Advanced Health Assessment -- Midterm Exam

Vitals

Pulse

palpable flow felt in the periphery as a result of pressure wave generation from stroke volume; Provides indicator of rate and rhythm of heartbeat as well as

local data on condition of artery

What do you assess pulse for?

rate, rhythm, force, and elasticity

Assess pulse by…

palpating radial pulse, beats for 30 seconds x 2

if irregular, count for 60 seconds.

How long do you ascultate for apical pulse?

ALWAYS 1 minute (or 60 seconds)

Document pulse force by…

• 3+ Full, bounding

• 2+ normal

• 1+ weak, thready (ill, dehydrated, bleeding)

• 0 absent

Blood Pressure

Blood pressure (BP) is force of blood pushing
against side of its container, vessel wall

Systolic pressure

maximum pressure felt on arteryduring left ventricular contraction, or systole

Diastolic pressure

elastic recoil, or resting, pressure that blood exerts constantly between each contraction

Mean arterial pressure (MAP)

pressure forcing blood into tissues, averaged over cardiac cycle

The mean oral temperature in a resting individual is

36.5°C (97.7°F)

What is the most common and easily accessible temperature site?

oral temperature

How much higher do rectal temperatures measure than oral?

The rectal temperature measures 0.4° to 0.6°C higher than an oral measurement

Above what temperature is considered febrile?

37.8°C (100.04°F)

Factors that influence Blood Pressure

• Age (rise together)

• Sex (females lower than males premenopause and higher after)

• Race

• Social Determinants

• Diurnal rhythm (Daily peak and trough levels r/t timing cycles)

• Weight (increases with obesity)

• Exercise (increases with activity)

• Emotions (increase in response to sympathetic nervous
  system)

• Stress (increases in times of stress)

Blood pressure is determined by…

• Cardiac output

• Peripheral vascular resistance

• Volume of circulating blood

• Viscosity

• Elasticity of vessel walls

Korotkoff Sounds

fifth Korotkoff phase is now used to define diastolic pressure

Percussion

Tapping with short, sharp strokes to assess underlying structures;

maps organs, signals density, detect mass, pain

Tympany

Loud, high-pitched (abdomen). Dulls with stool impaction

Dull

soft over solid or fluid-filled structures (liver, full bladder)

Flat (percussion sound)

bones

Resonance

a low-pitched, hollow, and airy sound heard when tapping over normal, healthy lung tissue

Data clustering

organizing the data gathered during assessment by potential diagnoses

Chief Complaint

patient’s reason for visit/reason for seeking care. Direct quotes – list and prioritize if

multiple reasons

PQRSTU

a pain assessment tool

P

Provocation/Palliation (what makes it better and what makes it worse?)

Q

Quality/Quantity (how would you describe the pain? how often do you feel this pain?)

R

Region/Radiation (where is it? does it spread?)

S

Severity Scale (numeric or faces)

T

Timing (When did it start)

U

Understanding

Cutaneous pain

a sharp superficial pain

Referred pain

pain felt at a distance from the organ where the disease or
injury is occurring

Somatic pain

a deep pain associated with injury to tissues or bones

Visceral pain

pain from cramping of hollow structures or organs such as the
intestines, ureters, gall bladder, etc

Communication

• Always communicate what you’re about to do

• Consider cultural use and meaning of touch

  • Dress, food, language, music, games, literature, rituals, beliefs, communication style, handling physical space, modest

• Ask permission and/or offer agency as patients may have undisclosed history of violence or abuse

• Therapeutic Communication

Thyroid

• Straddles trachea

• Synthesizes/secretes T3, T4

• Auscultate for bruit, if enlarged

What are the main neck muscles?

sternomastoid (head rotation and flexion) and trapezius (move the shoulders and extend and turn the head)

What cranial nerve (CN) intervates the main neck muscles?

XI (the spinal accessory)

Cranial Nerve 1 (I name and test)

Olfactory

sniff test

Cranial Nerve 2 (II name and test)

Optic

Visual acuity (Snellen, peripheral fields)

• Test with or without glasses

• Cover “better” eye first with patch or card

Cranial Nerve 3 (III name and test)

Ocularmotor

Pupillary Light Reflex – PERRLA (direct & consensual, accommodation)

Eye movements (EOMs)

Medial, diagonals except medial downward

Cranial Nerve 4 (IV name and test)

Trochlear

Eye movements (EOMs)

Medial downward

Cranial nerve 5 (V name and tests)

Trigeminal

whisp test

clench jaw

Cranial Nerve 6 (VI name and test)

Abducens

Eye movements (EOMs)

Lateral

Cranial Nerve 7 (VII name and test)

Facial

Facial expressions/symmetry

Cranial Nerve 8 (VIII name and test)

Vestibulocochlear

whisper test

Cranial Nerve 9 (IX name and test)

Glossopharyngeal

Uvula and palate rise midline (say “AHHHH”)

Cranial Nerve 10 (X name and tests)

Vagus

Talking and swallowing

Cranial Nerve 11 (XI name and test)

Spinal Accessory

Shrug shoulders, turn head

Cranial Nerve 12 (XII name and tests)

Hypoglossal

Stick tongue out

“Light, tight, dynamite” (tests articulation, mobility, and coordination of the tongue)

Snellen alphabet chart

the most commonly used and accurate measure of visual acuity

Normal visual acuity is 20/20

What does 20/30 mean?

You can read at 20 feet what an average person can read at 30 feet (that’s bad)

Age related changes in visual acuity

Central acuity may decrease, particularly after 70 years of age

Peripheral vision may be diminished

Pseudoptosis (Ptosis) of the eyelid

Common in aging adults

The drooping of the eyelid onto the eyelashes

Age related changes in ocular structures

• drooping

• loss of eyebrow hair

• dry eyes (decreased tear production)

• Pingueculae (yellow deposits in sclera)

• arcus senilis

• Xanthelasma

• smaller pupils

• slower reflex to light

• opaque lens

Arcus senilis

a gray-white arc or circle around the cornea

sign of accumulated lipids

common with old age with no effect on vision

Nystagmus

a fine, oscillating movement best seen around the iris. Mild nystagmus at an extreme lateral gaze is normal; nystagmus at any other position is not

Strabismus

deviated gaze

PERRLA

Pupils

Equal

Round

React to

Light and

Accommodate

Nose assessment

• inspect external nose for symmetry

• test patency of nares (close one at a time)

• inspect nasal cavity (mucosa for color, swelling or discharge)

• observe septum for deviation

Rhinitis

Nasal mucosa is swollen and bright red

Acute rhinitis

inflamed turbinates, clear mucoid discharge

Allergic rhinitis

pale, edematous, cyanotic or gray membrane; thin, clear mucoid or watery

discharge

Deviated septum

looks like a hump or shelf in one nasal cavity

common and is not significant unless air flow is obstructed

Sinus assesment

Palpate for tenderness

Frontal (under eyebrows)

maxillary (below (not over) the cheekbone)

ethmoid (not directly palpated)

Lymph node assessment

Using a gentle circular motion of your finger pads, palpate the lymph nodes

note their location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness

Which nodes are normally palpable in healthy persons?

cervical nodes

Normal nodes

feel movable, discrete, soft, and nontender

Metastatic solid tumor cancer (in lymph nodes)

fixed, enlarged, non tender, hard, asymmetric

Atopic triad

Atopic asthma, atopic dermatitis, allergic rhinitis

Grade 1 heart murmur

very faint, barely audible

Grade 2 heart murmur

soft but clearly audible

Grade 3 heart murmur

moderately loud; easy to hear

Grade 4 heart murmur

loud with associated thrill (palpable on the chest wall)

Grade 5 heart murmur

very loud + thrill; audible with diaphragm on end

Grade 6 heart murmur

very loud + thrill; audible with stethoscope off chest

S2

Closure of semilunar valves (aortic & pulmonic)

Loudest at base, not simultaneous with pulse

End of systole

S1

Closure of AV valves

Loudest at apex, simultaneous with pulse

Beginning of systole

Peripheral Vascular (PV) assessment

• assess arms and legs

• note capillary refill (ideal < 3 seconds)

• palpate pulses (Radial, femoral, popliteal, posterior tibial, dorsalis pedis)

Left sided heart failure signs and symptoms

• cannot pump blood out to meet the demand 

• Symptoms: Rales, Cough (frothy pink tinged), Pulmonary edema 

Right sided heart failure signs and symptoms

• pump can’t fill to meet demand

• pitting peripheral edema, liver engorgement, ascites

Cor pulmonale

right-sided heart failure caused by high blood pressure in pulmonary arteries and right ventricle

Common with emphysema

How to assess JVD (jugular vein distension)

Start from supine position → turn head away from examiner → as person is raised to a sitting positioned the vein should disappear

Normal finding for JVD assessment

distention must DISAPPEAR when patient is raised from flat to 45 degrees

Abnormal finding for JVD assessment

neck vein distension persists after the patient is raised to 45 degrees

Carotid artery assessment

palpate one at a time

Auscultate with bell, holding breath

• Do not want to hear a bruit: low-pitched whooshing sound

Point of maximal impulse (PMI)

Found at the apex of the heart (Apical pulse taken here for 60 seconds)

COPD signs and symptoms

• Hyperresonance (Louder than resonance due to airtrapping)

• AP diameter closer to equal to transverse (barrel-chested)

• Diminished breath sounds

• Clubbing of fingers

• Greater than 90-degree costal angle

How do you confirm symmetric chest expansion?

• place hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

• pinch up a small fold of skin between your thumbs

• Ask the person to take a deep breath

• your thumbs should move apart symmetrically

When do diminished breath sounds occur?

emphysema, pneumonia, atelectasis, pleural effusion, or pneumothorax

What can alter breath sounds?

obstruction in the passageways or by disease in the lung parenchyma, the pleura, or the chest wall

Thorax Anatomy (normal)

• right lung is shorter (w/3 lobes) due to liver

• left lung is narrower (w/2 lobes) due to heart

Normal Pleurae

• Envelope between lungs and chest wall

• Visceral: lines outside of lungs

• Pleural cavity forms a vacuum

Normal age variants in skin and hair

• Loss of elasticity

• dry

• Senile purpura

• breakdown

• delayed wound healing and replacement

• decreased melanin (Melanocytes)

• gray, fine hair

Why do the elderly have dry skin?

Decreased in number and function of sweat/sebaceous glands

Senile purpura

discoloration due to increasing capillary fragility

ABCDEF warning signs of skin cance

• Asymmetry

• Border irregularity

• Color variations

• Diameter great than 6 mm

• Evolution (change over time) or elevation (raised?)

• Funny looking

Hematoma

palpable bruise

Leakage of blood in a confined space caused by a break in a blood vessel

Hematomas are abnormal if…

• There is bruising over soft tissue areas of the body in the absence of injury 

• There are multiple bruises on the body in various stages of healing

Skin Turgor

skin elasticity, should not tent