Health Assessment Exam 1 Review

SOLER (Therapeutic Communication)

Sit squarely, open posture, lean forward, eye contact, relax.

Facilitation (Communication)

Encourages the patient to say more.

Reflection (Communication)

Echoing patient's words to help express meaning.

Orthostatic Hypotension

Drop in systolic BP >= 20 mmHg or diastolic >= 10 mmHg after standing.

Normal Adult Vital Signs

Temp 37C/98.6F, Pulse 50-95 bpm, RR 16-25, BP

Pediatric Temperature Assessment

Avoid rectal route; use oral when old enough or electronic thermometer.

Pediatric Blood Pressure

Not checked under 3; cuff width must cover 2/3 of upper arm.

OLDCARTS Pain Assessment

Onset, location, duration, character, aggravating factors, relieving factors, timing, severity.

Nociceptive

intact nerve fibers stimulated

Visceral pain

pelvic/abdominal/chest/intestinal receptors

Referred Pain

Felt at a particular site but originates from another location.

Four Components of General Survey

Physical appearance, body structure, mobility, and behavior.

PQRSTU Mnemonic

Provocation/palliation, quality, region/radiation, severity, time of onset/duration/intensity.

Review of Systems (ROS)

Subjective body symptoms collected in head-to-toe order.

Skin Color Changes

Pallor (pale), erythema (red), cyanosis (blue), jaundice (yellow).

Pressure Injury Stages

type I: non-blanchable erythema

type II: partial-thickness loss

type III: full-thickness loss

type IV: full-thickness tissue loss.

ABCDE Melanoma Assessment

Asymmetry, border irregularity, color variation, diameter, elevation/evolution.

ABCT Mental Health Assessment

Appearance, behavior, cognition, and thought process.

Montreal Cognitive Assessment (MOCA)

Assesses visuospatial, naming, memory, attention, language, abstraction, delayed recall, and orientation.

Mini-Cog Assessment

Uses a 3-item word recall and a clock drawing test.

Cerebellar Coordination Tests

Rapid alternating movements, finger-nose-finger, and heel-to-shin test.

Romberg Test

Patient stands with feet together, arms at side, eyes closed for 20 seconds.

PERRLA (Cranial Nerves II & III)

Pupils equal, round, reactive to light and accommodation.

Cranial Nerve VIII (Vestibulocochlear)

Assesses hearing and balance using the whisper voice test.

Cranial Nerves IX & X (Glossopharyngeal & Vagus)

Motor: say ahh (uvula);

Sensory: gag reflex.

Neuropathic Pain

nerve damage or malfunctioning nervous system.

type 1 of pressure injury

non-blanchable erythema

type 2 of pressure injury

partial-thickness loss

type 3 of pressure injury

full-thickness loss

type 4 pressure injury

full-thickness tissue loss.

somatic pain

tissue receptors.