Health Assessment Exam #1 (Ch. 1,3,4,8,9,10,12,18,27,29)

What does the health history provide?

Subjective and objective data

What is subjective data? what is an example?

SD is what the patient tells you

Example: headache, chest pain

What is objective data? what is an example?

OD are the signs perceived by the examiner through physical examination during assessment

Example: rash seen by a nurse, or temp taken with a thermometer

In what order are skills performed during a typical assessment?

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

If a patient has abdomen pain, what order do you do the assessment? Why?

1. Inspection

2. AUSCULTATION

3. Palpation

4. Percussion

Because of pain, don't touch or tap the tender area first. Start by inspecting and then listening before you feel the area.

What occurs during inspection, the first step?

-ALWAYS COMES FIRST

-begins when you first meet a person w/ a general survey

-you should start assessment of each body system with inspection

-requires: good lighting, adequate exposure, use of instruments including otoscope, opthalmoscope, penlight, or specula

What occurs during palpation, the second step?

Palpation applies sense of touch to assess

Can include:

temperature, texture, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, presence of tenderness or pain

-use fingers unless taking temperature

How can you assess factors during the palpation step?

by using different parts of the hands

During palpation, what should fingertips be used to feel?

-best for fine tactile discrimination of skin texture, swelling, pulsation, and determining presence of lumps

During palpation, what should fingers and thumb be used for?

-detection of position, shape, and consistency of an organ or mass

During palpation, what should the dorsa of hands and fingers be used for?

-best for determining temperature because skin here is thinner than on palms

During palpation, what should the base of fingers or the ulnar surface of hand be used for?

-best for vibration

**-vibrations are felt on the ulnar side of hand

During palpation, what type of palpation should you start with and why? What steps are next?

1. start with LIGHT palpation to detect surface characteristics and accustom person to being touched

-1 cm

2. then deeper palpations when needed

-intermittent pressure better than one long continuous palpation

-5 to 8 cm or 2-3 in

ALSO: bimanual palpation- requires use of both hands to envelop or capture certain body parts or organs such as kidneys, uterus or adnexa for precise delimitation

What occurs during percussion, the third step?

-consists of tapping a person's skin with short, sharp strokes to assess underlying structures

What uses does percussion have?

-mapping location and size of organs

-signaling density of a structure by a characteristic note

-detecting a superficial abnormal mass

1. percussion vibrations penetrate about 5 cm

deep

2. deeper mass would give no change in percussion

-eliciting pain if underlying structure is inflamed

-eliciting deep tendon reflex using percussion hammer

HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT THAN SOLID ORGANS

What are the two methods of percussion?

1. Direct, or immediate, which is when the striking hand directly contacts body wall

2. Indirect, or mediate, is when you use both hands and the striking hand contacts stationary hand fixed on person's skin

In regards to percussion, what is resonance and where does it occur?

Resonance is low pitch and it occurs over normal lungs

In regards to percussion, what is hyperresonant and where does it occur?

Hyperresonant is lower pitch and it occurs over child's lungs

In regards to percussion, what is tympany and where does it occur?

Tympany is high pitch and it occurs over air filled organs (stomach, intestines)

In regards to percussion, what is dull and where does it occur?

Dull is high pitch and it occurs over solid organs (liver, spleen)

In regards to percussion, what is flat and where does it occur?

Flat is high pitch and it occurs where no air is present such as over muscles/bones or a tumor

What occurs during auscultation, the fourth step?

Auscultation is when you listen to sounds produced by the body

-most sounds are soft and must be channeled through a stethoscope

-once you can recognize normal sounds, you can distinguish the abnormal sounds and "extra" or abnormal sounds

What is the single most important step in decreasing microorganism transmission?

WASH YOUR HANDS

-before physical contact with each patient

-after inadvertent contact with blood, body fluids, secretions, and excretions

-after contact with any equipment contaminated with body fluids

-after removing gloves

What else should you do in health care in addition to washing your hands?

WEAR GLOVES

-any time there is contact with body fluids

The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for the examination?

1. Palpation, percussion, inspection, auscultation

2. Inspection, palpation, auscultation, percussion

3. Inspection, auscultation, percussion, palpation

3

Are vital signs subjective or objective data?

Objective because they can be measured by a health care professional

What are the 5 vital signs?

1. Temperature

2. Pulse

3. Heart rate

4. Respirations

5. Blood pressure

What are the benefits of taking temperature orally?

-It is accurate and convenient

-The oral sublingual site has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature

What is a normal oral temperature range?

98.6 degrees F (37 degrees C) with a range of 96.4 degrees F to 99.1 degrees F (35.8 to 37.3 degrees C)

What is a normal rectal temperature range?

Rectal measures 0.7 to 1 degrees F (0.4 to 0.5 degrees C) higher

What is normal temperature influenced by?

-Exercise: moderate to hard exercise increases body temp

-Age: wider normal variations occur in infant and young children due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 97.2 degrees F (36.2 degrees C)

In regards to taking a temperature, how long should you wait if the patient has just consumed hot or iced liquids? What about if they just smoked?

Liquids- 15 minutes

Smoking- 2 minutes

What is a safe and accurate way to take children's temperature?

Axillary temperature

When should you take a rectal temperature?

-When other routes are not practical, for example, for comatose of confused persons, persons in shock, or for those who cannot close mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction or if no tympanic membrane thermometer is available

What should you do before inserting the thermometer probe in the rectum?

-Put on gloves

-Use lube

How should temperature be recorded?

-In celsius unless agency uses fahrenheit

What is the conversion for Fahrenheit to Celsius?

Celsius to Fahrenheit?

F to C: C = 59(F-32) or C = F-32+1.8

C to F: F = (95 x C) + 32 or F = 1.8(C) + 32

Know both Fahrenheit and Celsius scales and normal ranges ***

What is stroke volume?

What is normal in adults?

The amount of blood every heart beat pumps into aorta

-70 mL

Regarding pulse as a vital sign, what does palpating the peripheral pulse do?

It gives rate and rhythm of heartbeat, as well as local data on condition of artery

When is the radial pulse usually palpated?

When vital signs are measured

What should you use and where should you palpate the radial pulse?

-Use your first three fingers

-Palpate it at the flexor aspect of the wrist laterally along radius bone

-Push until strongest pulsation is felt

If the heart rhythm is REGULAR, how long should you count the number of beats for?

-30 seconds and multiply it by 2

Why is 30 seconds used to take the pulse?

because it is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular

How long should you count the pulse for if the rhythm is IRREGULAR?

1 full minute

-as you begin counting interval, start your count with "zero" for first pulse felt

What parts of a pulse should you assess?

-rate

-rhythm

-force

-elasticity

What is the normal heart rate range in a resting adult?

50 to 90 beats per minute

What causes heart rate to vary?

-age (more rapid in infants and children but more moderate during adult and older years)

What is tachycardia?

-A more RAPID heart rate, over 90 bpm

-occurs with anxiety or with increased exercise to match body's demand for increased metabolism

What is bradycardia?

-A SLOWER heart rate, less than 50 bpm

-occurs in well trained athlete

What is the force of the pulse?

Strength of heart's stroke volume

What does a weak, thready pulse reflect?

A decreased stroke volume

What does a full, bounding pulse indicate?

Increased stroke volume

-Such as with anxiety, exercise and some abnormal conditions

What kind of scale is pulse recorded on? What do the numbers indicate?

-A three point scale

3+ full, bounding

2+ normal

1+ weak, thready

0 absent

-some agencies use a four point scale

"90 bpm 2+"

What should someone's breathing be like? How should you monitor respiration?

-relaxed, regular, automatic and silent

-instead of telling someone you are monitoring their respiration, maintain your position of counting radial pulse and count respirations

How long should you count respirations?

-Count for 30 seconds or 1 minute if you suspect an abnormality

What is the ratio of pulse rate to respiratory rate?

4:1

-normally both rise as a response to exercise or anxiety

What is blood pressure defined as?

Force of blood pushing against side of its container, vessel wall

What is systolic pressure? Diastolic?

Systolic: maximum pressure felt on artery during LEFT VENTRICULAR CONTRACTION, or systole

Diastolic: elastic recoil, or resting, pressure that blood exerts constantly between each contraction

What is mean arterial pressure, or map?

pressure forcing blood into tissues, averaged over cardiac cycle, measured as diastolic (systolic-diastolic) /3 or diastolic pressure + 1/3 pulse pressure

What is average blood pressure in adults?

120/80 mm Hg

-varies with factors such as age (rise into adult years), gender (females lower than males until after menopause then it switches), race (African American usually higher than white)

Arm pressure, person may be sitting or lying, with bare arm supported at heart level. What are the steps of taking blood pressure?

1. Palpate brachial artery; with cuff deflated, center it about 1 inch above brachial artery and wrap it

2. Palpate brachial artery

3. Inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond

4. Deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissapate

What is a blood pressure cuff called? How many sizes are there?

Sphygmomanometer

-6 sizes

What should the dimensions of the rubber bladder on the BP cuff be?

-About 40% the width of the person's arm and the length should be 80% of this circumference

-Should cover 70% of arm from acromion to olecranon

If the BP cuff is too narrow/small, what can the reading be?

Falsely high, up to 50 mm Hg

If the BP cuff is wrapped too loose, what can the reading be?

Falsely high

If the BP cuff is too large, what can the reading be?

Falsely low

When should you not use an automatic BP cuff?

-If systolic < 90 mm Hg, irregular heart rate, shivering, tremors or seizures

Orthostatic, or postural vital signs: when should you take serial measurements of pulse and blood pressure?

-you suspect volume depletion

-person known to have hypertension or taking antihypertensive medications

-person reports fainting or syncope

How should you take postural vital signs?

-Have the person rest supine for 2 or 3 minutes and take baseline readings of pulse and BP

-Repeat with person sitting

-Repeat with person standing

-LYING, SITTING, STANDING

When should you take orthostatic, or postural vital signs?

-When the position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur

-Record BP by using even numbers

-Also record person's position, arm used, and cuff size, if different from standard size cuff

What is orthostatic hypertension?

B/P systolic drop of 20 mm Hg or increase in pulse by 20 beats/min with quick change to standing

How should you weigh an infant?

-on a platform-type balance scale

-by age 2 or 3, use upright scale

How should you measure an infant's body length?

Measure it supine by using horizontal measuring board

What is the best index of a child's general health?

Physical growth***

Arteries, aorta, away, oxygen

Study measurement of oxygen saturation

What is a normal range of SpO2 for someone with no lung disease and no anemia?

-97 to 99%

-greater than 95% with normal hemoglobin

At lower oxygen saturations, what is more accurate than the pulse oximeter?

An earlobe probe is more accurate and less affected by peripheral vasoconstriction

What is a general survey?

study of whole person

What does a general survey cover?

Covers general health state and any obvious physical characteristics

You should launch a general survey every moment you first encounter someone or a situation. What are some things you should look for?

What leaves an immediate impression?

-Does the person stand promptly as his or her name is called and walk to meet you? Or do they look sick, rising slowly, with shoulders slumped and eyes downcast?

-Is a hospital patient conversing with visitors, involved in reading or television, or lying perfectly still?

As you proceed through health history, measurements and vital signs, note following points that will add up to general survey. What are the four areas you should be aware of during a GS?

-physical appearance

-body structure

-mobility

-behavior

What does physical appearance consist of?

-age: person appears his or her stated age

-sex: sexual development appropriate for gender and age

-level of consciousness: person alert and oriented, attends to your questions and responds appropriately

-skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions

What does body structure consist of?

-facial features: symmetric with movement

-no signs of acute distress present

-stature: height appears within normal range for age, genetic heritage

-nutrition weight appears within normal range for height and body build; body fat distributed even

-symmetry: body parts look equal bilaterally and are in relative proportion

posture: person stands comfortably erect as appropriate for age

What does mobility consist of?

Gait, normally, base is as wide as shoulder width

-Foot placement: accurate, walk smooth, even and well balanced, symmetric in things such as arm swing

-Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth ad coordinated

-No involuntary movement

-Toe and heel walking

What does behavior consist of?

-Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation, e.g. serious, thoughtful or smiling and be sure to note expressions while face is at rest and while person is talking

-Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly

-Is it appropriate for situation?

-Speech: articulation clear and understandable

What does dress consist of?

-appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group

-for example: Amish women wear clothing from 19th century, Indian women may wear saris

-personal hygiene: person appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group

When measuring someones weight, what should you use?

-A standardized balance or electronic standing scale

-Instruct person to remove his or her shoes and heavy outer clothing before standing on scale

-When sequence is necessary, aim for same time of day and same type of clothing worn

How should you record weight measured?

In kilograms and pounds

What is the conversion for kilograms to pounds?

1 kg = 2.2 lbs

How do you measure height?

-Use wall-mounted device or measuring pole on scale

-Align extended headpiece with top of head

-person should be shoeless, standing straight, looking straight ahead, with feet and shoulders on hard surface

What is body mass index and how do you measure it?

-BMI is practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutriton, it assesses body fat distribution as indicator of health risk

-Waist to hip ratio

-Waist circumference is measured in inches at smallest circumference below rib cage and above iliac crest

-Hip circumference measured in inches at largest circumference of buttocks

Significant elevation in blood pressure measurements from one day to the next could be attributed to:

1. A decrease in cuff size

2. An increase in cuff size

3. New onset of pain or anxiety

4. Both 1 and 3.

#4, both 1 and 3

The concept of health and healing has evolved in recent years. Which is the best description of health?

a. health is the absence of disease

b. health is a dynamic process toward optimal fuctioning

c. health depends on an interaction of mind, body, and spirit within the environment

d. health is the prevention of disease

c. health depends on an interaction of mind, body and spirit within the environment

Which would be included in the database for a new patient admission to a surgical unit?

a. all subjective and objective data gathered by a health practitioner from a patient

b. all objective data obtained from a patient through inspection, percussion, palpation, and auscultation

c. a summary of a patient's record, including laboratory studies

d. all subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed

d. all subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed

You are reviewing assessment data of a 45 year old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of:

a. hypothetical reasoning

b. diagnostic reasoning

c. data cluster

d. signs and symptoms

c. data cluster

A patient is in the emergency department with nausea and vomiting. Which would you include in the database?

a. a complete health history and full physical examination

b. a diet and GI history

c. previously identified problems

d. start collection of data in conjunction with lifesaving measures

b. a diet and GI history

A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond?

a. "it would be most efficient if you visit on an annual basis"

b. "there is no recommendation for the frequency of health care visits"

c. "your visits may vary, depending on your level of wellness"

d. "your visits will be based on your preference"

c. "your visits may vary, depending on your level of wellness"