Health Assessment Exam #3

headaches, dizziness, seizures, loss of consciousness, change in movement, change in sensation, difficulty swallowing/communicating

chief complaints for cognitive assessment

olfactory-able to identify aromas

CN I

optic-able to read/see objects

CN II

oculomotor- PERRLA

CN III

pupils equal, round, reactive to light, accomodation

What does PERRLA stand for?

consensual reaction

constriction of one pupil when light is shone into opposite eye (whatever we do in one pupil, the other does)

direct constriction

constriction of pupil in the eye that is directly exposed to light

oculomotor, trochlear, and abducens- 6 cardinal fields of gaze

CN III, IV, VI

nystagmus

rapid, involuntary, and rhythmic eye movements; variance of 6 cardinal fields of vision

trigeminal-contraction of temporal and masseter muscles; light touch/sensation

CN V

facial-facial expressions

CN VII

acoustic-hearing

CN VIII

glossopharyngeal, vagus-rise of uvula and soft palate (swallowing)

CN IX, CN X

spinal accessory-shoulder shrugging

CN XI

hypoglossal-tongue movements (up & down, side to side)

CN XII

strike tendon just above elbow

How do elicit tricep DTR?

strike tendon in antecubital fossa (strike own finger)

how to elicit bicep dtr

strike tendon 1-2 inches above writst

how to elicit brachioradial dtr

strike tendon just below patella

how to elicit patella dtr

strike tendon at the level of ankle malleolus (back of ankle)

how to elicit achilles dtr

ankle clonus

involuntrary contractions/hyperactive reflex when foot is rapidly dorsiflexed

romberg test

test for balance, stand with feet together and eyes closed

stereognosis

place small familiar object in patient’s hands and ask them to identify with their eyes closed

graphesthia

using a blunt object draw a letter/number on patient’s hand

mood

the way a person feels emotionally

affect

observable response person has to emotions

chief complaints of mental health assessment

depression, anxiety, altered mental status, alcohol/drug use, interpersonal violence

when there is a change in patient’s orientation to time, place/person, attention span, or memory

When is a change in mental status evident?

chief complaints of HEENT assessment

headaches, dizziness, vertigo, vision difficulty, hearing loss, earache (otalgia), epistaxis, sore throat, mouth leisions

vertigo

feels like environment moving/spinning around you

dizziness

feeling faint/light headed

20/30 or better

expected outcome for near and distant vision

you must be 20 feet away to see an object clearly that a person with 20/20 vision can see from 30 feet away

What does 20/30 vision mean?

ptosis

drooping of one eye

exophthalmos

protrusion of eye

aniscoria

when pupils are two different sizes

the pinna should directly align with the outer canthus of the eye

What is proper alignment and position of the ear?

between 1-2+ (should not touch each other or the uvula)

tonsils expected outcome

malignancy of the lymph nodes

unilateral, hard, asymmetric, fixed (non moveable) and nontender

lymph nodes during infection

enlarged, tender, firm but moveable

preauricular nodes

lymph nodes directly in front of the ear

submandibular nodes

just under the jawbone/mandible, slightly behind the chin

submental lymph node

just underneath the chin, in the soft area between the tip of the jawbone and the hyoid bone (adam’s apple) in the neck

occipital nodes

back of the head, right at the base of the skull

supraclavicular nodes

in the hollow area just above the clavicle on both sides of the neck

care management process

designed to enhance health states, functional abilities, and quality of life for individuals, families and populations; emphasis on client-centered care and interprofessional collaboration (intra and interdisciplinary)

-population identification

-expected/desired outcomes identification and prioritization

-assessment

-variance identification

-interventions/strategies

-evaluation of care and outcomes

-modification

care management process components

population profile

describes relationship of a health alteration or disease to the specific population affected; foundation for the development of interventions at the health promotion and health protection levels of care delivery

SMART outcomes (specific, measurable, achievable, relevant, time-specific)

How to determine expected outcomes according to care management process?

disease management

understanding and treating the disease across population and the continuum of care

evidence based practice and assessments

How does a care management process model promote safety and quality?

QSEN competencies

-patient centered care

-teamwork and collaboration

-evidence based practice

-quality improvement

-informatics

-safety

birth-28 days

neonate/newborn age range

1-12 months

infant age range

1-3 years

toddler age range

3-5 years

preschool age range

6-12 years

school age age range

12-18 years

adolescent age range

appearance (skin color), pulse (heart rate), grimace (reflex ability), activity (muscle tone), respiration (respiratory effort)

What does APGAR stand for?

120-160

newborn heart rate

30-60

newborn respiratory rate

60-90/20-60

newborn blood pressure range

90-140

toddler heart rate

24-40

toddler respiratory rate

80-112/50-80

toddler blood pressure

75-100

school aged heart rate

18-30

school aged respiratory rate

84-120/54-80

school aged blood pressure

60-90

adolescent heart rate

12-16

adolescent respiratory rate

94-139/62-88

adolescent blood pressure

baby thats > 33.5% gestational age

When is NIPS used?

any patient greater than or equal to 100 days old

When is N-PASS used?

FLACC scale and Oucher pain scale

What pains scales are used for infant-7 y/o and non-verbal?

wong baker faces scale

pain scale for school-aged children

numerical pain scale

pain scale for 8 y/o - adolescents

milia

white bumps/clogged pores within first 3 weeks of life

erythema toxicum

splotchy red patches with pustules on face, trunk, or limbs

mongolian spot

benign, flat, blue-gray birthmarks, typically found on the lower back or buttocks of newborns, particularly those with darker skin; document to avoid being confused with bruising later

languo

fuzzy hair baby is born with on body

fontanels

tough, fibrous membrane-covered gaps in a newborn’s skull where cranial bones haven't yet fused; soft spot of skull

8 weeks

When does the posterior fontanel close?

12-18 months

When does the anterior fontanel close?

dehydration

What does a sunken in fontanel indicate?

increased pressure from fluid accumulation or infection

What does a bulging fontanel indicate?

allergic salute

repeated rubbing or wiping of the nose to alleviate itchiness or congestion that leads to a transverse nasal crease

enlarged post-auricular and occipital nodes

expected lymph node findings for children less than 2

enlarged cervical and submandibular nodes

expected lymph node finding for older child

acrocyanosis

blue color of hands and feet; normal for first few hours; caused by the physiological adjusting of infant being responsible for own blood supply to vital organs

meconium

infant’s first stool; dark, tarry, thick

moro reflex

birth to 1-4 months; startles to loud noise- abducts and extends arms and legs

palmar reflex

birth to 3-4 months; infant grasps finger

tonic neck reflex

birth-6 wks to 4-6 months; arm and leg extend on side to which head turns

plantar reflex

birth to 9-12 months; toes flex down to grasp

babinski reflex

birth to 18 months; fans toes when lateral surface of sole is stroked

step in place reflex

birth to 3 months; paces forward using alternate steps

rooting response reflex

birth to 3-4 months; infant turns head in direction of stimulus and opens mouth

sucking reflex

birth to 10-12 months; sucking motion follows with lips and tongue when lips touched

presumptive signs of pregnancy

felt by the woman, includes:

-breast changes

-amenorrhea

-nausea/vomiting

-quickening (fetal movement)

probable sings of pregnancy

observed by the nurse, includes:

-chadwick’s sign

-goodell’s sign

-hegar’s sign

-ballottement

-positive pregnancy test (serum or urine)