Exam 1 Health Assessment

subjective datå

information that is provided by the patient (eg. what they tell you, health history, etc.)

objective data

actual information obtained from assessing the patient (vitals, diagnosis, etc)

Health promotion

Behavior motivated by the desire to increase well-being and actualize human health potential

Health protection

Behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within its constraints

Open-ended questions

“What brings you into the clinic today?”

• Encourage a free-flowing, open response

• Allows patients to describe their health in

their own words

Directive questions/ close-ended

Is your pain sharp, dull, or aching?”

• Also called closed-ended questions

• Leads patients to focus on specific

aspects of their health

Inspection

Examine visually

Palpation

Feel texture, size, shape, consistency, pulsation, and location of body parts

Percussion

Evaluate internal organs, detect tenderness, determine extent of body cavity fluid

Tones: tympany, resonance, hyperresonance, dullness, flatness

Auscultation

Listen to sounds within the body

Characteristics: intensity, pitch, duration, and quality

Spirituality

“A search for the sacred”

CAGE assessment

Cut down, Annoyed, Guilty, Eye-opener

primary screening tool used when a patient reports heavy or regular drinking (such as consuming 6 beers every night) to evaluate for potential alcohol abuse or dependence

TEMPERATURE

regulated by the hypothalamus

lowest temps found in early morning, highest in late afternoon and early evening

Temperature Ranges

Normal range: 96.4°F to 99.1°F (35.8°C–37.3°C)

Average: 98.6°F (37°C)

Temperature Routes

Oral (most common)

Temporal artery

Tympanic membrane

Axillary

Rectal (most accurate)

Heart rate

assessed through palpation

Rate: number of pulsations felt in 1 minute

-If pulse feels regular, can count for 30 seconds and

multiply by 2

- If pulse feels irregular, count for a full minute

Heart Rate Ranges

Normal adult rate range: 60-100 bpm

- Tachycardia: HR > 100 bpm

- Bradycardia: HR < 60 bpm

Respiratory rate

Ventilatory cycles completed in one minute (full expiration and inspiration = 1)

- Influenced by fever, anxiety, exercise, altitude

If regular, count for 30 seconds x2

- If irregular, count for 1 minute

Respiratory rate Ranges

Normal adult range: 12-20 (breaths/min)

Oxygen saturation

Can measure via finger (most common), toes, earlobe, nose, forehead

Blood pressure

Force of blood against arterial walls (CO x PR) = BP

Measurement: millimeters of mercury (mm Hg)

- Reflects the relationship between cardiac

output and peripheral resistance

Expect a systolic BP 10-40 mmHg higher in the leg**

Cardiac output

volume of blood ejected from the heart each minute

Peripheral resistance

force that opposes flowof blood through the vessels

Systolic Blood Pressure:

Pressure in arteries when the heart contracts (ventricles squeeze). Indicates how much pressure blood exerts on artery walls during a heartbeat.

Diastolic Blood Pressure

Pressure in arteries when the heart relaxes (between beats). Reflects how well the arteries maintain pressure in between heartbeats.

Normal Blood Pressure

120/80

Elevated Blood Pressure

120-129/<80

Hypertension Stage 1

130-139/80-89

Hypertension Stage 2

140/90

Hypertensive Crisis

180/120

Orthostatic hypotension

Blood pressure measured in a sequence of lying, sitting, and standing
Systolic BP decreases ≥ 20 mmHg OR

Diastolic BP decreases ≥ 10 mmHg

Within 3 minutes of standing

May be accompanied by dizziness, lightheadedness, and syncope

False Highs

• legs crossed

• arm below level of heart

• cuff too small or narrow

• cuff too loose/uneven

• deflating cuff slower than 2-3 mmHg per second

• failing to wait 1-2 mins before next measurement

False Lows

arm above heart level

cuff too wide

deflating cuff to faster than 2-3 mmHg per second

Pressing diaphragm of stethoscope too firmly

Threshold

point at which stimulus is perceived as pain

Tolerance

duration or intensity of pain that a person endures or tolerates before responding outwardly

Acute

lasting less than 6 months

Persistent/Chronic

lasting longer than 6 months

Nociceptive: Somatic Pain

comes from the bones, joints, muscles, skin, or other connective tissues

Nociceptive: Visceral Pain

originates from the internal organs located in the chest, abdomen, or pelvis

Neuropathic Pain

results from injury or malfunction of the nerves or nervous system itself, rather than from direct damage to body tissues like muscles or skin

OLDCART

Onset- When did it begin?

Location- Where?

Duration - Constant or comes and goes?

Characteristics- What does it feel like?

Aggravating Factors- What makes it worse?

Related Symptoms- Any other symptoms?

Treatment- What have you done to treat it?

Obesity

BMI greater than 30

Overweight

BMI greater than 25

Extreme Obesity

BMI greater than 40

Hyperlipidemia

Elevated blood levels of cholesterol and triglycerides

Protein-calorie malnutrition

Most common form of undernutrition

Vitamin A deficiency

impaired vision

protein deficiency

Hypopigmented hair and abdominal edema

Findings of Acute Pain

 Increased heart rate

Increased blood pressure

Changes in respiratory rate

Facial grimacing

Food Dairy

everything the patient eats and drinks over the next several days.

Routine nutritional examination

Measure height and weight.

Inspect the oral cavity.

Inspect the hair and nails.

Inspect and palpate the skin.

evaluating an older adult's nutritional status

Assess for unintentional weight loss.

Nutrition assessment is similar to other adults.

Conduct functional assessments.

evaluating an Infants and children nutritional status

Assess feeding patterns and body weight.

Plot weight, length, and head circumference on a growth chart.

Observe for rooting reflex, effective suck effort, and swallowing in infants.

Observe for tooth decay in children.

components of a mental status assessment

Orientation

Memory

Calculation ability

Judgment and reasoning

Abstract reasoning

Intake recall

24-hour intake recall

evaluating and adolescent’s nutritional status

Collect data on dietary intake.

Ask about perceptions of current weight and behaviors associated with eating

disorders.

Goniometer

measures ROM and joint angles

Skinfold Caliper

used during a nutritional assessment to measure subcutaneous fat thickness and estimate overall body fat

Woodlamp

light source (black light or UV) for skin inspection to identify dermatologic conditions

Ophthalmoscope

lightened magnifying lens used to inspect eye

Otoscope

magnifying lens used to inspect the ear internally

Tuning Fork

used during physical and neurological exams to evaluate auditory hearing conduction or vibratory perception

Doppler

ultrasonic stethoscope device used to detect and amplify blood flow or peripheral pulses that are difficult to palpate manually

Monofilament

used to evaluate peripheral tactile sensation and touch perception

Transilluminator

strong light source shone through body tissues to evaluate the density of a body cavity or distinguish between fluid, air, and solid masses