Health Assessment - Module2

General Survey

Begins during interview phase of health ass. where history is collected and has initial impression

Vital Signs

Important indicators of patient's physiological status, response to the environment

Temperature, Pulse Rate, Respiratory Rate, Blood Pressure, and pain

5 vital signs

Urgent Assessment

An assessment that is performed to address a serious and abrupt change in a patient's status

Extreme Anxiety, Acute Distress, Pallor, Cyanosis, or Mental Status Change

5 indicators of an urgent situation

Fever or Hyperthermia

Above the normal range of temperature

Hypothermia

Core body temp. is less than 35 degree

Hyperpyrexia

extremely high body temperature or fever

Pulse

The throbbing sensation that can be palpapted or auscultated caused by the contraction of the heart causes blood to flow forward creating a pressure wave

Temporal, Carotid, Apical, Brachial, Radial, Ulnar, Femoral, Popliteal, Dorsalis Pedis, Posterior Tibial

10 sites of pulses

Respiration

The act of breathing which supplies oxygen to the body and vital organs

Dyspnea

difficulty breathing

Hyperpnea

Deeper and more rapid

Apnea

absence of breathing

Hyperventilation

deep, rapid breathing which results from hypoxia, anxiety, exercise, or metabolic acidosis

Hypoventilation

Shallow, slow which related to sedation

Tachypnea

Rapid, Persistent respiratory rate greater than 24 breaths per min

Bradypnea

Less than 8-12 breath

Oxygen Saturation

the % which hemoglobin is filled with O2

Pulse Oximetry

Non invasive technique to measure oxygen saturation of arterial blodo

Blood Pressure

the pressure that is exerted by the blood against the walls of blood vessels

SBP

maximum pressure exerted on the walls of the arteries with contraction of the left ventricles

DBP

Happens when the left ventricle relaxes between beats

Age, Gender, Ethnicity, Weight, medications, Circadian Cycle, Position, Exercise, Emotions, Stress, Smoking

11 factors that affects BP

Mean Arterial Pressure

the average arterial pressure throughout one cardiac cycle, systole, and diastole

MAP = SBP + 2(DBP) / 3

MAP Formula

Cultural Variation

refers to the differences in social behaviors that different cultures exhibit around the world

Mental Status

The total expression of a person's emotional responses, mood, cognitive function, and personality

General Appearance and Behavior, Speech, Mood and Affect, Thought, Perception, Cognition, Judgement, and Insight

The 8 components of mental status

general appearance

Body build and physical appearance, physical health, grooming, hygiene, self-care, dressing, faces.

Attitude towards the examiner

Cooperative, friendly, attentive, interested, frank, seductive, defensive, apathetic, playful, evasive, guarded.

Comprehension

If the client is intact or impaired

Gait and Posture

Normal and Abnormal (Way of sitting, standing, walking, or lying)

Motor Activity

movement produced by use of the muscles

Akathisia

motor restlessness

Hallucinatory Behavior

Is the client smiling or crying without reason? Are they muttering or talking to their self?

Speech

oral expression of language

Dysphonia

Difficulty making laryngeal sounds

Aphonia

total loss of voice

Apraxia

inability to convert the intended speech

Agraphia

inability to write

Alexia

inability to understand written words

Mood

a temporary state of mind or feeling. Are they relaxed, happy, anxious, or angry?

Content of Thought

Delusions, religiosity, paranoia, magical thinking

Delusions

Unrealistic ideas or beliefs content of any delusional system

Thought Broadcasting

Thought being heard by others

Thought Insertion

Thought being inserted into persons mind by others

Confabulation

Making up of answers unrelated to facts

Echolalia

Involuntary repetition of words spoken by others

Neologism

Word coined that is meaningful only to them (own meaning of words)

Agnosia

the inability to recognize familiar objects like form and nature of objects or person

Hallucination

Unrealistic sensory perception (Might be auditory, visual, tactile, olfactory, gustatory)

Illusion

Misinterpretation of a real stimuli

Depersonalization

Altered perception of self

Derealization

Altered perception of environment

Glasgow Coma Scale

Any disturbance of consciousness should be rated on what scale?

Proverb Testing, Similarities, and Differences

3 tests or methods to measure abstract thinking

Social Judgement

Observed during the hospital stay and during the interview session

Good, Intact, Normal or Poor, Impaired, abnormal

Judgement is rated as _?

Sensorimotor Stage

in Piaget's theory, the stage (from birth to about 2 years of age) during which infants know the world mostly in terms of their sensory impressions and motor activities. THey interact with the environment

Preoperational stage

in Piaget's theory, the stage (from about 2 to 6 or 7 years of age) during which a child learns to use language but does not yet comprehend the mental operations of concrete logic. Represent the world symbolically

Concrete Operational Stage

in Piaget's theory, the stage of cognitive development (from about 6 or 7 to 11 years of age) during which children gain the mental operations that enable them to think logically about concrete events

formal operational stage

in Piaget's theory, the stage of cognitive development (normally beginning about age 12) during which people begin to think logically about abstract concepts

Pain

Unpleasant sensory and emotional experience which primarily associated with tissue damage

Bradykinin & Prostaglandin

Peripheral Nerve Endings

Acute Pain

pain that is felt suddenly from injury, disease, trauma, or surgery

Chronic Pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

Headache, Back Pain, Joint Pain, Stomach Pain, Cardiac Pain, Referred pain

6 site of pain

Based on Duration, Location, Intensity, and Etiology

4 classification of types of pain

Nociceptive and Neuropathic

2 classification of pain based on ETIOLOGY

Nociceptive Pain

experienced when an intact, properly functioning nervous system sends signals that tissues are damaged requiring attention and proper care

Somatic and VIsceral pain

2 classficiations of Nociceptive Pain

Somatic Pain

Pain that originates from skeletal muscles, ligaments, or joints.

Visceral Pain

pain originating in the internal organs in the thorax, cranium, or abdomen

Neuropathic Pain

Associated with damaged or malfunctioning nerves

Peripheral and Central Neuropathic Pain

2 types of Neuropathic Pain

Peripheral Neuropathic Pain

Pain caused by a lesion or disease of the peripheral somatosensory nervous system

Central Neuropathic Pain

Pain caused by a lesion or disease of the central somatosensory nervous system.

Precipitating or Alleviating Factors, Quality of Pain, Radiation, Severity, and Timing

the Pain assessment sequence

FLACC

Face, legs, activity, cry, and consol ability scale. Used for children with COGNITIVE IMPAIRMENT

Verbal Rating Scale, Binary Scale, and Visual Analog Scale

3 unidimensional pain instruments

Mc Gill pain questionnaire, Brief Pain Inventory, Memorial pain assessment Card

3 types of Multidimensional pain assessment