Health Assess Exam 1

Ole! Ope! Occ! To Try A Few Very Good Vaginas, Ah Heaven!

CNI Olfactory: smell

CNII Optic: vision

CNIII Oculomotor: eye movement, pupils

CNIV Trochlear: eye movement

CNV Trigeminal: chewing, facial sensation

CNVI Abducens: eye movement

CNVII Facial: facial movement

CNVIII Vestibulocochlear: hearing/balance

CNIX Glossopharyngeal: swallowing

CNX Vagus: swallowing, voice

CNXI Accessory: shoulder shrug, head movement

CNXII Hypoglossal: tongue movement

CNI Ole!

Olfactory

Smell

CNII Ope!

Optic

Vision

CNIII Oc!

Oculomotor

Pupil response, eye movement

CNIV To

Trochlear

Eye movement

CNV Try

Trigeminal

Chewing facial sensation

CNVI A

Abducens

Eye movement

CNVII Few

Facial

Movement

CNVIII Very

Vestibulocochlear

Hearing and balance

CNIX Good

Glossopharyngeal

Swallowing

CNX Vaginas

Vagus

Swallowing and voice

CNXI Ah

Accessory

Shoulder shrug and head movement

CNXII Heaven

Hypoglossal

Tongue movement

Purpose of obtaining a health history

To get an idea of pts baseline as well as what brings them in. Can help determine new vs old issues

Subjective data

Pt self report of feelings

Stomach hurts

Objective data

Nurse can observe

Patient is grimacing and hr is high

Why is effective nurse patient communication important?

To build trust with pt, ensures they understand issues/intervention, assure nothing was missed

What are two ways a nurse can build trust with a pt?

Active listening, recognition, summarizing, reflecting

Open ended question vs closed

What are your concerns today?

Was your poop brown?

PQRST

Pain

Quality

Radiating/relieving

Severity

Timing

OLDCARTS

Onset

Location

Duration

Characteristics

Alleviating/aggravating

Radiating/relieving

Timing

Severity

Why is a thorough pain assessment important?

To find a resolvable underlying cause, to administer pain relief to improve pt outcomes, to make sure we are treating the pain correctly

What info should the nurse collect about a pts pain?

PQRST, OLDCARTS

meds for relief? History of chronic issues

What are important considerations when interviewing a child?

Perceptions and expressions vary, may have trouble communicating, difficulty describing issues, being afraid of the provider or treatment

What is especially important when interviewing a teenager/adolescent?

Suicide assessment

Peak development stage: physical emotional spiritual sexual

What should the nurse consider when interviewing an older adult

Allow adequate time: mobility issues extensive med history polypharmacy

Sensory aids

Tired

What info is included in a basic health history

CC, medical history, medications, allergies,family hx, social hx, and lifestyle

What is healthcare access, and what are some barriers that may prevent a pt from receiving healthcare?

Insurance, providers, transportation,

Why does the nurse compare the right side of body to left

Check for deviation

Why is ROM assessed?

Check for impaired mobility

How does the nurse assess muscle strength?

Resistance exercises during assessment

What is erythema

Reddening

What should the nurse assess when a joint or extremity has swelling?

Pain, injury, ROM, circulation, temp, color

What is an ataxic gate, why is it important?

Uncoordinated, could indicate stroke, Parkinson's or neuro deficit

What is metabolism

Chemical reactions of the body, convert food into monomers for absorption

Questions to assess bowel and urinary habits

Last BM

Description of stool

Diarrhea or constipation

Diet

Abd pain

Difficulty with urination

Color/smell or urine

Frequency hesitation

Correct order for abdominal assessment

Inspection AUSCULTATE percuss palpate

Purple striae

Recent skin stretching

3 ways to improve healthy bowels

Balanced diet, fiber, hydration

Percuss

Help ID size, density, position of organs. Presence of gas or fluid or abnormalities

Urine can provide info

UTI, diabetes, medications, dehydration

PERRLA

Pupils

Round

Reactive to

Light

Accommodation