Health Assessment and Promotion Exam 2

subjective data for respiratory health

cough, SOB, chest pain with breathing, past history of respiratory infections or allergies, history of smoking, previous chest surgery, environmental exposures, self-care behaviors

signs of early respiratory distress

restlessness and anxiety

signs of late respiratory distress

hypoxia and cyanosis

barrel chest

kyphosis

scoliosis

inspection of lungs and thoracic cavity

shape and chest configuration, facial expression, quality and rate of respirations, skin color and condition, level of consciousness

palpation of lungs and thoracic cavity

symmetric expansion, spinal alignment, tactile fremitus

percussion of lungs and thoracic cavity

normal percussion sound in adult is resonance

auscultation of lungs and thoracic cavity

breath sound characteristics based on location, adventitious breath sounds

bronchial breath sounds

expiration louder and longer than inspiration

bronchovesicular breath sounds

inspiration and expiration are about equal in loudness and time

vesicular breath sounds

inspiration is louder and longer than expiration

adventitious breath sounds

crackles, wheezes

crackles or rales

means fluid is in the lungs

wheezes or rhonchi

means restricted airflow

pleural friction rub

low pitched, sounds like leather rubbing together

high pitched wheeze

high pitched, musical squeaking sounds

low pitched wheeze

monophonic, single note, more prominent on expiration

stridor

high pitched, monophonic inspiratory crowing, signifies an upper airway obstruction

health promotion of the respiratory system

do not smoke, avoid exposure to secondhand smoke, well-ventilated environment with household chemicals, limit exposure to ozone, practice deep breathing, get regular strenuous exercise, avoid breathing in chemicals of any type, wear mask as needed

aging changes in the lungs and thorax

thorax less mobile, respiratory muscle strength declines, lungs are less elastic, loss of intra-alveolar septa and decreased number of alveoli, increased risk for dyspnea on exertion, increased risk for postoperative pulmonary complications

order of blood flow through the heart

superior and inferior vena cava, right atrium, tricuspid valve, right ventricle, pulmonic valve, pulmonary artery, lungs, pulmonary vein, left atrium, mitral valve, left ventricle, aortic valve, aorta, systemic circulation

S1

closure of AV valves, listen over tricuspid and mitral valves

S2

closure of semilunar valves, listen over aortic and pulmonic valves

S3

occurs when ventricles are resistant to filling during rapid filling phase of early diastole

S4

occurs at end of diastole, at presystole, ventricle is resistant to filling, vibrations are heard before S1

subjective data for heart and great vessels

chest pain, dyspnea, cough, fatigue, cyanosis, edema, nocturia, past cardiac history, family history, personal habits increasing risks

inspection of heart

inspect the neck

palpation of the heart

palpate carotid arteries one at a time

auscultation of the heart

auscultate carotid artery for a bruit

strategies to promote health of cardiovascular system

screen for pre-hypertension, don't smoke, maintain healthy BMI, no drug use, heart health diet, health blood sugar, aerobic exercise, regular use of low dose ASA

aging in the cardiac system

widening pulse pressure, check for orthostatic hypotension, caution when palpating and auscultating carotid arteries, increase murmurs, increased anteroposterior diameter

subjective data with peripheral vascular and lymphatics system

leg pain or muscle cramps, skin changes in arms or legs, swelling, lymph node enlargement, medications

pulse rating system

0=absent, 1+=weak, 2+=normal, 3+=increased full bounding

simultaneous pulse palpation

radial, ulnar, brachial, femoral, posterior tibial, doralis pedis

bilateral and separate palpation

carotid, femoral, popliteal

arteries

deliver oxygen and other nutrients to tissues

signs of arterial insufficiency

dependent rubor, thin shiny skin, thick-ridged nails, loss of hair, deep muscle pain, claudication pain, cold pale extremity, cold pale extremity, reduced pulse intensity, bruit, distal gangrene

signs of venous insufficiency

aching pain worsening with dependent positioning, firm brawny edema, pigment discoloration, thickened skin, pulses normal, dermatitis, petechiae

strategies promoting health of peripheral vascular system

regular exercise, no nicotine, limit caffeine, avoid standing for prolonged periods, maintain healthy weight, lie or sit with legs higher than heart, consider wearing support hose if prolonged standing or sitting is job expectation

strategies to promote peripheral vascular health for immobile patients

early ambulation, pneumatic compression devices, compression stockings, administration of low doses of unfractionated heparin or low dose molecular weight heparin or warfarin

expected or potential changes to peripheral vascular disease

dorsalis pedis and posterior tibial pulses are more difficult to find

subjective data of breast exam

pain, lumps, discharge, rash, swelling, trauma, history of breast disease or surgery, medications, axilla, rash

mammogram preparation

no deodorant, schedule for when breasts are not tender, bring prior films and dates

vertical strip pattern

best way to detect breast mass, gold standard

wedge technique

start at nipple area in a circular pattern and end at axillary area

concentric circle pattern

begin at nipple in a circular pattern and end at axillary are

bimanual technique

used for women with large, pendulous breasts

observations for breast exam

location, size, shape, consistency, mobility, distinctness, nipple, skin tenderness, lymphadenopathy

normal findings of breast assessment

may be lighter skin than rest of body, intact skin, midline and everted or flat nipple

abnormal breast assessment findings

localized area of redness, bulging, dimpling, inverted nipple, increased pigmentation, heat with inflammation, unilateral or dilated superficial veins in a non-pregnant woman, edema or swelling, orange-peel look to skin

risk factors for breast cancer

two or more first degree relatives with breast cancer, recent or long term use of menopausal hormone therapy containing estrogen and progestin

preventative measures of breast cancer

full term pregnancy, breast feeding

screenings for breast cancer

mammograms and self breast exams

health promotion for breast cancer

healthy weight, diet, avoiding red meet and saturated fat, vitamin D, minimize alcohol intake, exercise, tobacco products, stress management, sleep, breastfeeding, careful decisions 0 HRT post menopause, scheduling mammograms and CBE, performing SBE monthly

characteristics of breast cancer lump or mass

location, diagram of location, size, shape, consistency, mobility is important, distinctness, examine nipple, skin over lump, tenderness, lymphadenopathy

abdominal assessment subjective data

appetite, dysphagia, food intolerances, abdominal pain, n&v, bowel habits, past surgeries or GI illness, medications, nutritional assessment

sequencing of abdominal assessment

inspection, auscultation, percussion, light palpation, deep palpation

observations of abdominal assessment

symmetry, umbilicus, skin, pulsations or movement, hair distribution, demeanor

aging changes of abdomen

increased abdominal fat, reduced salvation/dry mouth, reduced taste, delayed esophageal emptying increased risk for aspiration if not upright after meals, decreased gastric acid secretion, reduced iron absorption and malabsorption of calcium, increased incidence of gallstones, liver size decreases

health promotion for abdomen

maintain BMI between 18.5 and 24.99, eat foods rich in fiber, washing food, hand hygiene, refrigerator audit, avoid excessive alcohol, avoid high fatty foods, monitor required screening times, stay hydrated, kegel exercises (women), avoid prolonged bladder distension

subjective data of head, face, and neck

headaches, head or neck injury, dizziness, neck pain, lumps or swelling, head or neck surgery, thyroid problems

head and face findings during inspection

size, shape, skin characteristics, palpate skull and facial bones and temporal artery and TMJ, facial structures

neck findings during inspection

symmetry, range of motion and strength, lymph nodes, trachea, thyroid gland

ROM of head and neck

flexion, extension, hyperextension, rotation, lateral bending

hyperthyroidism

intolerance to heat, bulging eyes, diarrhea, tremors, tachycardia and increased systolic BP, weight loss, fine-straight hair

hypothyroidism

intolerance to cold, facial and eyelid edema, constipation, muscle aches/weakness, lethargy, thick tongue, slow speech, weight gain, hair loss

health promotion of head and neck

ergonomic evaluation of workplace, use good posture, practice good body mechanics, stress reduction, lift weights, wear helmet, wear seatbelt

subjective data about eye health

vision difficulty, pain or itching, strabismus or diplopia, redness or swelling, watering or discharge, history of ocular problems, surgery, glaucoma, glasses or contacts, exams, medications, eye hygiene problems

observations during eye assessment

general and non-verbal signs of vision loss, eyebrows, eyelids and lashes, conjunctiva and sclera, cornea and lens, iris and pupil size and shape, pupillary light reflex, accomodation

inspection of eye

use ophthalmoscope to inspect red reflex, optic disk, retinal vessels, general background of fundus, macula

snellen eye chart

cover one eye and read the smallest line you can read, right left and both

confrontation test

have client look straight at you and compare each quadrant of vision as it compares to yours

corneal light reflex(hirschberg test)

shine a light at the client's nose and see the reflection in each eye to identify an issue with alignment

cover/uncover test

if hirschberg is abnormal, will perform this test

cardinal fields of gaze (diagnostic positions test)

have the client follow your finger with their eyes in 6 different directions to test EOM

health promotion for eyes

have comprehensive dilated eye exam, know family eye history, eat right to protect sight, maintain a healthy weight, wear protective eyewear, quit smoking, wear shades, give eyes breaks, clean hands and contacts properly, practice workplace eye safety