is the first step in a head-to-toe assessment. The information gathered during the general survey provides clues about the overall health of the client. The general survey includes the overall impression of the client, mental status exam, and vital signs.

2. Chief Complaint
The chief complaint is the main reason why a client is seeking medical attention. It is the symptom or problem that is most concerning to the patient and is the focus of their visit. It is typically the first thing the healthcare provider asks about when seeing a patient, as it helps to provide context and background for the rest of the assessment and treatment.

3. Health History
The health history is an excellent way to begin the assessment process because it lays the groundwork for identifying nursing problems and provides a focus for the physical examination. The importance of health history lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual’s lifestyle and current health status.

4. Assessment of the Integument
The skin, hair, and nails are external structures that serve a variety of specialized functions. Diseases and disorders of the skin, hair, and nails can be local or they may be caused by an underlying systemic problem. To perform a complete and accurate assessment, the nurse needs to collect data about current symptoms, the client’s past and family history, and lifestyle and health practices.

5. Assessment of the Head and Neck
Head and neck assessment focuses on the cranium, face, thyroid gland, and lymph node structures contained within the head and neck.

6. Assessment of the Eye and Vision
To perform a thorough assessment of the eye, one needs a good understanding of the external structures of the eye, the internal structures of the eye, the visual fields and pathways, and the visual reflexes.

7. Assessment of the Ear
Beginning when the nurse first meets the client, the assessment of hearing provides important information about the client’s ability to interact with the environment.

8. Assessment of the Mouth, Throat, Nose, Sinus
Subjective data related to the mouth, throat, nose, and sinus can aid in detecting diseases and abnormalities that may affect the client’s activities of daily living.

9. Assessment of the Thoracic and Lung
Subjective data related to the thoracic and lung assessment provide many clues about underlying respiratory problems and associated nursing diagnoses, as well as clues about the risk for the development of lung disorders.

10. Assessment of the Breast and Lymphatic System

This chapter covers the examination of non-pregnant women’s breasts. Remember, if the client reports any symptoms, you need to explore further by performing a symptom analysis using the following guide.


备考美国护士,获取NCLEX-RN 考试学习计划、考前冲刺测试题库等,可点击跳网盘下载,提前了解考试内容难度。
TAG标签: 护士出国

推荐阅读

加载更多...

联系
我们

联系我们

微信:13510355007
QQ号:1761083228