Health Assessment - Exam 2

Chapters: 15, 16, 17, 18, 21, 22, 32 (W) , 12 (H)

lymph nodes of head & neck - location

• peri/post auricular

• occipital

• tonsilar

• submandibular

• submental

• anterior/posterior cervical

• subclavicular

• deep cervical chain

enlarged lymph nodes

Tender, enlarged nodes suggest acute local or systemic infections; normally lymph nodes are not sore or tender.

implications:

• infection could be HIV mononucleosis - swollen/painful

• if cancer metastasizes to the lymph nodes, they may enlarge, but not be painful

Hypertension

elevated blood pressure

• increased risk of:

  • heart, brain, kidney damage

• complications:

  • organ damage

    • myocardial infarction, heart failure, damaged & narrowed arteries, aneurysms, kidney damage/failure, stroke, dementia, hypertensive emergency

Hypertension Classification

• Normal: <120 / <80

• Elevated: 120-129 / < 80

• Stage 1: 130-139 OR 80-89

• Stage 2: 140+ OR 90+

• Hypertensive Urgency: 180+ OR 120+

• Hypertensive Emergency: 180+ OR 120+

What is the difference between hypertensive urgency and hypertensive emergency?

urgency:

• no signs or symptoms of end organ damage

emergency:

• with objective findings of acute end-organ dysfunction

  (heart, kidneys, brain)

Hypertension risk factors - modifiable

modifiable:

• dyslipidemia

• obesity

• diabetes mellitus

• active/passive smoking

• physical inactivity

Diet-related risk factors for Hypertension

excessive sodium

insufficient potassium, calcium, magnesium, protein, fiber, fish fats

hypertension risk factors: non-modifiable

• advancing age

• family history

• male

• low economic status

• psychsocial stress

• chronic kidney disease

• obstructive sleep apnea

HTN risk factors - others

decreased renal function, and vasculature

insulin resistance

excessive alcohol intake

poor diet

Physiological factors affecting BP

• cardiac output

• peripheral vascular resistance

• circulating blood volume

• viscosity

• elasticity of vessel walls

cardiac output

amount of blood pumped by the ventricles during a given period of time (1 min)

→ Stoke volume x Heart rate

→ normal: 5-6L/min

→ assessed through capillary refill time

peripheral vascular resistance

An increase in resistance in the peripheral vascular system, as happens with people who have circulatory disorders, will increase blood pressure.

circulating blood volume

The total volume of blood circulating within the blood vessels, which influences blood pressure; increased blood volume raises blood pressure.

• an increase in volume will increase blood pressure. A sudden drop in blood pressure may indicate a sudden blood loss, as with internal bleeding.

viscosity

thickness of blood

• contributes to blood pressure:

  • increased blood viscosity = decreased blood flow = increased resistance = increased BP

• increased viscosity may lead to heart failure or ischemic events

  • symptoms of hyper-viscosity

    • fatigue, weakness, headaches, vision changes

elasticity of vessel walls

the ability of blood vessels to stretch and recoil, which affects blood flow and pressure.

• An increase in stiffness of the vessel walls (e.g., atherosclerotic changes) will increase blood pressure.

HTN Diagnosis

A high BP reading more than 2x on separate occasions

Obtaining BP

• ambulatory blood pressure monitoring

  • wearing a BP cuff on the arm that is attached to a small recording device and is worn for 24 hours, allowing measurements during a variety of activities, and has been associated with temporary sleep disturbance and extremity bruising

• home blood pressure monitoring

  • patients monitor their own BP episodically while in their own home, typically using an electronic BP device.

HTN Complications

• damages blood vessels, particularly in target organs such as the heart, kidneys, brain, and eyes

• prolonged, uncontrolled hypertension

  • MI, heart failure, left ventricular hypertrophy, kidney failure, stroke, TIA, and impaired vision

• acute elevation in BP

  • end-organ damage is termed hypertensive emergency

Older adults - assessing confusion

Assessing Skin in older adults

evaluate hydration status and skin integrity by checking for dryness, turgor, and any signs of pressure ulcers or lesions.

• Actinic keratoses, round or irregularly shaped tan, scaly lesions that may bleed or be inflamed (premalignancy)

• Waxy or raised lesions, especially on sun-exposed areas (basal cell carcinoma).

• Irregularly shaped lesions or scaly, elevated lesions (squamous cell carcinoma, melanoma).

• Herpes zoster vesicles (shingles) draining clear fluid or pustules atop an erythematous base following a clear, linear pattern and accompanied by pain. More than half of older adults with shingles will have neuralgia that persists after resolution of the skin lesions.

• Pinpoint-sized, red-purple, nonblanchable petechiae (common sign of platelet deficiency).

• Large bruises may result from anticoagulant therapy, a fall, renal or liver failure, or elder abuse.

Extremely thin, fragile skin (friable skin) with excessive purpura (possibly from corticosteroid use).

Dry, warm skin, furrowed tongue, and sunken eyes from dehydration (especially when the client has decreased urinary output; increased serum sodium, BUN, and creatinine levels; increased osmolality and hematocrit values; tachycardia; and mental confusion). Sudden heat or cold intolerance could be signs of thyroid dysfunction.

Torn skin (possibly the result of abrasive tape used to hold bandages or tubes in place).

abnormal findings - skin in older adults

inspect & palpate

abnormal findings

• actinic keratoses

• waxy/raised lesions

• ireregularly shaped lesions

• HPV

• Dry warm skin

• Fragile skin

• Bruises

• Nonblanchable petechiae

assessing eyes in older adults

inspect eyes for dryness, redness, tearing, increased sensitivity to light & wind

• abnormal:

  • severe entropion → ulcer corneal infection

  • abnormal blinking → parkingso’s disease

  • dull/blank staring → hypothyroidism

inspect cornea & lens

• cataracts, cloudy yellow/brown discoloration

test vision: ask pt to read newspaper

• abnormal: a significant decrease in central vision → may indicate cataracts or macular degeneration

assessing ears in older adults

Inspect → inflammation, drainage, swelling = infection

otoscopic examination → hard, dark-brown cerumen = impaction; darkened hole in tympanic membrane → perforation or scarring

assessing depression in older adults

Manifestations:

• memory deficits, paranoia, agitation,

• muscle aches, joint pains, GI disturbances, headache, weight loss

Pseudodementia

Geriatric Depression Scale: series of yes/no questions to assess depression

• 0-10 normal

• 11+ = possible indication of depression

musculoskeletal assessment for older adults

• observe posture:

  • abnormal:

    • humpback curvature → kyphosis from osteoporosis

    • difficulty extending hips & knees

    • postural instability → increased risk of falling & immobility

• observe gait:

  • abnormal

    • shuffling gait

• heberden nodes: enlargement of distal interphalangeal joints

• hand deformities: ulnar deviation, swanneck deformity, boutonniere deformity

• test ROM: limitations due to DJD, arthritis, grating, popping, crepitus, palpation of fluids

  • tenderness, stiffness, & pain in shoulders, elbows → polymyalgia rheumatica

  • increased resistance to passive ROM → sign of Parkinson’s disease

  • decreased resistance → peripheral NS disease, cerebellar disease, acute spinal cord injury

older adult patient education - constipation

caused by decreased GI motility

exacerbated by dehydration, immobility, and poor intake

may cause urine incontinence

• maintaining efficient elimination:

  • adequate fluid intake, dietary fiber, moderate exercise

older adults patient education - falls

poor balance & difficulty walking → increased risk of falls

rheumatoid arthritis → high risk of falls

swollen, tender lower extremity joints, fatigue

• evaluate pt environment, hazards, cognition

ADLs in older adults - assessment?

Use Katz Activities of Daily Living Tool

• includes activities necessary for well-being as an individual to society

Lawton Scale for Intstrumental Activites of Daily Living

• includes telephone use, shopping, food preparation, housekeeping, laundry, handling finances, mode of transportation, and managing medications

Patient education - caring for venous ulcers

Ulcer characteristics:

Location: Medial malleolus or anterior tibial area

Pain: If superficial, minimal pain; but may be very painful

Depth of ulcer: Superficial

Shape: Irregular border

Ulcer base: Granulation tissue—beefy red to yellow fibrinous in chronic ulcer

Leg edema: Moderate to severe

assessing arterial vascular disease

Evaluating blood flow and circulation in arteries, typically using methods such as Doppler ultrasound or ankle-brachial index. This assessment helps identify conditions like peripheral artery disease.

Characteristics of venous insufficiency

Pain: Aching, cramping

Pulses: Present but may be difficult to palpate through edema

Skin characteristics:

Pigmentation in gaiter area (area of medial and lateral malleolus)

Skin thickened and tough, may be reddish-blue in color

Frequently associated with dermatitis

Assessing venous insufficiency

Manual compression test:

Trendelenburg test

Observe venous filling

Manual Compression test

Ask the client to stand. Firmly compress the lower portion of the varicose vein with one hand. Place your other hand 6–8 in. above your first hand. Feel for a pulsation to your fingers in the upper hand. Repeat this test in the other leg if varicosities are present.

• palpable impulse indicates incompetent valves in a vein segment between hands

normal: no impulse

Trendelenburg test

The client should lie supine. Elevate the client’s leg 90 degrees for about 15 seconds or until the veins empty. With the leg elevated, apply a tourniquet to the upper thigh.

• normal: no pulsation palpated, saphenous vein fills -30secs

If valves are competent, there will be no rapid filling of the varicose veins from above (retrograde filling) after removal of tourniquet

• abnormal: feel a pulsation with your upper fingers if the valves in the veins are incompetent

Filling from above with the tourniquet in place and the client standing suggests incompetent valves in the saphenous vein. Rapid filling of the superficial varicose veins from above after the tourniquet has been removed also indicates retrograde filling past incompetent valves in the veins.

assessing peripheral perfusion

assess capillary refill time.

normal: refill in 2 secs or less

abnormal: 2+ sec refill → vasoconstriction, decreased CO, shock, arterial occlusion, hypothermia

patient education - smoking & heart health

quitting smoking has immediate health benefits

• reduce risk of CVD, lung disease

• causes cancer, increased risk of asthma, peptic ulcer disease, osteoporosis, and improves overall health and quality of life.

smoking increases risk of health, PAD

to quit: make lifestyle changes to reduce stress, improve quality of life, minimize time w/smokers, inform yourself, have a support system, medications/therapies

bruit assessment

blowing or swishing sound caused by turbulent blood flow through a narrowed vessel

• indicative of occlusive arterial disease

over aorta suggest an aneurysm. If present, do not palpate because this could rupture the aneurysm.

apical pulse assessment

measure mitral area

• 5th intercostal space near left MCL → apex of the heart

• for one minute using diaphragm of stethoscope

normal:

abnormal:

• pulse deficit → atrial fibrilation, atrial flutter, premature ventricular contractions, heart block

• heaves/lifts/pulsations → enlarged ventricle from an overload of work (heard other than the apical pulse)

• larger than 1-2cm during palpation → cardiac enlargement

• hard to palpate with pulmonary emphysema

carotid pulse assessment

palpate one side at a time on

auscultate one side at a time with bell of stethoscope

normal: equally strong 2+

abnormal: pulse inequality → arterial constriction or occlusion

• weak pulse: hypovolemia, shock, decreased CO

• bounding, firm pulse: hypervolemia, increased CO

• variations in strength

• delayed upstroke: aortic stenosis

• loos of elasticity: arteriosclerosis

• thrills: narrowing of the artery

Abnormal small, weak pulse - arterial

characteristics:

• diminished pulse pressure

• weak & small on palpation

• slow upstroke

• prolonged systolic peak

causes:

• conditions causing a decreased SV

  • heart failure

  • hypovolemia

  • severe aortic stenosis

• condt. causing increased peripheral resistance

  • hypothermia

  • severe congestive heart failure

large bounding pulse

characteristics:

• increased pulse pressure

• strong & bounding on palpation

• rapid rise/fall with brief systolic peak

causes:

• conditions that cause an increased SV or decreased peripheral resistance

  • fever, anemia, hyperthyroidism, aortic regurguation, patent ductus arteriosis

• conditions resulting in increase SV due to decreased HR

  • bradycardia, complete heart block, aging, atherosclerosis

Heart sounds

S1: closure of AV valves → beginning of systole “LUB”

S2: closure of SL valves → beginning of diastole “DUB”

S3: ventricular gallop → ischemic heart disease, hyperkinetic states, restrictive myocardial disease

S4: atrial gallop → coronary artery disease, hypertensive heart disease, cardiomyopathy, aortic stenosis

Heart murmurs

turbulent blood flow, swooshing, blowing sound

causes:

• increased blood viscosity

• structural valve defects

• valve malfunction

• abnormal chamber opening

Abnormal S1 sounds

• diminished: mitral valve is not fully open at the time of ventricular contraction

• accentuated: sound is louder than S2, when mitral valve is wide open and closes quickly

• split: left & right ventricles contract at different times

• varying: mitral valve is in different positions when contraction occurs

heart sounds assessment

auscultate with bell and then diaphragm of stethoscope

Aortic area

Pulmonic area

Erb’s point

Tricuspid area

Mitral area

edema assessment

sudden onset of edema in one leg with pain → blood clot in leg = deep vein thrombrosis

bilateral edema in both lower extremities at night → seen in heart failure due to a reduction of blood flow out of the heart causing blood going back to heart to backup

peripheral edema

results from obstruction of lymphatic flow or from venous insufficiency (most common) from conditions

hydration assessment

pinch skin and release to evaluate skin turgor

assess skin moisture, temperature, texture, elasticity

causes:

gastroenteritis, diabetic ketoacidosis,

s&s of dehydration:

• dry mucous membranes, decreased urine output, tachycardia, weight loss, sunken eyes, fatigue, thirst

AP-T ratio

1:2 → normal

1:1 → barrel chest; result of emphysema due to hyperinflation of the lungs

Abnormal chest configerations

• barrel chest: 1 to 1 AP diameter

• funnel chest: sunken sternum

• pigeon chest: protrusion of the sternum

adventitious sounds

abnormal lung sounds heard during auscultation

• wheezing (rhonchi) →

  • sibilant: heard in acute asthma, chronic emphysema

  • sonorous: bronchitis, single obstructions, snoring

  • stridor: harsh, honking wheeze

• crackles (rales)→ fine or coarse

  • fine: high-pitched heard in pneumonia, CHF

• pleural friction rub → heard in pleuritis

CVA assessment

palpate for any pain - feel for any tenderness

percuss for pain - if either kidney is inflamed due to infection percussion will cause pain

normal - no pain

abnormal - pain upon palpation or percussion, indicating possible kidney inflammation or infection. (positive for CVA tenderness)

Peripheral vision assessment & abnormal findings?

perform confrontation test → ask pt to close one eye, you cover same side eye, hold up number of fingers in each visual field and ask pt to say the numbers

• abnormal: delayed or absent perception of the examiners fingers

Consensual response assessment & findings

shine a light obliquely into one eye and observe the pupillary reaction, assess consensual response at the same time as direct response by shining a light obliquely into one eye and observing the pupillary reaction in the opposite eye.

• abnormal: pupils do not react at all to direct & consensual pupillary testing

Nasal mucos assessment and findings

inspect with otoscope using nasal speculum and penlight, tilt pt head back

• normal:

  • nasal mucosa is dark, pink, moist, and free of exudate

  • nasal septum is intact and free of ulcers or perforations

• abnormal:

  • mucosa is swollen, pale pink or bluish gray (allergies),

  • red and swollen (upper resp. infection)

  • exudate: infection

    • purulent: acute bacterial rhinosinusitis

  • bleeding/crusting: local irritation

  • ulcers: cocaine, trauma, chronic infection, chronic nose picking

  • small pale round firm overgrowth or masses: polyps (chronic allergies)

Tonsil size assessment & findings

palpate with finger pads in slow walking, gentle, circular motions

• assess bilaterally check for size/shape, delimination, mobility, consitency, tenderness

abnormal
- enlarged, swelling, tenderness, hardness, immobility, irregular shape

snellen test assessment & findings

test to assess distant visual acuity

• chart is placed on wall at eye level, pt stands 20ft from chart and cover one eye and read each line until they can’t

• abnormal: impaired far vision (myopia) present → 20/40

  • the higher the second number the poorer the vision

  • 20/200 → legally blind

  • 20/30 → refer for further evulation

whisper test assessment & findings

pt occlueds one ear first, nurse stands 2 ft behind the client and whisper two syllable words (apple pineapple) , ask pt to repeat them back

• passing: identifying 3/6 words whispered

• abnormal: unable to repeat the words after two tries → hear loss that requires follow up

Lung sounds

hear sounds with diaphragm of stethoscope on posterior chest, ask pt to breather deeply through the mouth for each area

• normal: bronchial, bronchiovascular, vesicular

• abnormal:

  • diminished/absent breath sounds → little/no air moving in/out of lungs

    • obstruction in the lungs: mucus plug, secretions, foreign object, pleural effusion, pleural thickening, pneumothorax

  • increased breath sounds: consolidation/compression resulting from denser lung area

Assesssing lungs - crackles

heard over normal breath sounds during ascultation

• late inspiration: restrictive diseases → pneumonia and CHF

• early inspiration: obstructive disorders → bronchitis, asthma, emphysema

Assessing respiratory rate

normal: relaxed, effortless. quiet, 10-20/min in adults

abnormal: labored, noisy → asthma or chronic bronchitis

• fast breathing: tachypnea

• slow breathing: bradypnea

Assessing respiratory patterns

• tachypnea

• bradypnea

• hyperventilation

• hypoventilation

• chyne-stokes

• biot

• kussmaul

• ataxic

• air tapping

Lung percussion

percuss for tone: start at apices above clavicles, move down through intercostal spaces across and down. compare sides

abnormal:

• hyperressonance → trapped air in emphysema/pneumothorax

• dullness → increased density seen in consolidation, pleural effusion, tumor

Patient prioritization - thorax assessment

ABC’s : Airway, Breathing, Circulation assessment order for thorax evaluation.