IUPUI health assesment exam 1

What is Health History?

A collection of subjective data that provides a detailed profile of the patient's health status

What information is taken during a Physical Exam?

Objective data that is collected using inspection, palpation, auscultation, and percussion

What is the importance of documentation of data?

Helps to serve as a baseline for the evaluation of subsequent changes and helps to make decisions related to care

What are symptoms?

Subjective characteristics of disease felt only by the patient

What are signs?

A collection of objective data completed by the nurse to help figure out a diagnosis

What is a comprehensive health assessment and when is it preformed?

Involves a detailed history and physical examination. Normally preformed at the onset of care at a primary care setting or admission to a hospital or a long-term care facility.

What is a problem-based/focused assessment and when is it preformed?

Involves a health history and physical examination that is linked to a SPECIFIC problem. Normally done at a walk-in clinic, ER, or other outpatient settings.

What is an episodic/follow up assessment and when is it preformed?

Done when patient is following up with a healthcare provider for a specific problem. For example, a patient with diabetes.

What is a shift assessment and when is it preformed? Why is it important?

Done when individuals are hospitalized. Nurses complete an assessment during each shift, which is done to assess any changes in the patient's condition from the baseline.

What is a screening assessment and when is it done?

This is a short examination used to detect diseases. Most likely done at a health care providers office.

What is context of care and how does it impact a health assessment?

The context of care can be referred to as the general environment during a health assessment. If the environment makes the patient feel unsafe, the health assessment may not be completed or may not be completed correctly.

What is patient need? How does it impact health assessment?

Patient needs could include age, general level of health, presenting problems, knowledge level of healthcare, or even their support system. If the patient has poor levels of these, the health assessment may be difficult to complete.

How does the experience of nurses impact health assessment?

Different types of assessments may be needed to get an accurate gauge on the patient, which requires knowledge and experience of a nurse.

What are the six steps in the nursing process?

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation

What are the three phases of the interview process?

Introduction, discussion, and summary.

What are the techniques used during the interview to enhance data collection?

Active listening, confrontation, clarification, facilitation, interpretation, reflection, and summarization

What are five things that diminish data collection?

Using medical terminology, expressing value judgements, interrupting the patient, being authoritarian/paternalistic, and/or using "why" questions

What are some methods of managing awkward situations?

-Answering personal questions (be brief)
-Silence (become comfortable with it)
-Displays of emotion (take a therapeutic approach)

What are four potential barriers/challenges to the interview process?

-An overly talkative patient
-Others in the room
-Disruptive individuals
-Angry/upset patients

Define each letter of OLDCARTS:

O: Onset
L: Location
D: Duration
C: Characteristics
A: Aggravating/Alleviating factors
R: Related symptoms
T: Treatment
S: Severity

What are three components of the present health status?

-Current health conditions
-Medications
-Allergies

What are some components of past health history?

-Childhood Illnesses
-Surgeries
-Hospitalizations
-Immunizations
-Last examinations
-Obstetric History (if applicable)
-Accidents and/or Injuries

What are the parts of personal/psychosocial history?

-Personal status
-Family and Social Relationships
-Diet/Nutrition
-Functional ability
-Mental Health
-Tobacco, alcohol, and/or illicit drug use
-Health Promotion Activities
-Environment

What is the importance of the review of systems?

So as to inquire about the past and present health of each of the patient's systems and note any changes and/or abnormalities.

Is the review of systems subjective or objective? Why?

Subjective, as you are asking the patient about their opinions.

What are special considerations during the interview process that need to be taken in to consideration for children, pregnancies, and older adults?

Children - data is mainly collected with a parent/guardian accompanying them.
Pregnancies - Emphasis on obstetric history, as well as pregnancy outcomes. Mainly episodic visits.
Older Adults - incorporation of various age-related questions, as well as questions involving functional status.

What is the order for PPE?

gown, mask, goggles, gloves

What is percussion/what is it used for?

Tap directly onto the skin in order to evaluate the size, borders, and consistency of internal organs as well as detect tenderness and determine the extent of fluid in a body cavity

What is the importance of sitting during a physical examination?

Provides full expansion of the lungs and provides better visualizations of the symmetry of the upper extremities.

What is the importance of being in the supine position during a physical examination?

This is the most normally relaxed body position and provides easy access to pulses.

What is the importance of being in the dorsal recumbent position during a physical examination?

This is used for abdominal assessment because it promotes the relaxation of abdominal muscles

What is the importance of being in the lithotomy position during a physical examination?

This provides maximum exposure of genitalia

What is the importance of being in the sims position during a physical examination?

This provides flexion of the knee and hip and improves exposure of the rectum.

What is the importance of being in the prone position during a physical examination?

Used to assess the flexion of the hip joint

What is the importance of being in the lateral recumbent position during a physical examination?

Assists in detecting murmurs

What is the importance of being in the knee-chest position during a physical examination?

Provides maximum exposure of the rectal area

What is the expected range of temperature?

96.4-99.1 degrees F

What are expected variances of temperature?

-Diurnal Variations (1-1.5 degrees F)
-Menstrual Cycle (0.5-1 degrees F)

What is the normal heart rate range for an infant?

100-160bpm

What is the normal heart rate range for a toddler?

98-140bpm

What is the normal heart rate range for a school age child?

74-118bpm

What is the normal heart rate range for an adolescent?

60-100bpm

What is the normal heart rate range for an adult?

60-100bpm

What is the normal respiratory range for an infant?

30-53 breaths per minute

What is the normal respiratory range for a toddler?

22-37 breaths per minute

What is the normal respiratory range for a school age child?

18-25 breaths per minute

What is the normal respiratory range for an adolescent?

12-20 breaths per minute

What is the normal respiratory range for an older adult?

12-20 breaths per minute

Where should the BP cuff be placed?

1 inch above the site of brachial pulsation, the bladder should be centered over the artery

What are Kortokoff sounds?

The sound of blood pulsating through the artery

What could cause false high BP measurements in a patient?

Patient's legs are crossed, arm is BELOW heart level, the cuff is too narrow, loose, or uneven; and/or the cuff is deflated too slow.

What could cause false low BP measurements in a patient?

Arm is ABOVE heart level, cuff is too wide, there is poor inflation in the cuff, if the cuff is deflated too fast, or the diaphragm of the stethoscope is placed too firmly over the brachial artery.

What are some physiological factors that can affect blood pressure?

Age, gender, race, pregnancy, diurnal variations, emotions, pain (acute pain may increase blood pressure), personal habits, and/or weight

Describe acute pain:

Recent onset, normally short, results from tissue damage and ends when the tissue heals

Describe nociceptive pain:

Caused by direct stimulation of peripheral nociceptors and is usually associated with inflammation; produces somatic or visceral pain

Describe referred pain:

Visceral pain that is experienced in an area other than the body part that is the source of the pain; can come from internal organs

What type of pain are A-delta fibers associated with?

Sharp, prickling, acute pain that is well localized and short in duration (think getting burned)

What type of pain are C fibers associated with?

Dull, aching, throbbing, or burning sensation that diffuses into a slow onset and has a relatively long duration (think chronic illnesses)

What is the difference between pain threshold and pain tolerance?

The pain threshold is the point at which a stimulus is detected and perceived as pain, whereas pain tolerance in the duration or intensity of pain that a person endures or tolerates without responding outwardly.

What are some assessment findings associated with respiratory distress?

Appearance of apprehension, restlessness, nasal flaring, use of accessory muscles when breathing, and supraclavicular or intercostal retractions

What is paradoxical chest movement?

Normally seen after chest trauma, a patient's chest will move in with inspiration and out with expiration

What is retraction?

Appears when intercostal muscles are drawn inward between the ribs and indicates airway obstruction. This may occur during an asthma attack or pneumonia

What are Kussmauls?

Rapid, deep, labored breathing

What is biot?

Irregularly interspersed periods of apnea in a disorganized sequence of breaths

What is Cheyne-Stokes breathing?

Periods of deep breathing that alternate with periods of apnea; caused by: heart failure, uremia, drug use, brain damage

What is air trapping?

Increase difficulty in getting air out, such as with COPD

What are some reasons for thoracic asymmetry?

-Scoliosis (may limit expansion of the chest)
-Barrel chest (linked with COPD or emphysema as these diseases limit gas exchange in the alveoli)

What should normal chest symmetry look like?

Ribs should slope at a 45 degree angle relative to the spine, spinous process should be straight

Describe vesicular breath sounds:

Soft, low-pitched breath sounds heard in the lung periphery.
Inspiration > Expiration: (2.5:1)

Describe bronchovesicular lung sounds:

Moderate pitch and intensity sounds
Heard over main bronchi
Inspiration and expiration heard for equal time (1:1)

Describe brachial lung sounds:

High pitched, loud intensity
Heard over the trachea
Inspiration < Expiration (1:2)

Describe crackles

-bubbling, crackling, popping
-low-to-high pitched, discontinuous sounds
-auscultated during inspiration
-not cleared by cough or changes in body position

What type of diseases can cause crackles?

Pneumonia, heart failure, and/or restrictive pulmonary diseases.

Describe wheezes

Continuous musical sounds heard predominantly during expiration that is caused by narrowing of passage way
Heard in diseases that causes a thickening of the airway (such as asthma)

Describe rhonchi

Low-pitched wheezing, snoring, or rattling sound in someone wtih partial airway construction (mucus)
Primarily heard during expiration
Coughing may clear this sound

What diseases may cause rhonchi?

Chronic Bronchitis or COPD

Describe a pleural friction rub

A gritty sound produced by the inflamed pleural surfaces rubbing together during the entirety of respiration.
Normally caused by pleurisy inflammation

Why would diminished breath sounds be heard in a patient?

When a patient's alveoli have been damaged

What types of diseases cause diminished breath sounds?

Emphysema or an asthma attack

Describe stridor

High-pitched inspiratory sound usually associated with an obstruction of the upper airway

What is fremitus?

a palpable vibration from the spoken voice felt over the chest wall

Describe normal findings of fremitus

Should feel bilaterally equal over the posterior and anterior chest walls.

What would abnormal findings or fremitus be?

When fremitus is felt asymmetrically and diminished when air, fluid, or tumor pushes the lungs away from the chest wall, most likely because of a pneumothorax, pleural friction, and/or tumor

How do you assess diaphragmatic excursion?

Ask patient to forcefully exhale and hold breath. Percuss down until the tone changes from resonance to dullness and mark location. Used to estimate the location of the diaphragm when increased downward expansion is detected.

What is vocal resonance?

The spoken voice transmits sounds through the lung fields that may be heard posteriorly with the stethoscope.

How is broncophony performed?

Done by asking the patient to repeat "ninety-nine", "e-e-e", or "one, two, three"

Why would you perform a whispered pectoriloquy?

When there is a positive finding of bronchophony; the patient is then asked to whisper "one, two, three"

Describe a egophony

Patient says "EEEEE." Abnormal if you hear "AAAA"

What can pull the trachea to the affected side during tracheal deviation?

Pulmonary fibrosis, atelectasis, and simple collapsed lung deviation

What can pull the trachea opposite of the affected side during tracheal deviation?

Thyroid enlargement, pleural effusion, and a pneumothorax

Describe acute bronchitis

An inflammation of the mucous membranes of the bronchial tree caused by viruses or bacteria. Cough is normally nonproductive, but may become productive with a presence of yellow or green sputum. Rhonchi are heard upon auscultation, and wheezing is heard during expiration.

Describe pneumonia

Infection of the terminal bronchioles and alveoli. May cause fear, tachycardia, and/or tachypnea. Patient may also experience chest pain while deep breathing and/or coughing.
Crackles or rhonchi may be heard

Describe viral pneumonia

Produces nonproductive cough or clear sputum

Describe bacterial pneumonia

Has a productive cough, with white, yellow, or green sputum.

Describe Tuberculosis

an infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs.
Primarily affects upper airways, lymph nodes, kidneys, and meninges (these can become infected).
May manifest itself in night sweats, fever, weight loss, and fatigue

Describe pleural effusion

Accumulation of serous fluid in pleural space, presenting with dyspnea and chest pain
May present itself in fever, tachypnea, tachycardia, decreased fremitus, tracheal deviation, and/or absent breath sounds on affected side.

Describe asthma

Bronchial hyper-responsiveness that causes REVERSIBLE bronchoconstriction and inflammation

Describe emphysema

the destruction of alveoli, which makes them unable to hold their functional shape upon exhalation.
Barrel chest is present in these cases, as well as a patient who demonstrates pursed lip breathing and is in the tripod position.
May have diminished breath sounds and clubbing

Define chronic bronchitis

Increased mucus production by goblet cells of the trachea and bronchi that cause obstruction of small airways and a chronic productive cough for over 3 months
Presents itself in rhonchi, cyanosis, and clubbing of the nails - think hypoxia

What are the signs of a hemothorax?

Hypotension, cold, clammy skin, tachycardia, and rapid, shallow breathing