health assessment exam 1

~~subjective and objective data~~

2

subjective data

anything patient says

objective data

measurement, auscultation, touch, inspection, percussion (MATIP)

supplemental data

client records, lab data, radiographic studies

objective data may be impacted by…

Open ended question, location of symptom, description of the symptom, timing, aggravating factors

objective data may be impacted by…

mental status, comfort, quality of questioning, communication, emotion

objective data may be impacted by…

accuracy of measuring devices

skill of examiner

integrity of examiner senses

ability of patient to withstand examining

~~Vital signs~~

3

weight children significant loss

>5% 1 month

>10% 6 months

weight children index

>85th: overweight

>95th: obese

adult weight cause for concern

>4.5kg 1 month

temperature normal range

98.6~100.4 F

pulse normal range

60~100

resp normal range

12~20

BP pre-hypertension

120~129/~80

BP hypertension stage 1

130~139/80~89

hypertension stage 2

140+/90+

medication for hypertension when?

at stage 2 (140+/90+)

medication for hypertension when if co-morbid?

at stage 1 (130~139/80~89)

age 60+ hypertension

not treated until 150+

UNLESS co-morbid

hypertensive crisis

>180/120 WITH SYMPTOMS

hypertensive crisis symptoms

chest pain

shortness of breath

severe headache/dizziness

vision changes

numbness/difficulty speaking

severe back pain

what to look for when hypotension?

MAP (mean arterial pressure)

MAP normal range

above 50

~~patient interview~~

5

a complete patient interview includes

Age

previous illness

surgical history

Medications history

family medical history

Allergies

Patient Identification

Chief Complaint

History of Present Illness

Surgical History, Family History, Social History

Review of Systems

during patient interview, nurses should NOT:

Give Advice

Ask biased Questions

Express false Reassurance

Use “Why Questions”

facilitation

responses designed to facilitate more information sharing

reflection

Repeating a portion of a clients statement in order to gain greater meaning "you say your getting tired of my lecture?”

clarification

Asking the client to expand on a topic to increase your understanding

empathetic responses

“I understand how you feel”

“that must be hard for you”

confrontation

Some issues or responses may require you to confront patients about their feelings

interpretation

A conclusion reached based on evidence and reasoning

~~health history~~

2

components of health history interview

Biographic Data (Patient Identification)

Allergies

Medications

Chief Complaint (CC)

History of Present Illness (HPI)

Past Medical History (PMH)

Past Surgical History (PSH)

Family History (FH)

Social History (SH)

Review of Systems (ROS)

History of Present Illness (HPI)

OLDCARTS

onset

location

duration

characteristics

aggravating and alleviating factors

radiation

temporal factors

severity

~~review of systems~~

1

review of systems

• Constitutional/General OverallHealth State

• Head, Ears, Eyes, Nose, Throat(HEENT) & Neck

• Skin (Derm)

• Respiratory

• Cardiovascular

• Gastrointestinal

• Musculoskeletal

• Neurological

~~Head, ear, nose, neck, mouth, throat~~

4

PQRST

• Precipitating or palliative (what brings it on)

• Quality or quantity (mild, sharp)

• Region or radiation (where?)

• Severity scale

• Timing

head assessment

• Inspect head and scalp

• Inspect face

• Palpate head

• Palpate face for Maxillary, frontal sinuses, and check for TMJ

• Palpate masseter muscle strength CN V (Trigeminal):

• Facial sensation CN V(Trigeminal)

• Facial symmetry CN VII (Facial)

neck assessment

• position of trachea

• palpate thyroid

• carotid pulses

• lymph nodes

• muscle mass/strength CN XI

thyroid assessment

posterior or anterior approach

head normal

• skull feels symmetric and smooth

• Cranial bones have normal protrusions

• no tenderness to palpation

• temporomandibular(TMJ) joint: smooth movement with no limitation or tenderness or crepitus (popping)

• maxillary & frontal sinuses has no tenderness/pain

lymph nodes normal

movable,soft, nontender

cranial nerve for swallowing?

CN IX, X

Presbycusis

age-related hearing loss

move adult pinna

up and back

move child pinna

straight down

whispered voice test CN

CN VIII

decreased saliva?

NOT normal with aging—anticholinergic effect of medication

epistaxis

nosebleed

smell CN

CN I

polyps

benign, may grow inside nose due to allergies

tongue movement CN

CN XII

tonsil grade 1

visible

tonsil grade 2

halfway between tonsillar pillars and uvula

tonsil grade 3

touching uvula

tonsil grade 4

touching each other

~~Thorax and lungs~~

11

1

anterior axillary line

2

midclavicular line

3

midsternal line

4

scapular line

5

vertebral line

6

anterior axillary line

7

posterior axillary line

8

midaxillary line

pediatric respiratory

lack surfactant to keep alveoli open

pregnancy respiratory

elevated diaphragm, widened thoracic cavity

aging adults respiratory

less elasticity in sternal cartilage

more fracture during CPR

pack-year

packs per day x how many years

O2 normal levels

97~98%

clubbing fingernails

chronic hypoxemia

barrel chest

chronic lung disease

Pectus carinatum

sternum sticks out like pigeon chest

pectus excavatum

sternum is dished in

tactile fremitus

palpate both sides of the chest, comparing density

lung percussion normal findings

• dull over scapulae

• Dull over heart on left

• Dull on right over liver

Diaphragmatic excursion

patient inhale & exhale, percuss and compare resonant and dull areas on both sides

pneumothorax

air in pleural space

effusion

serous fluid in the pleural space

hemothorax

blood in the pleural space

empyema

pus in the pleural space

~~cardiac and pulmonary vasculature~~

10

AV valve

tricuspid & mitral

SL valve

aortic & pulmonary

right AV valve

tRicuspid

left AV valve

mitraL

which is thicker: atrium or ventricles

ventricles

thickest heart chamber

left ventricle

what happens during diastole

ventricles relax and fill with blood

what happens during systole

heart contracts

blood leaves ventricles and travel through arteries

what happens during s1

lub

close AV valves

beginning of systole

what happens during s2

dub

close SL valves

end of systole

s3 & s4

abnormal

when is s3?

after s2

why s3 happens?

ventricles are resistant to filling (ventricular gallop)

when is s4?

before s1

why does s4 happen?

atrial gallop