Health Assessment (pt. 2)

The portion of the body over the heart and lower thorax, encompassing the aortic, pulmonic, tricuspid, and apical areas, and era's point is considered the

precordium

Which peripheral pulses should be not be assessed at the same time

carotid

This heart sound is an abnormal finding, excluding the very young, and takes the pattern of "lub-dub-dee"

S3

This heart sound is an abnormal finding and takes the pattern of "dee-lub-dub"

S4

You are assessing a pt's lower extremities and note that the skin is pale and cool, shiny with brown discolorations, hairlessness, and thick toe nails. What can you most likely assume about this patient

They have peripheral vascular disease

Phlebitis is

inflammation of a vein

Prolonged capillary refill is associated with

alterations in peripheral perfusion and cardiac output

What are expected age-related variations for an infant/child when assessing the cardiovascular system

-Visible cardiac pulsation if the chest wall is thin

-Sinus dysrhythmia( rate inc. w. inspiration and decreases with expiration)

-Presence of S3

-More rapid heart rate

T/F: It is an expected normal outcome to inspect the chest and be able to see pulsation from the aortic and pulmonic valve.

False, should only be able to see apical/PMI (if any)

What are expected age-related variations for an older adult when assessing the cardiovascular system

-Difficult to palpate apical pulse and distal arteries

-More prominent and tortuous blood vessels; varicosities common

-Increased systolic and diastolic BP

-Widening pulse pressure

You are assessing the radial pulse, you note that it is "bounding" bilaterally. What grade would you give the pulse amplitude

+3

You are assessing the radial pulse, you note it is "brisk" bilaterally. What grade would you give the pulse amplitude

+2, this is expected outcome

You are trying to assess the radial pulse, you are struggling to locate it and note how it is "diminished and weaker than expected" What grade would you give the pulse amplitude

+1

You are attempting to assess the radial pulse on a pt. You are unable to palpate it and note it as being "absent" What grade would you give the pulse amplitude

+0

Mrs. Jones is an 85 year old woman here for a routine health check up. You are preparing to assess her breast and axillae, what are some outcomes you'd expect to find "normal" with her age

Granular and pendulous breast

What are some expected age related outcomes for an infant/child when assessing the breast and axillae

-Breast enlargement and a white discharge from nipples up to 2wks of life

-Female breast growth beginning at 10-11 yo

-Temporary enlargement of one or both breast in pubescent boys

When assessing the abdomen, what is the order to auscultate the quadrants

RLQ,RUQ, LUQ, LLQ

Why is percussion done after auscultation of the abd

because percussion stimulates bowel sounds

Before documenting absent bowel sounds the RN must listen for ___ minutes in each quadrant

20

Hyperactive bowel sounds often indicate

diarrhea or early bowel obstruction

Hypoactive bowel sounds often are heard

post abd surgery, late bowel obstruction

absent bowel sounds indicate

peritonitis or paralytic ileus

What are bruits? How can they be auscultated

Abnormal "swooshing or blowing" sounds heard over blood vessels, caused by blood swirling in the vessel, rather than normal smooth flow

Listen with bell of stethoscope

What type of palpation should be used when palpating the abd

light

What are some normal age related variations when assessing the abdomen of an infant/child

-Umbilical cord in newborns; dries and falls off within the first few weeks of life

-A "potbelly" (under 5yo)

-Visible peristaltic waves

What are some normal age related variations when assessing the abdomen of an older adult

-Decreased bowel sounds and abdominal tone

-Fat accumulation on the abd and hips

What are some normal age related variations when assessing the musculoskeletal system of an older adult

-Loss of muscle mass and strength

-Decreased ROM

-Kyphosis

-Decreased height

-Osteoarthritic change in joint

What are some normal age related variations when assessing the musculoskeletal system of an infant/child

-C-shaped curve of spine at birth; anterior cervical curve dev. at about 3-4 months and the anterior lumbar curve develops between 12-18months

-Lordosis

-Pronation of the feet in children between 12-30 months

-Genu varum for 1 year after leaning to walk

If a pt is described as being full awake; orientated to person, place and time; responds to all stimuli, including verbal commands you'd consider them

awake and alert

If a pt is described as appearing drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying pt's name, you'd consider them

Lethargic

If a pt is described as being unconscious most of the time' has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; respond to painful stimuli with purposeful movements, you'd consider them

Stuporous

If a pt cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex), they'd be considered to be in a

Comatose state

A RN ask the pt. to protrude their tongue, what cranial nerve is being assessed

Hypoglossal (XII)

A RN ask the pt. to shrug their shoulders against the RN's resistance, which cranial nerve is being assessed?

Accessory (XI)

A RN ask the pt. to swallow and speak, which cranial nerve is being assessed?

Vagus (X)

A RN ask the pt. to say "ah" and have them yawn to observe the upward movement of the soft palate. Additionally, the RN observes the pt. ability to swallow and taste, which cranial nerve is being assessed

Glossopharyngeal (IX)

A RN is testing a pt. ability to hear, which cranial never is being assessed

Acoustic (VIII)

A RN asks the pt to raise their eyebrows, smile, show teeth, and puff out cheeks. Additionally the RN test the pt. ability to feel a cotton ball touching the pt. face, which cranial nerve is being assessed?

Facial (VII)

A RN has the pt. follow the RN's finger in different directions, which cranial nerve is being assessed?

Abducens (VI)

A RN asks the pt to clench and open their jaw while the RN palpates the muscle. Which cranial nerve is being assessed

Trigeminal (V)

A RN test the pt ability to move their eyes downward and inward, which cranial nerve is being assessed

Trochlear (IV)

A RN tests the pt pupillary reaction to light and ability to open and close the eyelids. Which cranial nerve is being assessed

Oculomotor (III)

A RN is testing a pt vision, which cranial nerve is being assessed

Optic (II)

A RN asks a pt. to smell a bottle of mint and identity what they are smelling, which cranial nerve is being tested

Olfactory (I)

When assessing an infant/child's neurological system, what are some age related variations

-+ babinski sign (normal in children less than 24mo)

-Grasp reflex (present at birth)

-Motor control develops in head, neck, trunk, and extremities sequence

When assessing an old adult's neurological system, what are some age related variations

-Slower thought processes and verbal responses

-Decreased sensory ability

-Slower coordination and voluntary movements

-Decreased reflex repsonse

-Appearance of confusion in unfamiliar surroundings

-Slower Gait, with a wider base and flexed hips and knees