Health Assessment Exam #3

What is optimal nutrition?

sufficient nutrients are consumed to support day to day body function needs

What is under nutrition?

nutritional reserves are depleted or nutritional intake is less than needed for day to day function

What are some risks associated with under nutrition?

risk for impaired growth and development, lowered resistance to infection and disease, delayed wound healing

What is over nutrition?

over consumption of caloric and nutritional needs

What are some risks associated with over consumption?

risk for obesity and is a risk factor for heart disease, T2 DM, osteoarthritis, sleep apnea, CKD, gallstones, and GERD

What are the different nutritional assessments?

- nutritional screening: weight loss, diet info and lab work
- comprehensive nutritional assessment: dietary history and clinical info, physical assessment for clinical signs, anthropometric measures, and lab work

What subjective data is collected during a nutritional assessment?

eating patterns, usual weight, changes in appetite, taste, smell, chewing, swallowing, recent surgery, trauma, burns, infection, chronic illnesses, n/v, diarrhea, constipation, food allergies or intolerances, medication and/or nutritional supplements, patient-centered care, alcohol or illegal drug use, exercise and activity patterns, and family history

What objective data is collected during a nutritional assessment?

- general appearance: cachectic or obese
- skin and hair: dry and flaky
- eyes: dryness, pale, or red conjunctiva
- mouth: dry lips and mucosa, cracked lips
- nails: brittle and cracked
- muscle wasting (atrophy) or joint pain
- disorientation or irritability
- decreased reflexes
- lab work: albumin, electrolyte levels

What are the abdominal muscles?

rectus abdominis, external oblique, internal oblique, and transversus

What is the function of the abdominal muscles?

protect and hold the organs in place and allow the vertebral column to flex

What organs are a part of the solid viscera?

organs that maintain their shape: liver, pancreas, spleen, adrenal glands, kidneys, ovaries and uterus

What organs are a part of the hollow viscera?

organs where their shape depends on their contents: stomach, gallbladder, small intestine, colon, and bladder

What are the abdominal quadrants and what organs are in each quadrant?

RUQ: liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon
LUQ: stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal, splenic flexure of colon, part of transverse and descending colon
RLQ: cecum, appendix, right ovary and tube, right ureter, right spermatic cord
LLQ: part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord

What subjective data is collected during an abdominal assessment?

appetite, dysphagia, food intolerance, abdominal pain, n/v, bowel habits, past abdominal hx, medications, nutritional assessment

What are you inspecting for in an abdominal assessment?

contour, symmetry, lesions, rashes, piercings, tattoos, striae, scars, pulsations or movement, hair distribution, have pt do a slight crunch to observe for diastasis

How should an abdominal assessment be conducted?

inspection and auscultation should occur before palpation and percussion

How should the abdomen be inspected?

bladder should be empty, have appropriate draping, good lighting, room warm, semi-reclining with knees bent, examine any painful areas last

What are the different abdomen contour classifications?

- flat: normal
- scaphoid: abdomen is inverted, normal
- rounded: abdomen is slightly rounded, normal
- protuberant: abdomen is very rounded, expected in pregnancy and liver disease

How should the abdomen be auscultated?

- auscultate with a warm stethoscope, diaphragm side
- listen for bowel sounds and note present, absent, hyper, borborygmus
- 5-30 sounds per min
- start in RLQ
- listen for vascular sounds: aorta, left and right renal artery, left and right iliac artery and left and right femoral artery, listening for bruits, use bell of stethoscope

How should the abdomen be percussed?

- listening for tympany and dullness
- tympany predominates due to air and dullness is over solid organs or masses
- liver scan: if indicated percuss mid clavicular line
- costovertebral angle tenderness: looking for renal infection

How should the abdomen be palpated?

- looking for rigidity, guarding, masses, tenderness
- light palpation over all 4 quadrants ( 1cm) assessing skin surface and musculature
- deep palpation over all four quadrants (5-8cm) assessing internal organs and vessels
- palpate the liver, spleen, kidneys, and aorta

How is rebound tenderness (Blumberg sign) conducted?

choose site away from painful area, push down slowly and deeply and release quickly, pain occurs when releasing the pressure indicating inflammation

How is inspiration arrest (Murphy's sign) conducted?

hold your fingers under the liver border and have patient take a deep breath, positive for cholecystitis if painful

How is iliopsoas conducted?

patient supine, have them lift their right leg straight up and press down on the upper thigh, if pain then positive sign for appendicitis

How is fluid wave conducted?

tapping the side of abdomen and feeling for fluid wave on other side, positive for ascites if wave is felt

What are expected findings in an abdominal assessment?

- flat or scaphoid abdomen, no bulges or masses
- warm dry and intact skin
- normal bowel sounds "gurgling, popping", about 5-30 times per min
- no bruits in vascular sounds
- general tympany on percussion
- no pain with superficial or deep palpation

What are unexpected findings in an abdominal assessment?

- rounded or protuberant abdomen, bulges or masses
- cool or hot, diaphoretic, open skin
- hypo or hyperactive bowel sounds, absent bowel sounds, borborygmus
- bruits in vascular sounds
- dullness or hyperresonance on percussion
- pain with superficial or deep palpation
- positive special tests

What are the two sphincters in the anal canal?

- internal sphincter: involuntary control by ANS
- external sphincter: under voluntary control

Where is the rectovesical pouch located?

between bladder and rectum in men

Where is the rectouterine pouch located?

between uterus and rectum in women

What subjective data is collected during an anal and rectum assessment?

usual bowel routine, change in bowel habits, rectal bleeding or blood in stool, pruritis, pain, burning, family hx, self care behaviors, and hx of prostate exam in men

What objective data is collected during an anal and rectum assessment?

inspection
- skin warm dry and intact
- anus should be moist and hairless with folded skin
- check for lesions and hemorrhoids
palpation
- anal canal for muscle tone
- tenderness
- males: prostate should be heart shaped, smooth, rubbery, slightly movable, and nontender to palpation
- any enlargement, nodes, tenderness, and swelling would be unexpected

What are nonsynovial/fibrous joints?

joints that that unite bones by fibrous tissue or cartilage and are immovable or only slightly movable
ex: skull, vertebrae

What are cartilaginous/amphiarthrotic joints?

joints that are slightly movable
ex: coastal cartilage between sternum and ribs

What are synovial/diarthrotic joints?

joints that are freely movable as the bones are separated from each other and enclosed in a joint cavity filled with synovial fluid, a layer of cartilage covers the surface of opposing bones
ex: shoulder, knee

What is characteristics of cartilage?

- in synovial joints
- avascular, stable connective tissue
- flexible
- cushions bone

What are ligaments?

fibrous bands that connect bone to bone

What are tendons?

connect muscle to bone

What is a bursa?

enclosed sac filled with synovial fluid, smaller to a joint, located in areas of friction

What is circumduction?

moving arm in a circle around the shoulder

What is inversion?

moving the foot inward at the ankle

What is eversion?

moving the sole of the foot outward at the ankle

What is rotation?

moving the head around the central axis

What is protraction?

move body part forward and level to the floor

What is retraction?

moving body part back and level to the floor

What subjective data is collected during a musculoskeletal assessment?

- any pain related to joints or muscles
- any swelling, heat, redness
- any limitation in movement
- muscle pain or cramps
- bone pain or deformity
- any weakness
- restless legs
- any trauma
- ADLs
- personal and family history

What objective data is collected during inspection in a musculoskeletal assessment?

- posture/balance
- gait
- joint ROM, active and passive if indicated
- symmetry of muscles
- swelling
- color: redness, bruising, pallor, rashes
- deformities
- fasciculation: tremors

What is crepitus?

grinding of bones/joints or air movement

What is contracture?

fibrosis of soft tissue, shortening or hardening of muscles, tendons, or other tissue

What is lordosis?

increased anterior curvature of lumbar spine

What objective data is collected during palpation in a musculoskeletal assessment?

- skin temp
- sensation, tenderness (w/ or w/o movement), swelling
- muscle tone
- nodules
- crepitus with movement of joint

What joints are tested for ROM?

temporomandibular, cervical spine and spine, shoulder, elbow, wrist/fingers, hips, knees, ankles/toes

How is ROM measured?

- 0/5: no contraction
- 1/5: muscle flicker, but no movement
- 2/5: movement possible, but not against gravity (test the joint in its horizontal plane)
- 4/5: movement possible against some resistance
- 5/5: normal strength: test by applying resistance to joint held in flexion or extension

What are the four lobes in the brain?

frontal lobe, parietal lobe, temporal lobe, and occipital lobe

What is the function of the frontal lobe?

executive functions, like thinking, planning, etc.

What is the function of the parietal lobe?

perception and spelling

What is the function of the temporal lobe?

memory and understanding

What is the function of the occipital lobe?

vision

What is a part of the limbic system?

basal ganglia, thalamus, hypothalamus, amygdala, and hippocampus

What is the function of the cerebellum?

motor coordination, equilibrium, muscle tone

What is a part of the brain stem?

midbrain, pons, and medulla

What is the spinothalmic tract?

pathway of the CNS that controls pain, temperature, and light touch

What are the posterior columns?

pathway of the CNS that controls position (proprioception), vibration, and finely localized touch (stereognosis)

What are the different kinds of reflexes?

- deep tendon
- superficial: corneal and abdominal
- visceral: pupillary response and accommodation
- pathologic: abnormal, Babinski in an adult

What subjective data is collected during a neuro assessment?

- h/a
- head injury
- dizziness/vertigo
- seizures
- tremors
- weakness
- coordination issues
- numbness/tingling
- difficulty swallowing
- difficulty speaking
- past history
- environmental/occupational hazards

What are the three types of neuro exams?

screening exam, complete exam, and recheck

What should be assessed during a screening exam?

- mental status (alert, response orientation to time, date, and place)
- cranial nerves: II, III, IV, VI, VII, and VIII
- motor function: muscle strength and movement, coordination, gait
- sensory function: light touch, sharp/dull proprioception

Who would you conduct a screening exam on?

patients who have no significant subjective findings

Who would you conduct a complete exam on?

patients who have neurologic concerns

Who would you conduct a neurologic recheck on?

patients who have neurologic deficits and need periodic reassessment

What should be assessed during a neurologic recheck?

- LOC
- Glasgow coma scale
- vitals
- pupillary response
- voluntary muscle movement
- muscle resistance

What equipment is needed for a neurologic exam?

penlight, tongue blade, cotton swab, cotton ball, tuning fork, and percussion hammer

What is the sequence of exams during a neurologic assessment?

mental status, cranial nerves, motor system, sensory system, and reflexes

What should be assessed during a mental status assessment?

- LOC: alert (spontaneous, responds to verbal stimulus, responds to painful stimulus, unresponsive), confusion, drowsiness, stupor, coma
- cognitive function: oriented to place, time, situation
- speech: clear, fluent, and articulate
- pupillary response: PERRLA

What are the cranial nerves?

CN I: olfactory (smell)
CN II: optic (vision)
CN III: oculomotor (eye movement and pupillary reaction)
CN IV: trochlear (eye movement, can depress and adduct eye)
CN V: trigeminal (face sensation and mastication)
CN VI: abducens (eye movement, can abduct eye past midline)
CN VII: facial (facial muscles and taste)
CN VIII: vestibulocochlear (hearing and balance)
CN IX: glossopharyngeal (swallow, voice, gag reflex)
CN X: vagus (swallow, voice, gag reflex)
CN XI: spinal accessory (SCM and trapezius)
CN XII: hypoglossal (tongue movement)

What is being assessed in a motor function assessment?

- muscle bulk and tone
- muscle strength
- Romberg test

What are findings when assessing for muscle bulk and tone?

- hypotonic: complete loss of tone
- hypertonic: rigid, spastic
- atrophy: decreased muscle tone
- hypertrophy: enlarged muscle
- involuntary movements: fibrillations, fasciculation
- asterixis: jerky hand movement when arms extended (encephalopathy)
- myoclonus: muscle jerk or spasm

How is balance assessed during a motor function assessment?

- first objective gait, smoothness of motion, ability to pivot/return, arm swing, length of stride. watch for fear of falling, use of furniture
- walk heel to toe (tandem walking) in straight line, looking for upper motor neuron lesions
- Romberg test: standing with arms at sides and eyes closed for 20 seconds
- jump on one foot

How is coordination and skilled movements assessed during a cerebellar function assessment?

- rapid alternating movements
- eye hand coordination (finger to finger, finger to nose)
- heel down shin

How is sensory function assessed?

- light touch: superficial touch with a cotton swab (sharp vs dull)
- pain: touch with a safety pin or broken off sharp piece of tongue blade
- temperature: done with suspected neuropathy, touch pt with warm and cold items
- point localization: assess for sensation by touching pt whose eyes are closed. compare side to side

What are additional sensory testing that can be done if findings are unexpected?

vibration sense, motion/position sense, tactile discrimination (fine touch), graphesthesia (ability to identify a number traced on hand), and stereognosis (recognize an object in hand)

How do you grade deep tendon reflexes?

- 0: nothing
- 1+: slight movement, less than normal
- 2+: normal
- 3+: more brisk than normal
- 4+: brisk with clonus (beats)

What are the two different types of CVAs?

ischemic: involves a clot in the brain or to blood flow to the brain
hemorrhagic: involves a ruptured blood vessel

What is the acronym FAST?

used to recognize the most common symptoms of stroke
Face: does one side of the face droop?
Arm: if a person holds both arms out, does one drift downward?
Speech: is their speech abnormal or slurred?
Time: its time to call 911 and get to the hospital if any of these symptoms are present

What is the "last known well time"?

last time the pt was without symptoms of a stroke

What are symptoms of a stroke?

difficulty walking, dizziness, loss of balance and coordination, difficulty speaking or understanding others who are speaking, numbness or paralysis in the face, leg, or arm on just one side of the body, blurred or darkened vision, and sudden headache

What are the external, internal, and glandular structures in a male genitourinary system?

- external: penis and scrotum
- internal: testis, epididymis, and vas deferens
- glandular: prostate, seminal vesicles, and bulbourethral glands

Where is the prostate located?

in front of the anterior wall of the rectum and behind the symphysis pubis

What is the function of the prostate?

it secretes thin milky fluid that helps sperm remain viable

What is the function of the cremaster muscle?

controls size of the scrotum allowing it to contract and bring the testis closer to the body for warmth if needed in order to protect sperm production and viability

What is benign prostatic hyperplasia?

prostate enlargement that can cause difficulty urinating

What subjective data is collected during a male genitourinary assessment?

- urinary frequency, urgency or nocturia
- dysuria
- hesitancy or straining
- urine color
- past GU Hx
- any penile pain, discharge, lesions
- scrotum self care
- sexual activities and contraceptive use
- STI Hx

What objective data is collected during inspection in a male GU assessment?

- lesions, rashes, hair distribution and any infestations
- position of meatus
- scrotum color, left scrotal sac is lower than the right, and size
- inguinal region while pt stands to assess for hernia

What objective data is collected during palpation in a male GU assessment?

- penis and scrotum tenderness, discharge
- testicular tenderness or enlargement
- palpate spermatic cord
- palpate for a hernia
- palpate inguinal lymph nodes

What are expected findings in a male GU assessment?

- skin warm dry and intact
- urethral meatus positioned centrally
- asymmetry of scrotum
- smooth, non tender spermatic cord
- no hernia palpated in inguinal area

What are unexpected findings in a male GU assessment?

- skin cool or hot, diaphoretic and not intact
- urethral meatus not positioned centrally
- scrotal pain with palpation
- thickened or tortuous spermatic cord
- hernia palpated in inguinal area

What subjective data is collected during a female GU assessment?

- menstrual Hx
- obstetric Hx
- menopause
- pelvic pain
- urinary symptoms
- vaginal discharge
- sexual Hx
- contraceptive and other hormonal use
- STI Hx

What should be inspected during a female GU assessment?

external genitalia and vagina nd cervix with the use of a speculum

What objective data should be collected during palpation in a female GU assessment?

- cervical motion tenderness
- size of uterus, fibroids
- ovaries size and tenderness

What are expected findings in a female GU assessment?

- skin color even, no lesions
- no pain with palpation
- cervix pink, midline and nulliparous (pre child birth) or parous (after child birth)