Health Assessment Exam 1 UCA

subjective data

what the person says about themselves based on how they are feeling

objective data

information that is seen, heard, felt, or smelled by an observer; signs

internal factors of an interview

liking others, empathy, ability to listen, self-awareness

external factors of an interview

ensure privacy, refuse interruptions, physical environment, dress, note-taking, computer charting

stages of an interview

introduction, working phase (asking open ended questions/closed questions & gathering data), and closing

Facilitation

encouraging client to say more

ex: "mmhmm go on"

silence

wait for a response

ex: waiting for response without interrupting

reflection

echo the client's words

ex: repeat part of what the client had said to you

empathy

support patient, allow to feel with the patient

ex: "That must be hard for you.."

clarification

clarify if the patient's words are confusing

ex: "The heaviness in your chest occurs with walking up the stairs or more than 1 block, but stops when you rest. Is that correct?"

confrontation

Clarifying inconsistent information

Focusing client's attention on an observed behavior, action, or feeling

ex: "you look sad or you look angry"

interpretation

make associations

ex: "It seems that every time you feel the stomach pain, you have some type of stress in your life...could it be that you're afraid?"

explanation

sharing information

ex: "You may not eat or drink for 12 hours before your blood test because the food could alter the test results."

summary

condenses facts and validates what was discussed during the interview

ten traps of interviewing

1. Providing false assurance or reassurance

2. Giving unwanted advice

3. Using authority

4. Using avoidance language

5. Engaging in distancing

6. Using professional jargon

7. Using leading or biased questions

8. Talking too much

9. Interrupting

10. Using "why" questions

nonverbal behaviors

- Nonverbal behaviors can tell a story; observe your patient and also be aware of what your nonverbal behaviors are "saying"

-What are some of these behaviors?

Posture, facial expressions, eye contact, tone of voice, rate of speech, pauses while speaking

oral temperature

most convenient/accurate (good blood supply from the carotid artery & quickly respond to changes to the inner core temperature)

rectal temperature

closest to the inner core temperature (patient on left side, lube it, insert 1 inch into the rectum, & leave until it beeps or until 2 minutes) & subtract a degree due to it being closest to our core temperature & we would put an R next to the temperature we documented) ex: 101.9 R

tympanic temperature

infrared emission, noninvasive, nontraumatic, minimal chance of cross contamination (gently place covered probe in ear canal; used more in clinics)

temporal temperature

infrared emission from temporal artery (slide across forehead; behind the ear) not very accurate; more of an average

things that can influence temperature

- Diurnal cycle: any pattern that occurs every 24 hours as a result of planet earth around its axis

- Menstruation cycle

- Exercise

- Age

normal ranges of temperature

Oral: 96.4 F- 99.1 F

Rectal: on average 1 F higher than oral

normal pulse

60-100 bpm

Force: describe 0, 1+, 2+, 3+

0 = absent

1+ = weak, strainy

2+ = good

3+ = over powering, more than usual

tachycardia

Greater than 100 bpm

Caused by: exercise, fever/infection, anxiety

bradycardia

Less than 60 bpm

Caused by: medications, heart problems, common in athletes

tachypnea

RR greater than 20

Caused by: anxiety, fear, exercise, fever, pain

bradypnea

RR less than 10

Caused by: drug overdose, increased intracranial pressure, diabetic coma

normal respirations

Normal: relaxed, unlabored, regular, silent

Regular: count for 30 seconds x2

irregular : count for 1 full minute

blood pressure

force of blood pushing against the vessel wall

systolic pressure

maximum pressure, felt during left ventricular contraction

diastolic pressure

resting, constant pressure exerted between contractions

pulse pressure

difference between systolic and diastolic

5 factors that determine blood pressure

- Cardiac Output: more blood pumped; increased BP

- Peripheral Vascular Resistance: constricted/narrow vessels; increase BP

larger/dilated vessels; decrease BP

- Blood Volume: higher volume = increase BP; lower volume = decrease in BP

- Viscosity: thicker blood increases BP

- Elasticity of Vessels: stiff, rigid vessels increase BP

hypertension

Abnormally high BP

Essential/primary HTN: no known cause; 95% of cases

Often is undiagnosed: "the silent killer"

hypotension

abnormally low BP

Caused by: acute MI, shock, hemorrhage, vasodilation

risk factors for hypertension

Smoking

Dyslipidemia

Diabetes mellitus

Age greater than 60

Gender

Family history

lifestyle modifications if you have HTN

Lose weight

Limit alcohol

Increase activity

Reduce sodium intake

Stop smoking

Reduce fat and cholesterol

orthostatic hypotension

Drop in systolic pressure of >20 mmHg or increase in pulse of >20 bpm

What causes this?

Procedure: take BP and pulse

Lying, Sitting, Standing

noiceptive pain

Nociceptive: pain develops when functioning and intact nerves are stimulated

Occurs in phases

Transduction, transmission, perception, and modulation

neuropathic pain

pain from damage to neurons of either the peripheral or central nervous system

Sources of Pain

Visceral

Somatic

Deep Somatic

Cutaneous

Referred

pain assessment tools

Initial pain assessment

Brief pain inventory

Numeric scale

Faces pain scale

PQRSTU method

- Provocation: What aggravates it?

- Quality: description of pain: dull, throbbing, sharp, shooting, etc.

- Region of pain/radiation: what is the location of pain?

- Severity: Rate the pain from 0-10

- Timing: when did the pain start, when does it occur, is it constant or intermittent, how long does the pain last?

- U (how pain affects you): how does the pain affect activities of daily living?

normal BP reading

less than 120/80

the aging adult: temp

more likely to have hypothermia not a fever

the aging adult: heart rate

50-95 bpm, but rhythm is usually slightly irregular

the aging adult: respiratory rate

shallower inspiratory phase, increased response rate

the aging adult: blood pressure

have an increase in both systolic and diastolic pressure

pulse oximeter

a noninvasive method to assess arterial oxygen saturation (SpO2)

normal SpO2

97-99 or greater than 95

visceral pain

originates from the larger internal organs

often described as dull, deep, squeezing, or cramping

somatic pain

originates from musculoskeletal tissues or the body surface

deep somatic pain

comes from sources such as blood vessels, joints, tendons, muscles, and bone

cutaneous pain

superficial pain usually involving the skin or subcutaneous tissue

referred pain

pain that is felt in a location other than where the pain originates

the aging adult: Pain

use the PAINAD scale:

- breathing, vocalization, facial expression, body language, and consolability

- a score of 4 or more requires a need for pain management

tension headache

Definition: Musculoskeletal origin

Location: usually both sides, everywhere

Character: bandlike tightening

Duration: gradual onset, lasts 30 minutes to days

Severity: Mild to moderate

Timing: situational

Aggravating factors: stress, anxiety, depression, poor posture

Associated symptoms: fatigue

Relieving factors: rest

migraine headache

Definition: Vascular origin

Location: commonly one sided

Character: Throbbing, Pulsating

Duration: rapid onset, peaks at 1-2 hours, lasts 4-72 hours

Severity: Moderate to severe

Timing: 2 per month

Aggravating factors: hormones, foods, hunger, sleep deprivation, sensory stimuli, activity, changes in weather, family history

Associated symptoms: Aura, prodrome, nausea, vomiting, looks sick

Relieving Factors: lie down, dark room, sleep

cluster headache

rare headache that is intermittent, excruciating, unilateral, with autonomic signs

always one sided ; often behind or around the eye, temple, forehead, or cheek

continuous burning, piercing, excruciating pain

abrupt onset, peaks in minutes, lasts 45-90 minutes and appears in "clusters"

normal lymph nodes

nonpalpable, nontender or moveable, discrete, soft and nontender

abnormal lymph nodes

Lymphadenopathy- enlarged greater than 1 cm

Infection- bilateral, enlarged, warm, tender and firm, freely moveable

Cancerous- unilateral, hard, greater than 3 cm, nontender, matted, fixed

Parkinson's disease

Decrease dopamine; flat, expressionless, elevated brows, staring, oily skin, and drooling ("masklike")

Cushing's disease

Increase adrenocorticotropin or chronic steroid use; Rounded face, prominent jowls, red cheeks ("moonlike")

acromegaly

Increase growth hormone after puberty; elongated head and massive face, large nose and jaw

cachetic

Wasting illness; sunken eyes, hollow cheeks, exhausted/defeated expression

hyperthyroidism

Increase thyroid; amped up; nervous, fatigue, hot, stare, moist skin, heat intolerance (Grave's Disease)

hypothyroidism

Decrease thyroid; slow-turtle; puffy, edematous face, feet, and hands, cool, dry skin, dry, coarse hair (Myxedema)

Bell's Palsy

peripheral neuron lesion; CN VII paralysis; unilateral, smooth forehead, drooling, pain behind ear

CVA (stroke)

central neuron lesion; uneven smile, can wrinkle forehead and close eyes

cants

corner of the eye

conjunctiva

a thin mucous membrane folded like an envelope between the eyelids and the eyeball (protective covering)

eye is controlled by what

Controlled by 6 muscles- 4 rectus (straight) and 2 oblique (slanting)

the aging adult: the eyes

Decrease in pupil size, tear production, lens elasticity

Presbyopia: decrease in ability to accommodate for near vision caused by loss of elasticity

Need more light due to decreased adaptation to darkness

Increase for falls and other injuries

cataract

clouding of lens. Age is the biggest risk factor. Women have higher risk

glaucoma

caused by increased intraocular pressure and categorized by the loss of peripheral vision

macular degeneration

yellow deposits and neurovascularly in macula and categorized by the loss of central vision.

diabetic retinopathy

leading cause of blindness

strabismus

cross-eyed

diplopia

double vision, the perception of two images of a single object

so what should the eye look like?

Lids intact without redness/lesions, lashes evenly distributed, brows symmetric with hair evenly distributed, Conjunctiva pink, sclera white, lacrimal apparatus non-tender, no discharge, cornea and lens clear, smooth, pupils 4mm equal, round

periorbital edema

swollen puffy lids; occurs with infections, crying, allergy, and hypothyroidism

ptosis

drooping upper lid; neuromuscular weakness

exophthalmos

protruding eye; hyperthyroid

exophthalmos

sunken eye; loss of fat in orbits; dehydration, wasting, injury

hordeolum (stye)

local staph infection of hair follicles of lid margin; painful, red and swollen

chalazion

infection or retention cyst of meibomian gland; beady nodule pointing inward

mydriasis

dilation of the pupil

miosis

constricted pupils

Conjunctivitis

infection of conjunctiva (pink eye); beefy, red, periphery

iritis

infection of iris; deep, dull, red halo around iris and cornea

Immediate referral.

3 parts to the ear

external: example the pinna

middle: tiny air filled cavity inside the temporal bone

- 3 functions: Conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear.

Protects inner ear by reducing the amplitude of loud sounds. Eustachian tube allows equalization of pressure on each side of the tympanic membranes so the membranes do not rupture

inner: Helps with equilibrium and hearing

Characteristics serves to funnel sound waves to external auditory canal

3 levels of hearing

peripheral: Ear transmit sounds and converts its vibrations into electrical impulses

brainstem: Is binaural (both ears)

•Permits locating the direction of a sound in space and identify the sound

cerebral cortex: Interprets the meaning of the sound and begins the appropriate response

conductive hearing loss

Involves a mechanical dysfunction of the external or middle ear.

Partial loss b/c the person is still able to hear-if the sound amplitude is increased enough to reach normal nerve elements in the inner ear

Caused by

Impacted cerumen (sair-uh-men)

Foreign bodies

Perforated tympanic membrane

Pus or serum in the middle ear

sensorineural hearing loss

Signifies pathology of the inner ear, cranial nerve VIII (vestibulocochlear) or auditory areas of the cerebral cortex

Simple increase in amplitude may not enable the person to understand words

Causes

Presbycusis (pres be q-us) (gradual nerve damage that occurs with aging)

Ototoxic drugs

clues that could indicate hearing loss

Watches lips more closely instead of eyes

Strains forward to hear

Positions head to better catch sounds

Frequently asks to the nurse to repeat themselves

Irritable or startled when the nurse raises voice

Patient's speech is garbled, inappropriately loud, or flat/monotonous tone of voice

whispered voice test

Stand 1-2 ft away

Test one ear at a time: patient pulsates on tragus of opposite ear

Shield lips and whisper

Normal is ability to repeat, may repeat test with 3/6 correct being normal

the aging adult: hearing loss

Hairs become coarse and wirey

Impacted cerumen

Decreased elasticity

Pendulous earlobes

Presbycusis

Sensorineural loss

Difficult to hear consonants

Words sound garbled

Difficult to localize sounds

otitis externa

swimmers ear

an infection of the outer ear with severe painful movement of the pinna and tragus, redness and swelling of the pinna and canal, scanty purulent discharge, scaling, itching, fever, and enlarged tender regional lymph nodes

otitis media

middle ear infection, occurs because of obstruction of the eustachian tube or passage of nasopharyngeal secretions into the middle ear