Health Assessment Exam 1

Therapeutic communication strategies

S- sit squarely to client and get close

O- open posture

L- lean forwad

E- eye contact

R- relax

components of communication: patient perspective

time, active listening, caring, non-judgemental attitude, honesty, trust, empathy, clarification

components of communication: examiner perspective

confrontation, interpretation, explanation, summary

temperature

37 C, 98.6 F

body maintains steady temperature through feedback mechanism regulated in hypothalamus

influenced by

• diurnal cycle

• menstruation

• exercise

• age

• hormones

• fat

hyperthermia

above 37.8

hypothermia

below 36

temperature- children

try to use electronic thermometer

avoid rectal

use oral (4,5,6 years old)

heart rate

number of times the heart beats in 1 minute

50-95 BPM

bradycardia <50bpm

tachycardia >95 bpm

heart rhythm

regular, even tempo

sinus arrhythmia

heart rate varies with respiratory cycle (speeds up with inspiration and slows down with expiration)

commonly found in children

pulse

pressure wave that expands and recoils the artery when the heart beats

pulse force

strength of hearts stroke volume

3+, 2+ (normal), 1+, 0

factors of pulse

fluid status

fever

medications

exercise

anxiety

pulse-children

palpate for A typical rate

in children 2+ use radial pulse

fluctuates more with children, naturally higher

respiration

relaxed, regular, silent breathing

20 breaths per min (16-25)

bradypnea vs tachypnea

bradypnea- 8-12

tachypnea- >25

factors influencing respiration

O2 status

age

anxiety

respirations- children

watch infants abdomen

sleeping RR is most accurate

count for a full minute

systolic vs diastolic pressure

systolic- pressure when heart contracts

diastolic- pressure when heart rests

120/80

BP- children

BP not normally checked in children less than 3

use correct size cuff and peds sized stethoscope

use electronic BP device

pulse pressure

difference between systolic and diastolic (lets us know Stroke Volume, or the amount of blood circulating body)

cardiac output

increase CO leads to increase in BP (vise versa)

vascular resistance

increased resistance (vasoconstriction) leads to increase in BP

volume of circulating blood

fluid retention leads to decreased BP

elasticity of arterial walls

increasing rigidity=increase in BP

factors influencing blood pressure

age, sex, race, social determinants, diunal rhythm, weight, exercise, emotions, stress

orthostatic blood pressure

have person rest supine for 3 minutes, take baseline reading of pulse and BP, then repeat with person sitting and then standing

orthostatic hypotension

drop in systolic pressure of more than 20 or diastolic pressure more than 10 after changing to standing

thigh pressure

when BP in arm is excessively high, compare with thigh pressure

thigh pressure is higher (systolic is 10 to 40 mm higher, diastolic is the same)

coarctation of aorta

arm pressure is higher than thigh pressure

Pulse Ox

assessment of arterial oxygenation 97-99%

OLD CARTS

O- onset (when did pain start, did it appear suddenly or gradually)

L- Location (where is the paid, does it radiate)

D- duration (how long does it last, does it come and go)

C-character (describe the nature of the pain)

A- aggravating factors (what makes your pain worse/triggers)

R- Relief (have you tried anything to relief the pain or make it better)

T- Timing (does the pain have a pattern throughout the day, when does it occur)

S- Severity (on a scale of 1-10 how bad is the pain)

nociceptive pain

when functioning and intact nerve fibers in the periphery and CNS are stimulated

throbbing, aching, cramping, squeezing, pressure

neuropathic pain

result of nerve damage or malfunctioning nervous system

• burning, shooting, tingling

acute pain

short term, self limiting, protective

signs- gaurding, grimacing, moaning, restlessness, stillness, diaphoresis, change in vitals

chronic pain

does not stop when injury heals

signs- bracing, rubbing, signing, change in appetite

malignant pain

chronic pain caused by tumor cells d/t tissue necrosis or streching of an organ by growing tumor

chronic nonmalignant

pain associated with musculoskeletal conditions like arthritis, low back pain, fibromyalgia

general survey

covers general health survey and any obvious physical characteristics

provide an overall impression

includes aread of physical appearance, body structure, mobility, behavior

components of general survey

1. physical appearance

2. body structure

3. mobility

4. behavior

physical appearance

age, sex, LOC, skin color, facial features, overall appearance

body structure

stature, nutrition, symmetry, posture/position, body build, contour, obvious physical deformity

orthopneic position

indicates respiratory distress

scoliosis, kyphosis, lordosis

mobility

gait, ROM, voluntary/involuntary movements

behavior

is it appropriate for the conversation

• facial expression

• mood & affect

• speech articulation and clarity

• speech pattern

• dress

• personal hygiene (can they care for themselves)

arthropometric measurements

height (indicates growth pattern)

weight (reflects nutritional status

BMI (helps assess risk for chronic conditions)

Waist circumference (assess central obesity)

weight considerations

use similar scale, clothing, time of day

hortontal measuring board for children

height considerations

no shoes, stand up straight

BMI categories

waist circumference

measure just above hip bones

female- 35>

male- 40>

if greater= increased risk for metabolic syndrome

infant and child growth

physical growth is the best indicator of child health

healthy growth is continuous but uneven (growth spurts)

red flags about growth

falls below 5th of above 95th percentile with no explanation

wide percentile differences with weight and height

growth suddenly stops

head circumference

measure at birth and every visit up to age 2, annually to 6 years

circle around head aligned with eyebrows at prominent frontal and occipital bones

newborn head/chest circumference

32-38 cm— 2cm larger than chest circumference

6 mo-2 years head/chest circumference

head equals chest

2 years and older head/chest circumference

chest larger than head

situational awareness

ability to notice what is happening around you, what it means, and anticipate what might happen next.

they recognize patterns, emotions, expressions, etc

the foundation for safe nursing care

purpose of health history

collect, subjective data, producing a complete picture of the persons past and present health

biographic data

name, age, DOB, birthplace, address, phone #, gender, race, ethnicity, job

reason for seeking care

quote patient as much as possible

present health

reason they are seeking care from the time of first symptom to now

for healthy person they may state “they feel healthy)

PQRST

provocation

quality

region/radiation

serverity

time

pas history

childhood illnesses, accidents/injuries, serious illness, hospitalization, surgeries, OB history, immunizations, allergies

medication reconciliation

all medications currently taken and taken in past to reduce errors and promote patient safety

family history

highlights diseases and conditions for which the patient may be at increased risk

• pedigrees

ROS- Review of Systems

collection of subjective data of our body systems limited to patient statements and in order of head to toe

purpose- evaluate past and present health of each bodily system

Health history questions for infants and children

birthmarks?

change in skin color?

rashes or sores?

diaper rash?

burns of bruises?

exposure to contagious disease?

nail biting or twisting hair?

what steps are taken to protect child from sun?

Health history questions for adolescents

skin problems such as pimples and blackheads

health history questions for adults

ask about changes in skin, delayed wound healing, skin pain, change in feet, falls history of diabetes or peripheral vascular disease, how do you care for your skin

physical exam techniques

assess skin throughout examination

separate skin folds (intertriginous areas)

inspect feet, toes, toenails

inspect skin color

pigmentation, freckles, moles, birthmarks

widespread color change- pallor, erythema, cyanosis, jaundice

inspect temperature

use back of hand to palpate

skin should be warm and equal bilaterally= normal circulation

hands and feet may be slightly colder

other skin inspections

moisture- dehydration/diaphoresis

edema

texture

thickness

mobility/turgor

vascularity/bruising

lesion inspection

elevation- flat, raised, pedunculated

pattern/shape- grouping

size- cm

location

exudate- color/odor

hair inspection

color

texture

distribution

lesions

nail inspection

profile sign- view index finger and note angle of nail base (160)

consistency- smooth, regular

color- pale pink, translucent

capillary refill

macule

a color change, flat, round, less than 1 cm

papule

felt, and caused by superficial thickening of epidermis

patch

macules that are larger than 1 cm

plaque

papules coalescing to form surface elevation wider than 1 cm

nodule

solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule

wheal

superficial, raised, transient and erythmatous, irregular shape d/r edema

tumor

larger in diameter, first or soft, deep in dermis, may be benign or malignant

urticaria (hives)

wheals coalesce to form pruritic reaction

vesicle

elevated cavity containing fluid up to 1 cm

cyst

encapsulated fluid filled cavity

bulla

larger than 1 cm, usually single chamber, superficial in dermis and ruptures easily

pustule

round, elevated, filled with pus

ABCDE

A- asymmetry

B- boarder irregularity

C- color variation

D- diameter

E- evolution/englargement

use sunscreen, avoid tanning beds, visit dermatologist regularly

Braden Scale

Scale used to assess pressure ulcer risk

risk factors for pressure injuries

1. sensory perception- ability to respond to pressure related discomfort

2. moisture

3. activity- physical activity

4. mobility- ability to change and control body position

5. nutrition- usual food intake pattern, how much they eat and how often

6. friction and shear

SCORE OF 12 OR LESS= HIGH RISK

pressure points

occiput (back of head)

shoulder blades

elbow

sacrum

ischial tuberosity

heel

toe

DEVICE

D- DETECT- be aware of devices and risk factors of skin breakdown

E- EVERY PATIENT, EVERY SHIFT

V- VISUALIZE- palpate skin under devices

I- INTERVENE- rotate pt

C- CUSHION with foam dressing

E- EDUCATE

pressure injury stages

stage 1- non blanchable

stage 2- partial thickness skin loss

stage 3- full thickness skin loss

stage 4- full thickness skin loss

Head/face/neck/lymphatic assessment

• inspect and palpate skin- size, contour, deformities, palpate temporal artery and TMJ, tenderness

• Inspect/palpate face- observe facial expression, cranial nerve VII (symmetrical movement), observe abnormal movements

• inspect/palpate neck: active ROM, enlargements and position of trachea, auscultate thyroid (nonpalpable)

Nose assessment

nose-

• position person sitting up straight with their head at eye level

• inspect external nose for symmetry

• palpation- test patency of each nostril

• inspect with nasal speculum nasal mucosa, septum, turbinates

• palpate sinus area (press under eyebrows and cheekbones

• swelling, bleeding, polyps, discharge

mouth and throat assessment

• position person sitting up straight with his head at the examiners eye level and offer paper towel for person to remove dentures

• move anterior to posterior, use penlight andd tongue blade

• inspect with penlight: mouth, teeth, gums, buccal mucosa, palate, tonsils, pharyngeal wall

• palpate when indicated

  • for adults bimanual palpation of mouth

  • in neonates, palpate for integrity of palate and assess sucking reflex

infant and children considerations

note infant head posture and control, can turn head side to side by 2 weeks

do nose, mouth, throat exam last for kids because it’s invasive

older adult considerations

sense of smell and taste decrease with age

saliva production decreases