Week 1: Health Assessment Review

List the 10 attributes of signs and symptoms

LATERSNAPS

-Location

-Associated Signs and Symptoms

-Timing

-Environmental/Exposure Factors

-Relieving Factors

-Severity/Quantity

-Nature/Quality

-Aggravating Factors

-Patient Perspective

-Significance to Client

What does IPPA stand for?

IPPA is a diagnostic tool that involves:

I: Inspection

P: Palpation

P: Percussion

A: Auscultation

What order is the abdominal physical assessment done?

Inspection

Auscultation

Percussion

Palpation

List the components assessed in vital signs

-Temperature

-Pulse

-Respirations

-O2 saturation

-Blood pressure

What body structure is considered the body's thermostat?

Hypothalamus

What is normal temperature range?

36.5-37.5 ˚C

What is the temperature diurnal pattern?

The natural cycle that occurs every 24 hours in which

temperature varies 0.5 to 1 degree over the course of day

What time of day is body temperature the highest and lowest?

Lowest: Early morning

Highest: Late afternoon/evening

What primary temperature route/reading do we compare other temperatures to?

Oral

What is best place to get an accurate core temperature measurement?

Rectal

What factors do we asses when taking a pulse?

-Rate

-Rhythm

-Strength (amplitude)

-Elasticity

What are the amplitude (strength) levels of a pulse?

0 to 4+

Outline the amplitude (strength) levels

0: Non-palpable or absent

+1:Weak, diminished, and barely palpable

+2: Strong

+3: Full, increased

+4: Bounding

What is the expected amplitude level?

2+

What is considered normal heart rate in an adult?

60-100bpm

What is tachycardia?

Fast heart rate, greater than 100bpm

What is bradycardia?

Slow heart rate, fewer than 60bpm

What is asystole?

The absence of a heartbeat/pulse

What is pulse deficit?

When the beat of the heart (apical pulse) is different than the peripheral (radial) pulse

How do you calculate for pulse deficit?

Apical pulse - Radial pulse

Which part of the stethoscope do you use to listen to apical pulse?

Diaphragm

Is inspiration an active or passive process?

Active process

Is expiration an active or passive process?

Passive process

What is considered normal respiratory rate in adults?

12-20 breaths/minute

What is considered normal respiratory rate in adults 65 and older?

12-24 breaths/minute

What is tachypnea?

Greater than 20 breathes/minute (persistent)

What is bradypnea?

Fewer than 12 breathes/minute

What is apnea?

The absence of breathing

What is eupnea?

Normal breathing

What is the expected O2 saturation?

SpO2 of 92-100%

What is auscultation?

Using a stethoscope to listen to sounds within the body

What are the two parts of a stethoscope, and what do they do?

Bell:

Used for low pitched sounds

Diaphragm:

Used for high pitched sounds

What is considered healthy blood pressure?

120/80mmHg

Which is longer systole or diastole?

Diastole

What is mean arterial pressure (MAP)?

The average pressure in the arteries throughout the cardiac cycle

What is the considered normal MAP in adults?

Minimum: 60mmHg (0-20 cmH20)

How do you calculate MAP?

[SBP + (2x DBP)] / 3

How do you calculate cerebral perfusion pressure (CPP)?

MAP - ICP (intracranial pressure)

What is considered normal intracranial pressure (ICP)?

0-15 mmHg (0-20 cmH2O)

What is pulse pressure?

The difference between systolic and diastolic blood pressure (Systolic pressure - diastolic pressure)

What is considered healthy pulse pressure?

40-60 mmHg

What is the bodies largest organ?

The skin

When assessing the patients skin temperature which part of your hands do you use?

Dorsal surface of hands

What is another name for moles?

Nevi

What are the ABCDEs of melanoma?

Asymmetry: One half of the mole is unlike the other half

Border:

Irregular, ragged, or poorly defined border (e.g jagged)

Color: Varying colours from one area to the next (shades of tan, brown or black, or areas of white, red, or blue)

Diameter: Melanomas usually have a diameter of greater than 6 mm, or the size of a pencil eraser

Evolving: The mole looks different and has evolved/changed over time

What is Acral lentiginous melanoma?

Most common type of melanoma found in the hand and feet of people of colour

What is skin turgor?

Test used to measure a patients level of hydration by seeing how quickly the skin returns to its normal position after being pinched. It should take less than a second to return to it's former position after being pinched

Where is the most accurate reflection of turgor in an adult?

The anterior chest just below the midclavicular area

What should you look for when palpating the nails?

Capillary refill of less than 3 seconds

Braden Scale

Standardized, evidence-based assessment tool used to assess a patient's risk for developing pressure injuries such as ulcers

What are the 6 categories assessed in the Braden scale?

1. Sensory perception

2. Moisture

3. Activity

4. Mobility

5. Nutrition

6. Friction/shear

What acronym should you use to identify someone having a stroke?

FAST

What is the FAST stroke acronym?

Face: Is the face drooping

Arms: Can they raise both arms

Speech: Is their speech slurred or jumbled

Time: Call 9-1-1 right away

When does the posterior fontanelle close?

By 2 months of age

When does the anterior fontanelle close?

By 24 months of age

The anterior fontanelle is also referred to as the ____

Soft spot

What should you do before you palpating the carotid artery?

Auscultate to check for bruits

How should a patient be positioned during an abdominal assessment?

Supine with the entire abdomen exposed (drape accordingly)

List the 12 cranial nerves

I. Olfactory

II Optic

III. Oculomotor

IV. Trochlear

V. Trigeminal

VI. Abducens

VII. Facial

VIII. Vestibulocochlear (acoustic)

X. Glossopharyngeal

X. Vagus

XI. Accessory

XII. Hypoglossal

What is considered normal vision?

20/20

What is vision is considered legally blind?

Visual acuity of less than 20/200

Where is the light reflex in the right ear?

5 o'clock

Where is the light reflex in the left ear?

7 o'clock

Define Gait

A person's manner of walking

What are the categories and levels on the glasgow coma scale?

Categories:

-Best motor response

-Best verbal response

-Eye opening

Levels:

Best motor and verbal response ranges from 1-6 and Eye opening ranges from 1-4, with 1 being no response

Best eye opening response levels

1: No eye opeing

2: Eye opening to pain

3: Eye opening to verbal command

4: Spontaneous eye opening

Best verbal response levels

1: No verbal response

2: Incomprehensible verbal response

3: Inappropriate verbal response

4: Confused verbal response

5: Appropriate verbal response

Best motor response levels

1: No motor response

2: Decerebrate (Head back and arms+ legs extend out)

3: Decorticate (Arms crossed over chest and legs extended)

4: Withdrawals

5: Localizes

6: Obeys

What glasgow score is considered mild, moderate, severe

Mild: 13-15

Moderate: 9-12

Severe: 3-8