Health Assessment : Final Exam

infant vs

HR: 100-160
RR: 30-53
BP: 72-104/ 37-56

toddler vs

HR: 98-140
RR: 22-37
BP: 86-106/ 42-63

school age vs

HR: 75-118
RR: 18-25
BP: 97-115/ 57-76

adolescent vs

HR: 60-100
RR: 12-20
BP: 110-131/ 64-83

adult vs

HR: 60-100
RR: 12-20
BP: 120/80

objective data

data that can be observed with senses (these are facts)

subjective data

what the patient tells you is happening

signs

what you can observe about the patient (objective)

symptoms

what the patient is telling you they feel (subjective)

When does the general inspection begin and what are the criteria?

Occurs the moment you meet the patient

Observing physical appearance and hygiene, body structure, body movement, emotional status, disposition, and behavior

What is the nursing process?

Assess

Diagnose

Plan

Intervention

Evaluate

skin assessment

Inspect skin

Palpate skin

Inspect + palpate the scalp + hair

Inspect facial + body hair

Inspect + palpate the nails

cyanosis in light skin

Grayish-blue tone, especially in the nail beds, earlobes, lips, mucous membranes, palms and soles of feet

cyanosis in dark skin

Ashen-gray color most easily seen in the conjunctiva of the eye, oral mucous membranes, and nail beds

jaundice in light skin

Yellowish color of skin, sclera of eyes, fingernails, palms of hands, and oral mucosa

jaundice in dark skin

Yellowish-green color most obviously seen in the sclera of the eye, palms of hands, and soles of feet

pallor in light skin

Pale skin color that may appear white

pallor in dark skin

Skin tone appears light than normal, may have yellowish-brown skin, may have ashen skin, loss of underlying healthy red tones of the skin

stage 1 pressure ulcer

Intact skin with Non blanchable redness, usually over a bony prominence

May be painful, firm, soft, warmer/cooler compared to adjacent tissue

May be difficult to detect in individuals with dark skin tones

stage 2 pressure ulcer

Partial thickness loss of dermis

Presents as a shiny/dry shallow open ulcer with pink wound bed without slough or bruising

May also present as an intact or open/ruptured serum-filled blister

stage 3 pressure ulcer

Full thickness skin loss involving damage/necrosis of subcutaneous tissue

Subcutaneous mau be visible, but bone, tendon, or muscle are not exposed

Slough may be present, wound may include undermining and tunneling

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, tendon, or muscle

Slough or eschar may be present within the wound bed

Undermining and tunneling present

who is at risk for pressure ulcers

People in the hospital → immobilized patients

What scale do we use to evaluate suspicious nevi and what does it stand for?

Asymmetry

Boarder

Color

Diameter

Evolving

What measurement tool is a national standard for pressure ulcers

braden scale

cardio assessment

General Appearance

Inspect for general appearance, skin color, and breathing effort

Heart

Inspect the anterior chest wall

Palpate the apical pulse

Auscultate the apical pulse

Auscultate the heart (listen for S1, S2, and, Murmurs)

Palpate temporal and carotid pulses

Inspect the jugular veins

Measure the blood pressure

Inspect the upper and lower extremities

Palpate the upper and lower extremities

Palpate the upper and lower extremity pulses

Check capillary refill on fingers and toes

Assess for edema in lower extremities

What do I need to document regarding the pulse to provide all the information?

Rate, rhythm, amplitude, and contour

Why do we check Capillary Refill, how is it recorded in the EMR? What is an expected finding?

Indicates the level of perfusion

Cap refill < 3 seconds

Should be less than 3 seconds

How is edema assessed?

Firm press on upper and lower extremities to make an indentation → skin should not make an indent

\
__**Grades 1-4 (0-4+)**__

*Grade 0:* No clinical edema

*Grade 1:* Immediate rebound, with 2mm pit

*Grade 2:* Less than 15 seconds rebound with 3-4mm pit

*Grade 3:* Rebound greater than 15 seconds but less than 60 seconds with 5-6mm pit

*Grade 4:* Rebound between 2 to 3 minutes with 8mm pit

S1

Systole

Ventricle CONTRACT

Lubb

mitral/tricuspid (atrioventricular)

S2

Diastole

Ventricles RELAX & FILL

Dubb

aortic/pulmonic valves (semilunar)

Why do we listen to all the heart tones?

Could indicate what valves are working properly and correctly → could reveal a murmur in certain locations

What are we listening for when using the bell?

Murmurs

What is heart failure often a result of?

High blood pressure/hypertension

What are the symptoms of heart failure?

Left sided: Fatigue, shortness of breath, orthopnea, dyspnea on exertion, paroxysmal nocturnal dyspnea

May reveal displaced apical pulse and palpable thrill

S3 heart sound heard → systolic murmur at apex

Crackles bilaterally


Right sided: Dependent peripheral edema

S3 heart sound heard at LLSB

Systolic murmur

Weight gain

What are the symptoms of MI?

Worst chest pain ever

Pain that lasts longer than 5 minutes

Radiate to left shoulder, jaw, arm, or other areas of the chest that is not relieved by rest or nitroglycerin

Dysrhythmias are common

Heart sounds may be distant with a thready pulse

respiratory assessment

Inspect patient’s appearance, posture, and breathing effort

Count respirations and observe breathing patterns and chest expansion

Inspect patient’s nails, skin, and lips

Inspect posterior and anterior thorax

Auscultate posterior, lateral, and anterior thorax

What do we do for a patient that has secretions in the upper airway?

Treat with medication

What muscles are used to breathe?

Diaphragm and intercostals

How do you document expected lung sounds? What do they sound like?

Breath sounds clear, with vesicular breath sounds heard over most lung fields

What does asthma sound like?

Audible wheeze and occasionally diminished breath sounds

What sounds are heard when there is fluid or consolidation in thelungs?

Crackles or wheezes

What is a pneumothorax? What can cause one?

Air in the pleural space

Three types:

Closed: May be spontaneous, traumatic, or iatrogenic (caused by illness or medical treatment)

Open: Following penetration of the chest

Tension: Develops when air leaks into the pleura and cannot escape (resp. emergency)

pulmonary edema

Condition caused by too much fluid in the lungs → collects in the air sacs of the lungs and make it difficult to breathe

COPD

Something that is blocking the airway

Breathing difficulty, cough, mucous productions, frequent respiratory infections



Swelling in ankles, feet, or legs

Coarse crackles

emphysema

Destruction of the alveolar walls that causes permanent enlargement of the air spaces

Underweight individual with barrel chest that becomes SOB with little exertion



Pursed-lip breathing and tripod position

Diminished breath sounds, possible wheeze and crackles

chronic bronchitis

Hypersecretion of mucous by the goblet cells of the trachea and bronchi → results in productive cough for 3 months in each of 2 successive years

Productive cough, increased mucous production, and dyspnea

Rhonchi, sometimes cleared by coughing

Cyanosis and clubbing

asthma

Hyperreactive airway that is characterized by bronchoconstriction, airway obstruction, and inflammation

Dyspnea and tightness of chest



Tachycardia, tachypnea with prolonged expiration, audible wheeze, use of accessory muscles, and cough

Inspiratory wheeze and diminished breath sounds

What is a common complication for elderly, immobile adults in the hospital?

DVT

abdominal assessment

Observe patient’s general appearance, behavior, and position
Inspect the abdomen
Auscultate the abdomen
Palpate the abdomen lightly
Palpate the abdomen deeply

What are the main functions of digestive system?

Digestion/Ingestion

Secretion

Absorption

Excretion

Ulcerative Colitis

Unpredictable periods of remission with relapses

Severe, constant abdominal pain

Fever during acute attacks and rectal bleeding

Profuse watery diarrhea with blood, mucous, and pus

UTI

Dysuria, frequency (more than every 2 hours), urgency, and suprapubic pain

Urine may contain blood or sediment

Older adults → nonlocalized abdominal discomfort and may have cognitive impairment

Diverticulitis

Complain of pain in the LLQ

Nausea, vomiting, and altered bowel habits (constipation)

Fever, decreased bowel sounds with LLQ pain on palpation

What is the dysfunction in pancreatitis? What are the causes? Clinical presentations?

Dysfunction: Inflammation of the pancreas

Causes: Alcoholism and cholelithiasis

Clinical Presentation:
-Sudden onset of severe pain, describes as steady, boring, dull, or sharp, that radiates to the back
-Becomes worse with food
-Preferred position is knee-chest
-Nausea, vomiting
-Fever, tachycardia, hypotension
-Ascites, jaundice, decreased/absent bowel sounds, abdominal tenderness

GERD

Gastric secretions that become chronic and go back up into the esophagus

Peptic Ulcers

Break in the duodenal mucosa lining that heals and scars to create ulcers

What are some modifiable and non-modifiable risk factors with Colon Cancer?

Modifiable:
\-Diet

\-Physical activity

\-Weight

\-Smoking

\-Alcohol use

Non-modifiable:

\-Age

\-Family history

\-Inherited

musculoskeletal assessment

Inspect skeleton and extremities

Palpate the muscles

Palpate bones and joints

Assess range of motion of each joint

Assess muscle tone

Assess muscle strength and compare sides

What are the presenting symptoms of Rheumatoid Arthritis?

Bilateral joint involvement

Pain, edema, and stiffness of the fingers, wrists, ankles, feet, and knees

Pain and stiffness after awakening in the morning that lasts more than 30 minutes

Causes by autoimmune response → fever and fatigue

risk factors for osteoporosis

Age > 50 years old

Women

Caucasian and Asian

Small-boned thin women

Long-term asteroid users

risk factors for osteoarthritis

An increased risk with age

Women > 50

Obesity

Joint injury in their history

Genetics

How do we grade and document muscle strengths?

No evidence of contractility: 0
Evidence of contractility: 1
Complete ROM with gravity eliminated: 2
Complete ROM with gravity: 3
Complete ROM against gravity with some resistance: 4
Complete ROM against gravity with full resistance: 5

Define Substance dependence.

When a person uses alcohol or other drugs despite extreme negative consequences such as impairment to their daily lives

What differentiates delirium and dementia?

Delirium:

-Altered level of consciousness
-Usually comes from infection
-Temporary
-Impaired memory
-Manifestations

Dementia:

-Onset occurs slowly over years
-Irreversible memory, judgment, and calculation are impaired
-Flat affect, speech is slow and incoherent

How is PTSD diagnosed?

At least one re-experiencing symptom: Flashbacks, bad dreams, or frightening thoughts

At least one avoidance symptom: Staying away from places, events, or objects that are reminders of the experience or avoiding thoughts or feelings related to the traumatic event

At least two arousal and reactivity symptoms: Being easily startled, feeling tense or “on edge,” having difficulty sleeping, and/or having angry outbursts

At least two cognitive and mood symptoms: Trouble remembering key features of the traumatic event, negative thoughts about oneself or the world, distorted feelings such as guilt or blame; loss of interest in enjoyable activities

What are the symptoms of major depressive illness?

Loss of interest or pleasure for at least 2 weeks and have at least 5 of the following:
-Depressed mood most of the day
-Markedly diminished interest or pleasure in all or almost all activities of the day
-Significant weight loss when not dieting or weight gain or decrease or increase in appetite
-Psychomotor agitation or retardation
-Fatigue or loss of energy
-Feelings of worthlessness or excessive or inappropriate guilt
-Diminished ability to think or concentrate or indecisiveness
-Recurrent thoughts of death, recurrent suicidal ideation without a specific plan
-Suicide attempt or a specific plan for committing suicide

HEENT assessment

Head:
-Inspect head
-Inspect facial features

Eyes:
-Test visual acuity
-Assess visual fields for peripheral vision
-Inspect ocular structures
-Inspect the corneal light reflex
-Inspect each sclera
-Inspect each cornea transparency and surface characteristics of each eye
-Inspect each iris
-Inspect the pupils

Ears:
-Assess hearing
-Inspect the external ears
-Inspect each external auditory meatus

Nose:
-Inspect the external nose

Mouth:
-Inspect the lips
-Inspect the teeth and gums
-Inspect the tongue
-Inspect the buccal mucosa and anterior and posterior pillars
-Inspect the palate, uvula, posterior pharynx, and tonsils

Neck:
-Inspect the neck
-Assess the range of motion
-Assess neck muscle strength

What are the characteristics of down’s syndrome?

Low-set ears or ears that are misaligned are abnormal

Enlargement of the tongue or hypothyroidism

When checking for drainage from the nose and ears following a head injury, what are we looking for and why?

Look for the description of discharge (color, consistency, odor)

thick/purulent green-yellow, malodorous discharge → bacterial infection

Foul-smelling discharge (unilateral) → foreign body or chronic sinus

Bloody discharge → neoplasm, trauma, or opportunistic infection (fungal disease)

Epistaxis → occurs secondary to trauma, chronic sinusitis, malignancy, or a bleeding disorder (also from cocaine use)

Look for other symptoms

Related symptoms may be consistent with allergic rhinitis → itching, swelling, discharge from eyes, postnasal drip, and cough

Symptoms related to infection → fatigue, fever, and pain

Asking what they have done to treat the discharge/bleeding

If the patient used nasal spray other than normal saline → should only be used for 3-5 days to avoid causing rebound congestion

What can cause a foul odor in the nares or ears?

Obstruction in the ear/nose

Dizziness

Symptom used by many patients to describe a wide range of sensations, including fairness, light-headedness, feeling as if their head is spinning, or the inability to maintain a normal balance in standing/seated position

Vertigo

The sensation of movement or spinning, the cardinal symptom of the inner ear system → controls balance identifies spatial orientation)

Light-headed

A vague description of dizziness that does not fit specific classifications

Pre-syncope

The feeling of faintness and the impending loss of consciousness → often a cardiovascular problem

Ex: patient falls postpartum on the way to the bathroom (BP probably dropped on her way)

What are the different types of hearing loss?

Conductive:
-Sudden, onset
-If there is a mechanical blockage or damage

Sensorineural:
-Permanent, nonreversible, progressive
-Causes deafness
-Occurs with age
-Caused by consistent, loud noises

When checking lymph nodes in the head, what are we checking for?

Palpable, soft, mobile, non-tender, and bilaterally equal in size

What does it mean if lymph nodes are swollen, tender, or movable? What if they are painless and fixed?

Could be an infection in the head if swollen, tender, or movable

If they are painless and fixed could mean malignancy

Know the lymph nodes we went over in class and their locations. 

Preauricular
Postauricular
Occipital
Parotid
Tonsillar
Submandibular
Submental

Who is at the greatest risk for oral cancer? How is this assessed?

Tobacco use (M)

Alcohol use (M)

Older than 55 → increased risk between ages 64 and 74

2:1 male to female incidence

HPV in mouth

Exposure to UV → increased risk for lip cancers (M)

Immunosuppression

Upon assessment of a patient with seasonal allergies, what would the nurse expect?

Sneezing, nasal congestion, and nasal drainage

Itchy eyes, cough, and fatigue → turbinate's are often enlarged and may appear pale or darker red

Define an eye emergency

Sudden onset of visual symptoms → could indicate detached retina (requires emergency referral)

Ptosis 

Drooping of the eye, seen in older adults, dry eye, drainage when waking up

Exophthalmos 

Graves' disease symptom → can see the sclera all the way around

Strabismus 

Cross eyes (fix by the age of 8)

Glaucoma (inner eye)

Pressure behind the eyes, treatable with eye drops, incurable

Cataracts (inner eye)

Film on the lens, gets worse, can be treated (but not entirely)

Diabetic retinopathy (inner eye)

Uncontrolled hypercalcemia

Conjunctivitis (external eye)

Conjunctiva is inflamed or infected

Corneal abrasion or ulcer (external eye)

Caused by a foreign body in the eye, wearing contacts for long periods of time (not changed, sleeping in them), heals pretty quickly with drops

What can cause a perforated septum?

The most common cause is cocaine use

Why is it concerning if a patients tonsils are swollen and almost meet in the middle?

Means that they are obstructing the airway and do not have a good passageway

neuro assessment

Assess mental status and level of consciousness

Assess speech

Notice cranial nerve functions

Observe gait

Assess extremities for muscle strength and tone

What are the presenting symptoms of meningitis?

Headache, fever, nuchal rigidity → diagnosis through a spinal tap

What are the presenting symptoms of Encephalitis?

Confusion, fever, vomiting

frontal lobe

responsible for personality, controls emotions, sense of self (space), Broca’s area

Primary motor cortex → voluntary motor activity

temporal lobe

auditory, receive messages, Wernicke’s area

Comprehension of spoken and written language

Thought and memory

occipital lobe

sensory (position, sense, touch, shape, and texture of objects)

parietal lobe

vision

Receiving and interpreting visual information

What is the earliest and most sensitive way neurological functioning is assessed?

Determining how alert and oriented the patient is based on admission