Health Assessment Exam 1

Nursing Process

1. Assessment: collect data

2. Analysis: to determine the problem

3. Outcome identification: patient’s goal

4. Planning: how to meet the goal

5. Implementation: doing/carry out plan

6. Evaluation: did the patient meet goal

Primary Health Promotion

Everyone, preventing problems

Ex: Immunization, healthy diet

Secondary Health Promotion

At risk people, early detection before possible/expected problems occur, at risk includes family/personal history or risk

Ex: Breast cancer screening, colonoscopy, ultrasound for pregnancy, mental health screening, Pap smear/cervical screening

Tertiary Health Promotion

People diagnosed with disease, treating and/or preventing complications from disease

Ex: Maintaining insulin and diet for diabetes management

Comprehensive Assessment

Detailed history at onset of care in primary care setting, admission to hospital, long-term care facility

Problem-based/Focused Assessment

History and exam are limited to specific problem, walk in clinic, emergency room

Shift Assessment

Head-to-toe assessment at routine times during a shift or based on changes

Screening Assessment

Short, focused on a specific potential problem

Episodic/Follow up

Follow up for previously identified problem, pneumonia follow up, diabetes

Review of systems

Subjective data collected directly from the patient regarding his/her perception of the following body systems

Hand Hygiene

The most important nursing action to reduce the transmission of microorganisms prior to beginning a physical assessment

Cephalocaudal

Working from head to toe

Parts of the Physical Assessment

1. Inspection: Always first, visual exam

2. Palpation: Touching by using hands

3. Percussion: Tapping or striking, ex: percuss over kidneys for tinderness

4. Auscultation: Listening, stethoscope, tubing usually 12-18 inches

Inspection

Visual exam including body movement, posture, and smell

Observe rate, depth, and effort of breathing (respiratory)

Color of skin, lips, nail beds (integumentary)

Palpation

Requires touch to determine: texture, size, shape, consistency, pulsations, location

Light palpation- 1 cm deep, skin pulsations, and tenderness

Deep palpation; 4 cm deep, organ size, contour

Percussion

Evaluates size, borders, and consistency of internal organs. Detects tenderness, determines extent of fluid in body cavity

Tympany- abdomen (stomach, gas bubbles)

Resonance: lungs (hollow)

Hyperressonance: over inflated lungs (booming)

Flatness: bones and muscles (extremely dull)

Dullness: liver (thud like)

Auscultation

Listening to sounds in the body

Audible to ear- stridor, severe wheezing, abdominal gurgling

Diaphragm: flat surface with rubber/plastic ring on the edge, used for high-pitched sounds such as breath, bowel. and normal heart sounds

Bell: concave in shape used to hear soft, low-pitched sounds; extra heart of vascular sounds (bruit)

Heart Rate Expectations

• Infant/newborn: 100-160 bpm

• Toddler: 98-140 bpm

• School age: 75-118 bpm

• Adolescent: 60-100 bpm

• Adult: 60-100 bpm

• Pregnancy: increases as much as 10-15 bpm

• Elevations in children: crying, fever, respiratory distress, dehydration

• Other reasons: physical exertion. anxiety, hypotension, hormonal imbalance

Respiratory Expectations

• Infant/newborn: 30-53 bpm

• Toddlers: 22-37 bpm

• School aged children: 18-25 bpm

• Adolescent and adult: 12-20 bpm

• Pregnancy: increased slightly during 3rd trimester, may be SOB

Blood Pressure Expectations in Adults

• Normal: less than 120, less than 80

• Elevated: 120-129, less than 80

• Stage 1 Hypertension: 130-239 OR 80-89

• Stage 2 Hypertension: 140 or higher OR 90 or higher

• Hypertensive Crisis: greater than 180 and/or greater than 120

Types of Pain

nociceptive pain, visceral pain, neuropathic pain, referred pain, phantom pain

Nociceptive pain

Arises from somatic structures- bones, joints, muscles, skin, or visceral organs, described as achy, throbbing

Visceral pain

Organs, described as cramping

Neuropathic pain

Originates from CNS or PNS, nerves, described as boring, numbness, tingling

Referred pain

Pain is felt in a location away from the tissue damage

Phantom pain

Pain is felt after amputation

Perfusion

Necessary to deliver oxygenated blood to and remove metabolic wastes from tissues

Intracranial Regulation

Supports respiratory function, requires adequate gas exchange

Inspiration Mechanics

Diaphragm contracts, intercostal muscles push chest wall outward, intrathoracic pressure decreases, negative pressure within lungs causes lungs to fill with air

Expiration Mechanics

Muscles relax, air is expelled as intrathoracic pressure rises

Barrel chest angle

Costal angle between costal margins should be less than 90 degrees, if it becomes larger than 90 degrees, it indicates barrel chest

Pleuritis

Chest pain with breathing

Sputum questions

color, odor, amount, consistency

White/clear sputum

allergies, viral infection, a cold

Yellow/green sputum

bacterial infection

Black sputum

smoke or coal, dust inhalation

Rust sputum

blood, mucus, bacteria, associated with TB and pneumococcal pneumonia

Pack year formula

(Number of cigarettes smoked per day X Number of years smoking) / 20

clubbing

caused by chronic hypoxemia (low blood oxygen)

Crepitus

Crackly sensation when palpating chest indicating air in the subcutaneous tissue, there is an air leak somewhere in the respiratory tree

Thoracic Expansion

Anterior: thumbs on costal margin and xiphoid process

Posterior: thumbs on T9 or T10

Vocal (tactile) Fremitus

• Place hand on anterior/posterior thorax and have the patient say “99” or “1-2-3-4”

• Fremitus/vibration should be bilaterally equal

Increased Vocal Fremitus

Consider vocal resonance with auscultation, bronchophony, whispered pectoriloquy, egophony

Diminished/absent vibrations

• Blocked, unilateral, or bilateral

• Pneumothorax, pleural effusion, tumor could be pushing lung away from the chest wall, bronchial obstruction, atelectasis, obesity

Bronchovesicular

• Pitch: moderate

• Intensity: medium

• Duration: 1:1

• Expected location: anterior- 1st and 2nd ICS at sternal border, posterior- T4 scapula

Vesicular

• Pitch: low

• Intensity: Soft

• Duration: Insp > Exp, 2.5:1

• Expected location: peripheral lung fields

Bronchial

• Pitch: high

• Intensity: Loud

• Duration: Insp < Exp, 1:2

• Expected location: over trachea/thorax (manubrium)

Fine Crackles (High pitched crackles)

• Inhaled air opens a small collapsed alveoli or air passage often fluid present

• High pitched, popping sounds, dicontinuous

• Ex: Pneumonia, congestive heart failure

Coarse Crackles (Low pitched crackles)

• Inhaled air flows through secretions in larger bronchi

• Low pitch, ripping velcro, discontinuous

• Ex: Mucus in bronchi

Wheeze (High pitched wheeze)

• Narrow passageway

• High pitched, musical sound/squeak, continuous

• Ex: Asthma due to narrowed/obstructed airway

Rhonchi (Low pitched wheeze)

• low pitched, snoring or moaning sounds, cough to see if it clears

• Ex: Chronic bronchitis, pneumonia

Stridor

• inspiration and expiration

• high pitched coring, honking sound

• Caused by partial obstruction of the larynx/trachea

• Medical emergency- tracheal obstruction, choking on an object

Pleural Friction Rub

• sound heard on inspiration and expiration

• pleurisy: inflamed parietal and visceral pleura rubbing against each other

Tracheal deviation

EMERGENCY, can cause heart attack

Hemothorax

Blood accumulated in the pleural cavity, often caused by trauma

Pleural Effusion

Fluid accumulated in the pleural cavity, often due to fluid volume overload, or cancer

Atelectasis

Collapsed alveoli