Health Assessment Final Exam

subjective data

information from the client's POV ("symptoms"), including feelings, perceptions, and concerns obtained through interviews

objective data

observable and measurable data ("signs") obtained through observation, physical examination, and laboratory and diagnostic testing

open ended questions

asks for narrative information

closed ended questions

asks for specific information leading to a forced choice (yes or no)

focused assessment

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

complete assessment

review and physical examination of all body systems

components of health history

- biographic data
- source of history
- reason for seeking care
- present health or history of present illness
- past health events
- family history
- review of symptoms
- functional assessment

BMI

- Underweight

BMI calculation

weight (kg) / height (m^2)

pulse range

50-95 bpm

temperature ranges

- Oral: 97.6F- 99.6F
- Tympanic: 96.6F-99.7F
- Axillary: 95.3F-98.3F
- Rectal: 98.6F-100.6F
- Temporal: 96.5F-99.6F

respirations

- 10-20
- Count for 30 seconds or a full minute if you suspect an abnormality.
- Using a pulse oximeter- non invasive arterial oxygen saturation- 97-99% in healthy adults

tacypnea

- Rapid, shallow breathing
- Increased rate >24 breaths per min
- Response to pain fever, fear, exercise, infection
- Body goes into hypermetabolic state and needs more oxygen

bradypnea

- Slow breathing
- Decreased but regular rate

hyperventilation

- Increase in both rate and depth (fast, deep breaths)
- Response to exertion, fear, and anxiety
- Trying to take more oxygen than than Co2 coming out

hypoventilation

- Irregular shallow pattern
- Can be caused by narcotics or anesthetics and conscious splinting of the chest to avoid pain

Cheyne-Stokes

- Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea)
- Cyclic episodes of apnea and hyperventilation

orthopnea

Difficulty breathing when supine

apnea

absence of breathing

dyspnea

labored or difficulty breathing

hypotension

hypertension stage 1

130-139/80-89

hypertension stage 2

140 or higher/90 or higher

orthostatic hypotension

refers to a drop in systolic BP ≥ 20 mm Hg or diastolic pressure ≥ 10 mm Hg after changing to a standing position.

duration of pain

- how long the pain has been going on
- acute and chronic

location of the pain

Can be well localized, such as in a joint, or widespread, occurring all over the body

quantity or intensity of pain

- use FACES
- mild, distracting, moderate, severe, intolerable

quality of pain

description of the pain, such as stabbing, crampy, dull, or sharp

chronology of pain

story of the pain

aggravating or alleviating factors

what makes the pain better or worse

clubbing

- indicates signs of hypoxia
- >180

pressure injury risk factors

impaired mobility, aging skin, decreased sensory perception, excessive moisture, shearing injury, poor nutrition, and infection

stage 1 pressure injury

Non blanchable (press down and doesn't turn pink) erythema; skin not broken

stage 2 pressure injury

partial thickness skin loss with exposed dermis

stage 3 pressure injury

full thickness skin loss

stage 4 pressure injury

full thickness skin and tissue loss

braden scale

- Evidence based tool that predicts the risk for developing a hospital acquired pressure injury
- Measures six categories: sensory perception, moisture, activity mobility, nutrition, friction/shear
- less than 9 severe risk
- 19-23 no risk

abnormal lymph node characteristics

- Acute infection: acute onset, bilateral, enlarged, warm, tender, and firm but freely moveable
- Chronic inflammation
- Cancerous /malignant nodes: Hard >3cm, unilateral, non tender, matted, and fixed

facial symmetry assessment

- have the patient smile
- observe the nasolabial folds for symmetry

thyroid glad assessment

- Enlarged thyroid association with hyperthyroidism may hear a bruit
- Bruit: the sound of blood flowing through a narrowed portion of an artery
- palpation: use anterior or posterior approach; locate isthmus below cricoid cartilage; note size shape, consistency, tenderness, an nodules

crackles

- discontinuous popping sounds heard over inspiration
- Emphysema, bronchitis pulmonary edema, pneumonia

wheezes

- Continuous musical sounds- constricted airway passage over expiration
- constricted airway, usually because of inflammation
- Acute Asthma, Chronic Emphysema, Bronchitis

stridor

- high pitched crowing or seal like sound
- heard on inspiration on the upper airway
- louder over neck
- needs to be treated very quickly
- Ex. croup, foreign body inhalation

pleural friction rub

- superficial sound that is coarse and low pitched
- sounds like two pieces of leather or sandpaper being rubbed together
- Ex. pleuritis

fremitus

- tactile vibration
- can hear when the patient is breathing

crepitus

- escaped air
-Rice krispies under the skin
- Can feel it not hear it

auscultation of thorax and lungs

- Patient sitting
- Listen anterior and posterior
- Side by side comparison
- Listen for one full respiration in each location: inhalation and exhalation
- Monitor breathing: Offers times for the client to rest and breathe normally

systole

heart contracts and pumps blood into the systemic and pulmonary system

diastole

ventricles relax and fill with blood

S1

- first heart sound
- Results from the closure of the AV valve (tricuspid and mitral)- lub

S2

- second heart sound
- Results from the closure of the semilunar valve (aortic and pulmonic)
- loudest at the base of the heart

heart ausculatory sites

- all patients take medications
- aortic
- pulmonic
- erbs point
- tricuspid
- mitral

carotid pulse assessment

carotid arteries should be palpated separately

pulse amplitude

3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent

pulse sites

temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis

characteristics of arterial insufficiency

- weak pulses
- cool skin
- color changes
- hair loss
- intermittent claudication

pitting edema 1+

mild pitting, slight indentation, no perceptible swelling of the leg

pitting edema 2+

moderate pitting, indentation subsides rapidly

pitting edema 3+

deep pitting indentation remains for a short time, leg looks swollen

pitting edema 4+

very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

left upper quadrant

- stomach
- spleen
- the left lobe of the liver
- body of the pancreas
- left kidney and adrenal gland
- splenic flexure of the colon
- part of the transverse and descending colon

right upper quadrant

- liver
- gallbladder
- duodenum
- head of the pancreas
- right kidney, and adrenal gland
- the hepatic flexure of the colon
- part of the ascending and transverse colon

left lower quadrant

- a portion of the descending colon
- the sigmoid colon
- left ureter
- left ovary, and fallopian tube (women)
- left spermatic cord (men)

right lower quadrant

- cecum
- appendix
- right ureter
- right ovary and fallopian tube
- right spermatic cord

abdominal assessment

- auscultate first, palpation last
- begin in the right lower quadrant (RLQ)
- listen for Bruits (turbulent blood flow)

bowel sounds

- high pitched gurgling noises
- present, hypoactive, hyperactive
- Listen for 5 minutes to determine if bowel sounds are not present

light palpation

- Goal: assess skin surface and superficial muscularate
- Palpate tender areas last- Assess for muscle guarding, rigidity, large masses, tenderness ( looking for hardening)
- When there is tenderness make sure to palpate last

deep palpation

- Goal: organ palpation
- Assess location, size, consistency, and mobility or palpable organs
- Assess for tenderness, masses, or abdominal enlargement
- Palpate liver edge, spleen, kidney

abduction

movement away from the midline

adduction

movement toward the midline

flexion

bending a joint

extension

straightening of a joint

eversion

turning outward

inversion

turning inward

protraction

moving a part forward

retraction

moving a part backward

rotation

moving left to right

pronation

turning the palm downward

supination

movement that turns the palm up

circumduction

circular movement of a limb at the far end

elevation

move shoulder up

depression

move shoulder now

muscle strength grading

5: Full ROM against gravity, full resistance
4: Full ROM against gravity, some resistance
3: Full ROM with gravity
2: Full ROM with gravity eliminated (passive motion)
1: Slight contraction
0: No contraction

kyphosis

- Convex curvature of the spine
- Common in older adults
- Adolescence from poor posture
---Caused by bookbags

arthritis

- Joint effusion or synovial thickening
- Redness and warmth of joints
- Occurs with rheumatoid arthritis (autoimmune), gout, osteoarthritis, and trauma

osteoporosis

loss of bone density

Glascow Coma Scale

- Standardized objective assessment that defines "level of consciousness" by giving it a numerical value
- eyes, verbal, motor
- Max- 15 pts, below 8= coma

CN I

- olfactory (smell)
- test sense of smell in those who report loss of smell, head trauma, and abnormal mental status, and when presence of intracranial lesion is suspected.
- not tested routinely
- abnormalities: anosmia

CN II

- optic (vision)
- sensory
- Test visual acuity and visual fields by confrontation.
Using an ophthalmoscope, examine the ocular fundus to determine color, size, and shape of the optic disc.

CN III

- oculomotor
- EOM
- helps to adjust and coordinate eye position during movement
.- controls eye movement, pupil constriction, & eyelid movement
- abnormalities:
--- Dilated pupil, ptosis, eye turns out and slightly down
--- Failure to move eye up, in, down
----Absent light reflex

CN IV

- trochlear nerve
- EOM
- enables movement in the eye's superior oblique muscle. This makes it possible to look down. The nerve also enables you to move your eyes toward your nose or away from it
- confrontation and accommodation

CN V

-trigeminal
- motor
-assess the face for strength and sensation
- assess muscles of mastication by palpating temporal and masseter muscles as a person clenches his or her teeth
- with a person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on a person's face: forehead, cheeks, and chin
- Tests all three divisions: ophthalmic, maxillary, and mandibular.

CN VI

- abducens nerve
- EOM
- innervate the ipsilateral lateral rectus muscle and partially innervate the contralateral medial rectus muscle
- abnormalities:
----Failure to move laterally, diplopia on lateral gaze

CN VII

-facial
- motor
- Note mobility and facial symmetry as a person responds to selected movements.
- Have the person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides
- When indicated, test sense of taste by applying cotton applicator covered with solution of sugar, salt, or lemon juice to tongue and ask the person to identify taste.

CN VIII

- vestibulocochlear (acoustic) nerve
- sensory
- Test hearing acuity by ability to hear normal conversation and by whispered voice test.

CN IX

-glossopharyngeal
- sensory
- assess mouth for taste
- assess mouth for movement of soft palate and the gag reflex
-assess swallowing and speech
- mediates taste on the posterior one third of the tongue, but technically too difficult to test.
- no gag reflex

CN X

- vagus
- abnormalities:
----uvula deviates to side
----No gag reflex
----Voice quality
----Hoarse or brassy, nasal twang or husky
----Dysphagia, fluids regurgitate through nose

CN XI

-spinal accessory
- motor
-assess the shoulders for strength
- Examine sternomastoid and trapezius muscles for equal size.
- Check equal strength by asking the person to rotate head against resistance applied to side of chin.
- Ask the person to shrug shoulders against resistance.

CN XII

- hypoglossal nerve
- motor
- inspect tongue; no wasting or tremors should be present.
- note forward thrust in midline as the person protrudes tongue.
- Ask the person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct.
- abnormalities:
----Tongue deviates to side
----Slowed rate of tongue movement

tactile discrimination

- distinguish different textures by touch
- sharp and dull pain