Health Assessment Exam 1

objective data

physical exam, diagnostic testig

subjective data

patient interview/ perspective

4 components of general survey

physical appearance, body structure, mobility, behavior

physical appearance

age, sex, LOC, skin color, facial features

body structure

height, weight, symmetry, posture, build, position

mobility

gait, ROM, movement coordination

behavior

facial expression, mood, speech, hygeine

orthopnea

unable to breathe due to position

position for orthopnea

tripod position

position for abdominal pain, depressive/anxious state

fetal position

considerations for measuring daily weights

same time of day, same clothing, same scale

1 kg=

2.2 lbs

normal BMI

18.5-24.9

height for 0-2 years

supine/ infant length board

height for 2+ years

standing, standing scale/wall ruler

newborn head circumference

32-38cm, 34cm

newborn head/ chest circumference

head circumference 2cm larger

6 months- 2 years head/ chest circumference

about the same

2+ years head/ chest circumference

chest circumference larger

order of techniques

inspection, palpation, percussion, auscultation

order of techniques for abdomen

inspection, auscultation, palpation, percussion

2 types of inspection

general, systematic

general inspection

physical appearance, body structure, mobility, behavior

systematic inspection

focus on area of CC

inspection guidelines

adequate light, not rushed, occasional use of instruments, validate findings, expose only areas needed for exam

types of palpation

light, deep, bimanual

fingertips

tactile discriminations of skin, swelling, moisture, pulsation, presence of lumps, tenderness

grasping (fingers/thumb)

detect position, shape, consistency of a mass

dorsum of hand

determine temp

base of fingers/ ulnar surface of hand

detect vibrations

light palpation senses

technique for moisture, texture, temp, pulsations, tenderness, superficial masses/ lesions

light palpation depth

1cm

palpation considerations

keep patient relaxed, keep fingernails short, warm hands, slow, systematic, calm, gentle

deep palpation

determines organ size, one/ two hands, intermittent pressure

when to avoid deep palpation

internal injury/ pain

bimanual palpation

light/ deep, assess for mass/organs (reproductive, kidney)

flat tone sound

quiet tone

flat tone

bones/ muscle

tympani sound

loudest

tympani

abdominal area, gastric bubble

resonance sound

clear hallow sound

resonance

lungs

hyperresonance sound

booming

hyperresonance

emphysema in adults, normal in children

dull sound

quiet, thud

dull

dense organs, fluid filled lungs

auscultation

listen to heart, blood vessels, lungs, abdomen

diaphragm

high pitched sounds, firm pressure

high pitched sounds

breath, bowel, normal heart sounds

bell

low pitched sounds, light pressure

low pitched sounds

murmurs, bruits

considerations for auscultation

quiet, warm stethoscope, wet body hair if needed, always on skin

vital signs

objective data

normal temp ⁰F

96.4⁰F- 99.1⁰F

normal temp ⁰C

35.8⁰C-37.3⁰C

mean oral temp

36.5⁰C/97.7⁰F

febrile

37.8⁰C+/ 100.4⁰F+

rectal temp range

0.4⁰C-0.6⁰C higher; core temp

between oral/rectal

temporal

most variable

tympanic temp

diurnal cycle/ temp

highest in evening, lowest early morning

what affects oral temp

hot/ cold beverages, smoking, tachypnea

blue tip

oral

red tip

rectal

tympanic temp for 3+ years

pull up/back

tympanic temp for 0-3 years

pull down/back

fever of unknown origin

fever w/ undetermined cause

pulse

how many times heart beats per minute

normal pulse rate

60-100bpm

bradycardia

less than 60bpm

tachycardia

100+bpm

pulse rhythm

regular, irregular

when to measure pulse for 60 sec

irregular rhythm

pulse force

strength

0

absent

+1

weak, thready

+2

normal

+3

bounding

never palpate…

both carotid arteries

what to use if pulse if difficult to assess

doppler

respirations

breaths per minute

normal respiration rate

12-20 breaths/minute

tachypnea

20/25+ breaths/minute

bradypnea

less than 12 breaths/minute

dyspnea

SOB

DOE

SOB on exertion

eupnea

respirations are w/i normal limits/ not labored

blood pressure

force of blood being pushed against vessel wall

systolic pressure

maximum pressure felt on artery during LV contraction

diastolic pressure

resting pressure that blood exerts between contractions

influences on BP

age, sex, race, weight, exercise, emotions, stress, hypovolemia, hypervolumeia, meds

diurnal cycle/ BP

low in morning, high in evening

factors that determine BP

CO, peripheral vascular resistance, volume of circulating blood, viscosity, elasticity of vessel walls

BP considerations

rest for at least 5 min, sitting w/ legs uncrossed, arm at heart level

how to pick arm for BP

avoid AV shunts/fistulas, post mastectomy, IV site

too small cuff size

false high BP

too large BP

false low BP

Phase I

clear tapping tone, systolic pressure

Phase V

cessation of sounds, diastolic pressure

ausculatory gap

temporary disappearance of Korotkoff sounds during end of Phase I