Health Assessment Exam 1

Health Assessment

A systematic method of collecting and analyzing data to make clinical judgments about a patient's health status.

Subjective Data

Information reported by the patient (e.g., pain, dizziness, nausea).

Objective Data

Information observed or measured by the nurse (e.g., vital signs, lab results, physical findings).

Complete Health Assessment

Full health history and physical exam; used in primary care or admission settings.

Focused Health Assessment

Targets a specific problem (e.g., chest pain, shortness of breath).

Follow-up Health Assessment

Reassessment of a previously identified problem.

Emergency Health Assessment

Rapid collection of crucial information in life-threatening situations.

Nursing Process

A series of steps including Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Physical Examination Techniques

Methods used to assess a patient including Inspection, Palpation, Percussion, and Auscultation.

Inspection

Observing appearance, posture, and movements.

Palpation

Using touch to assess texture, temperature, moisture, swelling, tenderness.

Percussion

Tapping body parts to assess underlying structures.

Auscultation

Listening to body sounds (e.g., heart, lungs, bowel).

First-level priority

Life-threatening conditions (e.g., airway obstruction, severe respiratory distress).

Second-level priority

Needs requiring prompt intervention (e.g., acute pain, abnormal lab values).

Third-level priority

Important but not urgent (e.g., patient education, emotional support).

ABC framework

A prioritization method focusing on Airway, Breathing, and Circulation.

Cultural Assessment

A systematic approach to understanding a patient's cultural beliefs, values, and health practices.

Importance of Cultural Assessment

Enhances patient trust and communication, prevents errors due to cultural misunderstandings, and ensures culturally competent care.

Key Components of Cultural Assessment

Health beliefs and practices, communication styles and language, family roles and social structures, religious and spiritual beliefs, dietary preferences.

Social Determinants of Health (SDOH)

Factors that influence health outcomes, including economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

Impact of SDOH on Health

Lower-income individuals may have limited access to health care, language barriers can lead to misunderstandings in care, and poor housing and unsafe environments contribute to health disparities.

Verbal & Nonverbal Communication

Includes active listening, open-ended vs. closed-ended questions, awareness of body language, and use of professional interpreters.

Barriers to Effective Communication

Language differences, cultural misinterpretations, and health literacy limitations.

Cultural Competence in Nursing

The ability to understand, communicate with, and effectively interact with people across cultures.

Cultural Awareness

Recognizing one's own cultural background and biases.

Cultural Knowledge

Learning about different cultural practices and worldviews.

Cultural Skill

Conducting accurate cultural assessments.

Cultural Encounter

Engaging in direct cross-cultural interactions.

Mental Status Assessment

Mental status refers to a person's emotional and cognitive functioning.

Factors Affecting Mental Status

Biologic, environmental, and sociodemographic influences; traumatic life events, such as bereavement; mental disorders, including organic (e.g., dementia) and psychiatric disorders (e.g., schizophrenia).

Components of Mental Status Examination

A-B-C-T: Appearance, Behavior, Cognition, Thought Processes.

Appearance

Posture, body movements, dress, grooming, and hygiene.

Behavior

Level of consciousness, facial expression, speech, mood, and affect.

Cognition

Orientation (time, place, person); attention span, recent and remote memory, new learning ability.

Thought Processes

Thought content, perceptions, and logical thinking.

Face Assessment

Evaluate for symmetry (eyebrows, palpebral fissures, nasolabial folds, mouth corners), facial expression, and involuntary movements.

Neck Assessment

Assess head position, trachea alignment, and thyroid gland; palpate lymph nodes for size, shape, mobility, tenderness.

Visual Acuity Tests

Snellen Chart (distance vision) and Rosenbaum Chart (near vision); refer if vision is poorer than 20/30.

Eyebrows Assessment

Symmetry, lesions, scaling.

Eyelids & Lashes Assessment

Proper closure, no ptosis, lashes evenly distributed.

Conjunctiva Assessment

Transparent, no redness or swelling.

Sclera Assessment

White or slightly gray-blue in darker skin tones.

Cornea Assessment

Smooth and clear, no opacities.

Iris Assessment

Round, evenly colored.

Pupillary Assessment (PERRLA)

Pupils Equal, Round, React to Light (direct & consensual), and Accommodation (near vision adjustment).

External Ear Assessment

Assess size, symmetry, skin condition.

External Auditory Meatus Assessment

Check for redness, swelling, cerumen.

Whisper Test

1-2 feet away, patient repeats 4/6 whispered items correctly.

Tuning Fork Tests

Weber (lateralization) & Rinne (AC>BC).

External Nose Assessment

Symmetry, midline placement, skin lesions, patency of nostrils.

Sinus Assessment

Palpate frontal and maxillary sinuses for tenderness.

Lips Assessment

Color, moisture, cracking, lesions.

Teeth and Gums Assessment

Alignment, decay, gingival health.

Tongue Assessment

Color, texture, symmetry, moisture.

Buccal Mucosa Assessment

Color, moisture, lesions.

Tonsils Grading

1+ Visible, 2+ Halfway between tonsillar pillars and uvula, 3+ Touching the uvula, 4+ Touching each other.

Posterior Pharynx Assessment

Color, presence of exudate, gag reflex.

Skin

Largest organ in the body, functions include protection, temperature regulation, sensory perception, absorption & excretion, vitamin D production, communication & identification.

Hair

Assess for color, texture, distribution, and lesions.

Nails

Assess for shape, contour, color, consistency, and capillary refill.

Pallor

Loss of color, may indicate anemia.

Erythema

Redness due to excess blood in capillaries.

Cyanosis

Bluish color, indicates decreased oxygenation.

Jaundice

Yellowing, indicates rising bilirubin levels.

Temperature

Use back of hands, skin should be warm.

Moisture

Check for dryness, diaphoresis (excess sweating).

Texture & Thickness

Smooth, even, normal thickness.

Turgor

Pinch skin to assess hydration status.

Edema

Pitting (graded 1+ to 4+) vs. non-pitting.

Vascularity & Bruising

Petechiae, purpura, ecchymosis.

Lesions

Assess color, elevation, pattern, size, location, exudate.

Macule

Flat, <1 cm (e.g., freckles).

Patch

Flat, >1 cm.

Papule

Elevated, <1 cm (e.g., mole).

Plaque

Papules coalescing, >1 cm.

Wheal

Raised, red, transient (e.g., hives).

Vesicle

Fluid-filled, <1 cm (e.g., blister).

Bulla

Fluid-filled, >1 cm.

Pustule

Pus-filled, circumscribed (e.g., acne).

Crust

Dried exudate.

Scale

Flakes of dead skin.

Fissure

Linear crack.

Ulcer

Deep tissue loss.

Scar

Permanent fibrotic change.

Keloid

Overgrown scar tissue.

ABCDEF Rule

A - Asymmetry, B - Border irregularity, C - Color variation, D - Diameter >6mm, E - Elevation/Evolution, F - Funny-looking (different from others).

Stage 1 Pressure Injury

Non-blanchable erythema.

Stage 2 Pressure Injury

Partial-thickness skin loss.

Stage 3 Pressure Injury

Full-thickness skin loss.

Stage 4 Pressure Injury

Full-thickness skin loss with exposed bone, muscle, or tendon.

Braden Scale

Predicts pressure injury risk based on sensory perception, moisture, activity, mobility, nutrition, friction & shear.

Normal Capillary Refill

Return to normal color in 5 seconds.

High Risk Braden Scale Score

A score ≤12 indicates high risk.

Good lighting

Ensure adequate illumination for assessment.

Patient positioning

Position the patient supine with knees bent for comfort.

Warm hands & stethoscope

Warmth is necessary before starting the assessment.

Contour

Ranges from flat to rounded; check for distention.

Symmetry

Observe for bulging, visible masses, or asymmetric shape.

Umbilicus

Should be midline, with no discoloration, inflammation, or hernia.