Health Assessment Comprehensive Final Exam

Weight is a good measurement of

fluid/nutrition status

Newborn's head measures about _____ to _____ and about _____ _____ than chest circumference

Newborn's head measures about 32 to 38 cm and about 2cm larger than chest circumference

Rectal temperature measure ___ to ___ higher

.7°F to 1°F

What is a normal oral temperature in a resting individual?

37°C (98.6°F)

Pulse rate =

number of pulsations felt (palpated) in 1 minute

Rhythm =

regularity of the pulsations (time between each beat)

Heart rate at where is the most accurate?

apical pulse (5th intercostal space at left midclavicular line)

Respiratory rate =

number of times the patient completes a ventilatory cycle (inhalation and exhalation) each minute

Respiration variations

can vary with age, fever, anxiety, exercise, and increased altitude

tachypnea: too fast (32 for an adult)

bradypnea: too slow (RR 6)

apnea: long pauses or not breathing at all

Systolic pressure:

maximum pressure felt on artery during left ventricular contraction, or systole

Diastolic pressure:

elastic recoil, or resting, pressure between each contraction

Mean Arterial Pressure (MAP):

pressure forcing blood into tissues, averaged over cardiac cycle

Systolic BP is normally __ to __ mm Hg higher in the leg than in the arm

10 to 40 mm Hg higher

Normal BP

120/80 mm Hg

Level of BP is determined by five factors

1.) cardiac output (pump)

2.) peripheral vascular resistance

3.) volume of circulating blood

4.) viscosity

5.) elasticity of vessel walls

Errors in BP that can make it falsely high

-anxiety, anger, pain

-arm below level of heart

-too small cuff

-crossing legs

-failing to wait 1-2 mins before repeating

Errors in BP that can make it falsely low

-arm above level of heart

-operator error (pushing stethoscope too hard)

-deflating cuff too quickly

-too large of cuff

Position changed from supine to standing normally you will see a

slight decrease (less than 10 mm Hg) in systolic pressure may occur

Oxygen saturation measures

estimates the % of oxygen saturation in hemoglobin in the blood (normal is >93%)

When checking RR for pediatrics

it is most accurate when sleeping and watch the abdomen

Nociceptive pain is described as

dull, achy, throbbing, or sharp pain

Neuropathic pain is

due to a lesion or disease in the somatosensory system

Short-term and self-liming pain

warns individual of potential tissue damage and usually dissipates after an injury

Malignant pain

induced by tissue necrosis or stretching of an organ by growing tumor

Non-malignant pain

musculoskeletal conditions, such as arthritis, lower back pain, or fibromyalgia

Complete Assessment of pain should include:

-time

-description

-level

-alleviate and aggravate

-ADL dysfunciton

-reaction to pain

-what does pain mean to you?

FACES pain scale

great for pediatric and cognitively declined patients

PAINAD scale

pain assessment for advanced dementia patients who are unable to verbalize what is going on with them

Behavior Pain Scale

assess pain in critically ill, sedated, and intubated patients in the ICU who cannot verbally communicate

FLACC Pain Scale

for the pediatric clients and is observer based assessment

CRIES Pain Scale

used in assessing infants

Pharmacological Interventions

-analgesics

-anti-inflammatory

-opioids

-antidepressants

-anticonvulsants

-muscle relaxants

-creams and patches

Non-Pharmacological Interventions

-heat/cold

-guided imagery

-massage

-low stimuli

Managing Awkward Emotions: Anger

deal with it directly

-identify source of anger

-discuss approaches and acknowledge feelings

-if the patient is unable to continue, honor request to work with another nurse

Comprehensive Health History

establishes complete database

Problem-based or focused health assessment

includes data limited to the scope of problem

Episodic follow up assessment

focus on specific problems for which patient is already receiving treatment

Localized infection

the patient has symptoms, such as pain and tenderness and redness at the site (example: wound infection)

Systemic infection

affects the entire body instead of just a single organ or part and can become fatal if undetected and untreated (symptoms can include fever, fatigue, n/V, and malaise)

The most important basic technique in preventing and controlling transmission of infection is

hand hygiene

Principles of Surgical Asepsis

1.) a sterile object remain sterile only when touched by another sterile object

2.) only sterile objects may be placed on a sterile field

3.) a sterile object or field out of range of vision or an object held below a person's waist is contaminated

4.) a sterile object or field becomes contaminated by prolonged exposure to air

Droplet Precautions

surgical mask in addition to universal precautions

Airborne Precautions

N95 respirator in addition to universal precautions

Active ROM

patient returns your demonstration

Passive ROM

if you see a limitation

Muscle Testing

Cyanosis

Increased amounts of deoxygenated blood

Light Skin: dusky blue, especially in conjunctiva, nail beds, earlobes, lips, oral membranes, soles, and palms

Dark Skin: ashen gray lips and tongue, nail beds, oral mucosa, and conjunctiva

Pallor

Decrease in hemoglobin content

Light Skin: loss of rosy glow in skin, especially face

Dark Skin: ashen gray appearance in black skin and a more yellowish-born color in brown skin

Erythema

Increased amounts of blood flow of RBCs

Light Skin: redness easily seen anywhere on body, bright cherry red

Dark Skin: much more difficult to assess, rely on palpitation for warmth or edema, purplish tinge

Jaundice

Increased bilirubin in skin or sclera

Light Skin: yellow staining seen in sclera of of eyes, skin, fingernails, soles, palms, and oral mucosa

Dark Skin: most reliably assessed in sclera, hard palate, palms, and soles

Macule and Patch

Macule: <1 cm, flat, circumscribed

Patch: > 1 cm

Papule and Plaque

Papule: < 1 cm, solid, elevated, something you CAN FEEL

Plaque: > 1 cm

Nodule and Tumor

Nodule: > 1 cm, solid, hard, or soft, elevated

Tumor: > a few centimeters, malignant or benign

Wheal and Hives

Wheal: superficial, raised, erythematous with irregular shape due to edema (mosquito bite, allergy reaction)

Hives: a collection of wheals due to extensive reaction

Vesicle and Bulla

Vesicle: up to 1 cm, elevated, fluid filled (blister, herpes, zoster)

Bulla: > 1 cm, fluid filled, easily ruptures

Pustules

circumscribed, elevated, turbid fluid filled (pus)

Cyst

encapsulated fluid filled cavity, dermis or subcutaneous layer, tensely elevated skin

Crust

thickened, dried exudate when a vesicle or pustule burst

Scale

compact, flakes of skin, dry or greasy, silvery or white, caused by shedding or dead skin cells

Fissure

linear crack into dermis caused by moisture breakdown and abrupt edges

Erosion

scooped-out shallow depression, superficial

Ulcer

depression extending into dermis, irregular borders, and may bleed

Excoriation

self-inflected abrasion, superficial. scratches from purritis

Scar

permanent fibrotic change after injury

Lichenification

formed from prolonged intense scratching, skin thickens and produces thickly packed pustules

Keloid

benign excess of scar tissue beyond sites of original injury, more common in Black, Latino, and Asian

Petechia

small (pinpoint), purplish, hemorrhagic spots on the skin, associated with bleeding tendencies or emboli to skin

Ecchymosis

a bruise that is superficial, bleeding under the skin or a mucous membrane, associated with trauma or bleeding tendencies

Purpura

hemorrhagic disease that produces ecchymosis and petechia, usually at multiple sites

Cherry Angioma

bening, compressible mass of blood vessels

Telangiectasia

a vascular lesion formed by dilation of a group of small blood vessels

Spider Angioma

a branched growth of dilated capillaries on the skin, resembling a spider

Pitting nails

small depressions in the nails are common in people with psoriasis, may cause the nails to crumble

Beau's lines

indentations that run across the nail, growth air the area under the cuticle is interrupted by injury or severe illness, such as a heart attack or also a sign of malnutrition

Onycholysis

nail separated from the nail bed (thyroid disease, fungal disease, drug reactions, reactions to acrylic nails, or psoriasis)

Pregnant Clients Hair/Skin/Nails variations

increase in sweating and sebaceous activity

increased blood flow to the hands and feet

skin thins and separated with stretching (striae)

hyperpigmentation forms down pregnant belly (linea nigra)

Abdominal Assessment Order

inspection, auscultation, percussion, and palpation

Borborygmi

normal hyperactive bowel sounds

Caution: If bruits are heard...

do NOT palpate abdomen

In a healthy adult the chest to side ratio is

2:1 (the chest is wider than it is deep)

Crepitus

ABNORMAL, free air in subcutaneous tissue, crackling sensation, seen in patients with chest trauma

Bronchial Breath Sounds

location: heard over trachea and larynx

pitch: high

amplitude: loud

duration: heard during expiration

quality: harsh, hollow, or tubular

Bronchiovesicular Breath Sounds

location: over the major bronchi

pitch: moderate

amplitude: moderate

duration: inspiration and expiration are equal

quality: soft, breezy sound with a slightly tubular tone but mostly mixed sounds

Vesicular Breath Sounds

location: outer edges of the lungs where air flows through smaller bronchioles and alveoli

pitch: low

amplitude: soft

duration: inspiration is longer than expiration

quality: rustling like wind blowing through trees

Emphysema

alveolar walls are weakened and enlarge and collapse; crackles noted

Chronic Bronchitis

airway becomes swollen and produces excessive mucus and hx of productive cough for 3 months of the year for 2 years in a row

When counting RR for infants you must

count for one full minute

Orthopnea

is dyspnea that occurs when a person is lying down (can be assessed by asking pt how many pillows they use when sleeping or lying down)

Claudication

pain, aching, or fatigue, usually in the calves, thighs, or buttocks, caused by insufficient blood flow (ischemia) to muscles during exercise, which resolves with rest

Paroxysmal Nocturnal Dyspnea

is a sudden acute type of dyspnea common in patients with left-sided congestive heart failure. During sleep the body fluid is redistributed, leading to pulmonary edema, and the individual wakes up gasping for air and coughing.

Syncope

fainting

Deep Vein Thrombosis Assessment

measure calf around the largest part of calf

> or equal to 2 cm difference indicates possible DVT

assess for warmth and erythema of calf

Arterial Ulcers

round smooth sores

black eschar

generally toes and feet

(dry and black)

Venous Ulcers

sores with irregular borders

yellow slough or ruddy skin

ankles

(red and icky)

Normal capillary refill

<3 seconds = normal

Carotid pulses should be assessed

one at a time

Jugular Vein Distension

seen with right-sided HF

Assessing UE temperature

dorsal aspect of hands and compare side-to-side simultaneously

Pulses expected/normal rating is

2+

Types of Edema

pitting or non-pitting: accumulates in extremities

pulmonary edema: accumulates in the lungs

ascites: accumulates in the abdominal cavity