Health Assesment Exam 2(March 2nd)

50 Questions Total. Respiratory = 14. Nose/Mouth/Throat = 6. Ears = 5. Nutrition= 14. Integumentary = 11

Don’t listen to lungs over scapulas

Breathing

• Automatic

• Controlled by the respiratory center in the brainstem

Diaphragm

• Primary muscle of breathing

Inspiration

• Muscles contract, thorax expands

Expiration

• Muscles relax, thorax contracts

Accessory Muscles

• Sternocleidomastoids

• Scalenes

• Abdominal muscles

Dyspnea

• Shortness of breath

Wheezing

• Airway obstruction, inflammation, asthma

Cough

• Heart failure, infection (pneumonia)

• Medications

Sputum

• Blood-streaked sputum (hemoptysis), purulent sputum

Chest Pain

• Cardiac, aortic aneurysm (dissection), GI, musculoskeletal, anxiety

Health History Respiratory(Past)

• Get past history any surgeries, prior problems, allergies, traveled outside US, etc

Health History Respiratory(Family)

• Current respiratory infection or disease

• Lung cancer

• Asthma

• Cystic fibrosis

• Tobacco use

Health History Respiratory(Lifestyle/habits)

• Tobacco products, recreational drugs

• Exposure to second-hand smoke

• Exposure to environmental hazards

• Use of oxygen, nebulizers, and the like for

breathing difficulties

Physical Examination(Inspection)

• Right when u walk into patient room!

• Rate, rhythm, depth, and effort of breathing

• Facial expression

• Level of consciousness

• Assess patient’s skin color

• Listen to patient’s breathing

• Inspect the neck

• Observe and inspect shape of chest

• Deformities (funnel, barrel, pigeon, trauma, scoliosis), retractions

Cyanosis

• Bluish or greyish color of skin, lips, or fingernails

Physical Examination(Palpation)

• Tender areas? (trauma, fractured rib(s)?

  • Abnormalities

  • Chest expansion

  • Tactile fremitus

  • Compare symmetric areas

Barrel Chest

• Normal aging and hyperinflation

  of lungs

• AP diameter is significantly greater in patients with COPD(Chronic Obstructive Pulmonary Disease)

Pectus Excavatum

• Usually not symptomatic

• Body image concern

• Sunken or funnel chest

Pectus Carinatum

• Usually not symptomatic

• Body image concern

• Pigeon chest

Sciolosis

• May reduce lung volume

Kyphosis

• Potential for respiratory system

  compromise (usually not)

Unequal chest expansion occurs with:

• Marked atelectasis

• Lobar pneumonia

• Pleural effusion

• Thoracic trauma

• Pneumothorax

Chest Percussions(flatness)

• Intensity = Soft

• High pitched

• Short duration

• Location in thigh

Chest Percussions(dullness)

• Intensity = meduim

• Medium pitched

• Medium duration

• Location in liver

Chest Percussions(resonance)

• Intensity = loud

• Low pitched

• Duration = long

• In healthy lung

Chest Percussions(hyperresonance)

• Intensity = loud

• Lower pitched

• Duration = longer

• Location = usually none

Tympany

• Intensity = loud

• High pitched

• Duration = longer

• Location = gastric air bubble or pulled-out cheek

Auscultation

• Listen to sounds generated by breathing(say 99)

• Listen for any adventitious sounds

• Listen to sounds of spoken word through chest wall if any abnormality is suspected

Difference between normal CXR and abnormal CXR

• Normal- Full of air and black in the background, bones are white in color, fluid/blood are white in color

• Abnormal- Lungs are clouding and white color, can’t see black in the background

Bronchial breathing sounds

• Location: Trachea and larynx

• Expiratory last longer than inspiratory ones

• Loud

• Relatively high pitched

• Over the manubrium is heard at all

Bronchiovesicular

• Inspiratory and expiratory sounds are equal

• intermediate sound

• intermediate pitched

• Often in first and second intercostal spaces anteriorly and between scapulae

Vesicular

• Soft sound

• Relatively low pitched

• Over most of both lungs, peripheral lung fields

Auscultate the Chest for Breath Sounds

• Instruct person to breathe through mouth

• Use diaphragm of stethoscope and hold it firmly on patient's chest wall

• Listen to at least one full respiration in each location

• Have patient cough in attempt to clear sounds, if needed

• Side-to-side comparison is most important

• Do not confuse background noise with lung sounds tubing, hairy chest, clothing or table paper, tubing

Adventitious Breath Sounds, added(Crackles/ rales)

• Discontinuous and nonmusical sounds

Discontinous

• Intermittent, nonmusical, and brief

• Like dots in time

• Fine crackles: soft, high-pitched,

  very brief (5 to 10 msec)

• Coarse crackles: somewhat louder,

  lower in pitch, brief (20 to 30

  msec)

Continous sounds

• Wheezes: musical, relatively high

  pitched, with hissing or

  shrill quality

• Rhonchi: relative low pitched, with snoring quality

Pulse oximetry

• Healthy person has an SpO2 of 95% to 100%

• Oximeter compares the amount of light emitted to

  the amount absorbed and calculates the percentage

  of oxygen saturation

• Probe is placed on the patient’s finger or earlobe

  - Toe is used for infants and young children

Poor perfusion, hypotension, dyes in some nail polishes, and excessive ambient light may cause inaccurate readings.

Nasal Cannula

• Patients on long term oxygen therapy most commonly use this

• Allows speech and eating/drinking and nonclaustraphobic

• FIO2 always goes up 3%

• Room air = 21% FIO2

• People wear this who have a lung disease

Physical assesment on infants/children

• Normal: No flaring of nostrils, no sternal retractions, no intercostal retractions occur

• Abnormal: Flared nostrils, sternal retractions, intercostal retractions

• Rates for newborn: 30 to 60 per minute

• Use smaller pediatric diaphragm end piece or place bell over infants interspaces, not over ribs

• Observe abdomen bugler with each inspiration

• Assess when infants are first born, first 3 months babies breath through nose

• Count respiratory rate for infant for full minute and normal rate for newborn 30 to 60 per minute

Peak Flow Assesment(on test)

• Assesses the maximum volume of air expelled from the lungs during a vigorous exhalation

• Decrease in flow volume = diseases that reduce outflow of air

  (asthma)

• Can be accurately performed by most people over 5 years

of age

• Peak flow = expiration

• Teach patient to use take deep breath in and then out and ball will go up to peak flow meter

Vulnerable groups( for undernutrition)

Infants, children, pregnant women, recent immigrants, older adults, hospitilized pwoplw, nd people with low incomes

• Impaired growth and development

• Lowered reisstance to infection/disease

• Delayed wound healing

• Longer hospital stays and higher HC costs

Concerns in Undernutrition

• 5% od body weight lost in 6-12 months

Over nutrition and weight gain

• Caloric intake exceeds caloric

expenditure over time

• Reduced body metabolism

• Abnormal accumulation of body fluids

• Depression, eating disorders

Over hydration

• Heart failure

• Kidney failure

• Liver disease

• Increased sodium intake

• Excess IV fluid

Dehydration

• Exposure to excessive heat

• Exercise in heat

• Decreased mobility

• Inability to drink

• Medications

• Vomiting/diarrhea

• Burn injuries

• Hemorrhage

Health History(nutrition)

Review:

• Weight changes

• Fatigue

• Allergies

• Problems with any system

Health patterns

• Nutrition

• Exercise patterns

Changes in Weight

Consider time frame in weight loss

or weight gain

• OLD CART

• Ask about food allergies or intolerances

• Ask about family chronic illnesses

• Food intake record

Body Mass Index (BMI)

• Uses measurements of height and

  weight

Underweight

• < 18.5

Normal weight

• 18.5-24.9

Overweight

• 15-29.9

Obesity 1 and 2

• Obesity 1:30-34.9

• Obesity 2: 35.0-39.9

Extreme Obesity

• ≥ 40

Waist to hip ratio

• For athletes, since BMI does not take muscle mass into consideration

Skin, hair, nails

Protein needed

• Skin: dryness, flaking, cracking, sores

• Skin turgor: tenting indicates dehydration

• Hair texture: thinning, loss of color

• Nail shape or brittleness

Head, ears, eyes, nose, throat

• Dark circles under eyes indicate anemia(b12 or folacle deficiency)

• Mucous membranes: dryness, color, intactness, cracking in corner of mouth

• Enlarged thyroid(goiter) indicates iodine deficiency(in salt, not seen much in US)

Cardiovascular and Peripheral Vascular

• BP and pulse (dehydration = LBP, pulse goes up; over hydration = HBP, pulse goes up)

• Vein observations (dehydration: hard to find vein: over hydration: easy to find vein)

• Capillary refill

• Jugular distention

• Inspect for edema(swelling)

• Petechiae and ecchymosis(bruise)- vitamn k needed

Gastrointestinal

• Inspect for distention- leaking fluid goes into peritoneal around organs to get excess fluid(ascites) with severe protein deficiency(kwashiorkor)

Musculoskeletal

• Muscle wasting- protein deficiency

Vitamin deficiency

• Bone pain, bowing of tibia, osteomalacia- Vitamin D deficiency

• Marasmus: severe calorie deficiency

Neurologic

Parenthesias- Tickling, tingling, pricking, burning numming at ends of fingers and toes

• Inability to concentrate

• Irritability

• Mental status

Recommendations for Healthy Eating Patterns

• Limit saturated and

trans fats

• Limit added sugars

• Limit sodium intake

• Drink alcoholic beverages only in moderation

• Maintain moderate physical activity

Structure of skin

• Epidermis(does not have blood flow, relys on dermis and subq to feed it)

• Dermis

• Subcq

Glands

• Sebaceous glands- present on all skin surfaces except palm and soles of feet. Lubricate hair and skin. produces oil through hair follicles.

• Sweat glands(found everywhere on skin)- Stimulated by stress

• Eccrine- Help control body temp(body odor)

Functions of skin

• Protection

• Temp regulation

• Sensation

• Vitamin D production

• Immunity

• Absorption and excretion(any topical medication)

• Storage

Blood vessels in the skin dilate to dissipate heat

True

Health History(integumentary)

• Disease of the skin

• Systemic diseases(what is now causing skin disorder)

• Physical abuse

• Risk for pressure injury

• Risk for skin cancer

• Need for health promotion

• Use OLDCART!

Common/concernign symptoms

• Rash: Nonhealing lesions, moles(Nevus), growths

• Lesions: Bruising(ecchymosis), hair loss, nail changes

Assesment(color)

• Check color of skin, look for increased/loss of pigmentation, redness of skin

• Assess for cyanosis(blue color- loss of oxygen), or pallor(sudden loss of color in skin-pale, white, grayish)

• Assess for jaundice- yellow discoloration due to increased bilirubin in blood(check eyes)(could have liver disease or gallbladder issue)

Skin pigmentation

• Melanin- Brown pigment genetically determined(produced with sun exposure)

• Carotene- Golden yellow exists in SQ fat(shows more on soles of feet and palms of hands)

Oxyhemoglobin

Bright red pigmentation predominates in areas with arteries and capillaries blood flow causes reddening(exercise, fever, alc)

Deoxyhemoglobin

• Draker, blue color

• Central cyanosis- Blueish lips

• Peripheral cyanosis- blue discoloration on tips of fingers

Cyanosis

• Bluish or purplish sicolration of skin due to low levels of oxygen in blood

• Dark-skinned people, cyanosis looks white or grey

• Causes: Severe respiratory disorders, congential heart defects, severe infections like sepsis

Cafe-au-lait spot

• Collection of melanocytes-may grow(looks like a bigger birthmark)

Vitiligo

• Melanocytes stop producing melanin(loss of skin color)

• Could be autoimmune or genetic

Tinea versicolor

• Superficial fungal infection = hypopigmentation

• Similar to vitiligo, but temporary

• Caused by moisture

Acanthosis nigricans

• In body folds/creases- insulin resistant(in the neck or groin)

• Found in most overweight, or pre-diabetic/diabetic patients

Check moisture/temp of skin

Moisture

• Should be dry to touch without flaking or cracking

• Carefully inspect skin folds

Temp

• Use back of hand

• Note areas of increased temp with erythema

• Note if warm or cool

Texture of skin

• Roughness or smoothness

• Check tugor of older people through chest wall

• Lift fold of skin

• Ease with which it lifts- mobility

• Speed it returns into place

Turgor

• Skin with decreased turgor remains elevated after being pulled up and released

Atopic Dermatitis(eczema)

• Inflammatory skin condition

• Their are 7 types

• Genetics, environmental, mmune system, stress

• Common sites: Hands, neck, inner elbows and ankles, knees, around eye

Keloid

• Resulted from abnormal wound healing in response to skin trauma or inflammation

• Can also happen from genetic and environmental factors

• Higher incidences are seen in darker skinned individuals of African, Asian, and Hispanic descent

Psoriasis

• Chronic disease in which the immune system becomes overactive, causing skin cells to multiply too quickly

• Patches of skin become scaly and inflamed, most often on scalp, elbows, or knees

Edema

• Localized: injury

• Systemic: most often in the dependent portions of body

• Pitting: interstitial fluid mobile

• Nonpitting: local infection or trauma; brawny edema

• +1: nail goes 2mm depression, barely decteble, immediate rebound

• +2: nail goes 4mm depression, < 15 sec to rebound

• +3: nail goes 6mm deep pit, up to 30 sec to rebound

• +4 nail goes 8mm very deep pit, > 30 to rebound

Assessment of lesions

• Color of lesions – is it uniform in color or variegated (multiple changes in color)

• Size – in mm or cm

• Elevation – flat = cannot palpate with eyes closed

• Number of lesions– solitary or multiple

• Texture – scaling or smooth

Diff types of lesions

• Macule – flat, colored spot on skin (freckle, flat mole)

• Papule – small bump or pimple (acne) less than 1 cm

• Vesicle – small blister containing serous fluid (ezcema, chicken pox)

• Nevus – mole or birthmark

Primary lesions

Primary – initial lesions/abnormal growth

• Occur as initial reactions to the internal or external environment.

• Flat – macules or patches

• Fluid filled = Vesicles, bullae, and pustules, and burrows

• Solid masses = Nodules, cyst, papules, wheals, and plaques are

palpable

Secondary lesions

Secondary – arise from primary lesions

• Brought about by modification of the primary lesion either by the individual with the lesion or through the natural evolution of the lesion in the environment

• Scales, crusts, excoriations, erosions, ulcers, fissures, scars,

lichenification, and keloids.

Acne vulgaris

Caused by:

• Proliferation of keratinocytes

• Increased production of sebum

• Combine to form plug

• Bacterial growth causes increased inflammation

Contributing factors:

• Cosmetics

• Humidity

• Heavy sweating

• Stress

Vascular lesions

Common abnormalities of the skin

• Spider angioma- dilated blood vessels

• Spider vein- damaged blood vessels

• Cherry angioma- dilated capillaries

Purpuric lesions

Discoloration of the skin or mucous

membranes produced by bleeding outside of vessels

• Petechia & purpura- bleeding disorder

• Ecchymosis- local trauma

Lesion patterns/shapes

• Linear- lesions in straight line

• Confluent- lesions run together

• Geographic - resemble map

• Target - bulls eye

• Clustered- grouped

• Zosteriform- follow a nerve root

• Serpiginous- appear to creep; wavy or serpentine border

• Annular/arciform- circular shape

Pressure injuries

• Localized damage to skin and underlying

tissue that occurs over a bony prominence or is related to the use of a medical device

• Acute or chronic

• Soft tissue is compressed between a bony prominence and an external surface

• Soft tissue undergoes pressure in combination with shear and/or friction

Bradens scale

Stages of skin

1. skin is unbroken but inflamed

2. skin is broken to epidermis or dermis

3. Ulcer expands to subcutaneous fat layer

Assessing hair

• Note quantity, distribution, and texture

• Inspect the scalp for lesions, flaking, and parasites

• Inspect body, axillae, and pubic hair.

Changes

• Loss of hair on legs: peripheral artery disease

• Changes in pubic or axilla: hormonal problems

• Inquire about laser hair removal treatments

Diff types of hair texture

• Terminal: coarser, thicker, conspicuous, usually pigmented

• Vellus: short, fine, nconspicuous, unpigmented

Alopecia Areata

• Clearly demarcated round or oval patches of hair loss, usually affecting young adults and children. There is no visible scaling or inflammation.

Trichotillomania

• Hair loss from pulling, plucking, or twisting hair. Hair shafts are broken and of varying lengths. More common in children, often in settings of famoly or psychosocial stress