Exam/Unit 1 Health Assessment

General Survey

- This begins as soon as you walk in the room and meet your patient

1. physical appearance (hygiene correct age?)

2. body structure

3. mobility

4. behavior/ level of consciousness

Physical Appearance (assessment skill)

1. Age (appears stated age)

2. sex and gender presentation

3. skin color and condition

4. hygiene and grooming

5. signs of distress

Body Structure and Mobility (assessment skill)

1. Height and Weight'

2. Posture and Position

3. Gait and Movement

4. Use of Assistive Devices

Behavior and Mental Status

1. Facial Expression

2. Speech and Articulation

3. Mood and Affect

4. Eye Contact

5. Orientation

Vital Signs

• temperature

• pulse

• respirations

• blood pressure

• oxygen saturation

• pain (considered 5th vital sign)

Assessment Techniques

• Inspection - visual analysis

• Palpitation - Touching analysis

• Percussion - “drumming” seeing where fluid as moved in the body

• Auscultation - listening to internal body sounds

• Use of appropriate equipment

Head and Face Assessment

• Skull Shape and Symmetry

• Scalp and Hair distribution

• Facial Features and movement

• Presence of lesions and tenderness

Eye Assessment

• PERRLA (pupils, equal, round, reactive to light and accommodation).

• Inspect corner of one eye to the next.

Normal Findings: Sclera white and conjunctiva pink. Clear cornea and normal iris shape. pupils reactive to light (constricting)

Cultural Variation: Sclera yellow or gray tint. Eye shape up slanted palpebral fissures (opening between the eyelids) and epicanthal folds (skin folds covering eye)

Ears Assesment

Techniques: Inspection, palpitation and hearing tests (Whisper test, Rinne, Weber)

Normal Findings

• symmetrical ears, no lesions

• External ear canal, gray tympanic membrane

Cultural Variations

earlobe shapes differ, Cerumen (earwax) color/consistency variation

Nose Assessment

Techniques: Inspection and palpitation of sinuses

Normal Findings - Symmetrical, Mucosa pink/moist. No tenderness or obstruction

Cultural Variation - Nasal Bridge shape and size. Pigmentation differences in nasal mucosa

Throat Assessment

Techniques: inspection, palpation of tongue and oral structures

Normal Findings: Lips and oral mucosa (pink, moist and intact). Tongue midline smooth. Uvula rises with “ah”

Cultural Variations: Oral mucosa pigmentation. Tonsil size

Neck Assessment & Lymph Nodes

Techniques: Palpitation for size, tenderness and mobility

Normal Findings: Nodes small, mobile, non - tender. Neck full ROM

Cultural Considerations: Larger Nodes, Neck creases

Chest and Lung Assessment

• Chest Shape and symmetry

• Respiratory rate and effort to breath

• Breath sounds

• Use of accessory muscles

Abdomen

• Inspection (shape,scars)

• Auscultations (bowel sounds)

• Palpitate (tenderness)

• percuss

LOOK, LISTEN then TOUCH!!!!

Musckoloskeletal Assesment

• Muscle strength

• Joint range of motion

• Symmetry

• Ability to move independently

Neurological Assessment

• Level of Consciousness

• Orientation

• Motor Strength

• Sensation

• Basic Reflexes

Skin assessment

• color and temperature

• moisture

• integrity (is it intact)

• turgor (gently lift skin)

• presence of wounds or pressure injuries

obtundation

only arouses with a loud auditory or physical stimulation. The client is confused and speaks in one-word sentences when awake and falls back to sleep without constant stimulation.

stupor

unconscious but will respond to physical stimuli or pain with movement or have incoherent vocalizations.

delirium

acute confusion that occurs suddenly and comes and goes.

dementia

chronic, progressive confusion

Myoclonus

Alteration in muscle movement that is seen as a sudden jerking of muscle. Examples include hiccups, seizure activity, jerk of the arm or leg when falling asleep.

Fasciculation

Alteration in muscle movement seen as a continuous, rapid twitching of a muscle at rest.

arrhythmia

Abnormal heartbeat rhythm classified by heart abnormality

The exchange of oxygen and carbon dioxide happens through 3 processes

Ventilation - total volume of gas inspired and expired in a unit of time

Diffusion - moment of gas or solutes from high to low pressure

Perfusion - movement of blood or other fluids through blood vessels or natural channels in the body

Visceral Pain

Pain that is associated with larger internal organs deep in the body

Somatic Pain

Pain associated with the musculoskeletal system.

Referred Pain

Pain that is felt in one area but originates elsewhere

BMI Ranges

underweight - less than 18.5

In range - 18.5 to 24.9

overweight - 25-29.9

Obese - 30+

Narcotics effect on the body

This depresses the body which means it slows respiration rates due to the fact it slows down the CNS

Follow the finger eye test.

up, down, make an X and then in and out to check for accommodation

Head to toe Steps

Follow - keep a consistent order

Compare - bilateral findings

Report - abnormal findings promptly

Document - Clearly and Accurately

Spasticity

Alteration manifested as increased muscle tone when you try to increase the velocity of movement. For example, increased resistance when attempting to passively extend a joint

Rigidity

Alteration in muscle tone described as resistance to any manipulation of the joint at all

Apnea

Absence of spontaneous respirations

Acute Pain

Short duration or injury where symptoms last less than 6 months

Chronic Pain

Persistent recurrent symptoms that last longer then 6 months and even 20 years or longer

PQRST Method

Provocation/Palliation - How did it happen and what makes it better or worse

Quality - describe the pain

Region - where is the pain

Severity - how bad is the pain

Timing - what time did it start

Objective vs Subjective Data

Objective - information based on facts such as the prcence of lesions or bruising

Subjective - you need to ask high quality questions to gain understanding of clients pain

BMI formula

weight (lb)/height (in)² x 703.

cyanosis

blue discoloration of the skin not getting oxygen to the skin.

*Most often a lack of supply to extremities (fingers and toes)

Snellen Visual Test

Ask the client to cover one eye at a time, keep glasses on if normally worn, and read the letters from top to bottom, recording the smallest line read accurately

Whisper test

Stand 2 feet behind the client, whisper a combination of letters and numbers, and ask the client to repeat what was heard

Rinne Hearing Test

1. Bone first: A vibrating tuning fork is placed on the mastoid bone (behind the ear) until the person can't hear it.

2. Then air: The fork is moved next to the ear canal; if they hear it louder here, it's normal (Air > Bone).

3. Abnormal: If they hear it better behind the ear (on the bone), it's a negative Rinne, suggesting a blockage (conductive loss). 

Weber Hearing test

• A vibrating tuning fork is placed on the midline of the skull (forehead, top of head).

• Sound travels through bone to both cochleas.

• You say if the sound is louder in the right, left, or middle

Trying to test and see if the patient can hear equally in both ears

PERRLA

Pupils Equal, Round, Reactive to Light, and Accommodation