DMS110+PATHOPHYSIOLOGY_DMS110Epp-1+%284%29

Health Assessment

  • Definition: A health assessment is a plan of care that identifies a person's specific needs and how these needs will be addressed by the healthcare system or skilled nursing facility.

  • Purpose: Evaluates health status through physical examination and health history, aiming to understand symptoms and laboratory values.

Data Types in Health Assessment

  • Objective Data:

    • Obtained through observation; verifiable (e.g., "A leg is red and swollen").

  • Subjective Data:

    • Derived from patient reports (e.g., "I have back pain").

Questions Specific to Body Structures and Systems

Neck Assessment

  • Do you have swelling, soreness, lack of movement, or abnormal protrusions?

  • Duration of the problem?

  • Activities that aggravate the condition?

Thyroid Anatomy and Function

Components of the Neck

  • Superior thyroid artery, internal jugular vein, thyroid cartilage, cricoid cartilage.

Thyroid Disorders

  • Common in women (8 times more likely than men) and increase with age.

  • Hormones T4 (thyroxine) and T3 (triiodothyronine) regulate energy, growth, and metabolism.

    • Primary Hypothyroidism: TSH levels increase, but thyroid doesn't release hormones.

    • Secondary Hypothyroidism: TSH levels decrease without adequate hormonal response.

Hyperthyroidism

  • Definition: Excessive production of T3/T4.

  • Main Cause: Graves' disease (autoimmune disorder).

  • Symptoms: Rapid heart rate, high blood pressure, weight loss, irregular menstrual cycles.

Warning Signs of Thyroid Problems

  • Thinning hair/loss, trouble regulating temperature, weight changes, joint pain, depression, fatigue, insomnia.

Respiratory System Assessment

  • Questions:

    • Shortness of breath?

    • Productive cough?

    • Night sweats?

    • Previous treatments for respiratory conditions?

Cardiovascular System Assessment

  • Questions:

    • Chest pain or palpitations?

    • Irregular heartbeat or shortness of breath?

    • Family history of heart disease?

Breast Assessment

  • Questions:

    • Monthly self-examinations?

    • Noticed any lumps or changes?

    • Family history of breast cancer?

Assessment Mnemonic "LMNOP"

  • Lumps: Inspect for masses.

  • Mammary changes: Inspect for tenderness.

  • Nipple changes: Inspect for lesions or discharge.

  • Other symptoms: Check size and appearance of skin.

  • Patient risk factors: Family history assessment.

Gastrointestinal System Assessment

  • Questions:

    • Symptoms like nausea or vomiting?

    • Recent weight changes?

    • Changes in bowel movement regularity?

Urinary System Assessment

  • Questions:

    • Burning during urination?

    • Nighttime urination frequency?

    • Blood in urine?

Reproductive System Assessment

Female

  • Questions:

    • Regular menstrual periods?

    • History of pregnancy or infections?

Male

  • Questions:

    • Testicular self-examinations?

    • Any discharge or pain noted?

Musculoskeletal System Assessment

  • Questions:

    • Difficulty with walking or standing?

    • History of arthritis or injuries?

Endocrine System Assessment

  • Questions:

    • Unusual tiredness?

    • Changes in hunger or thirst?

    • Hair texture/color changes?

Physical Assessment Norms

  • Normal pulse: 60-100 beats/min

  • Normal respirations: 16-20 breaths/min

  • Normal blood pressure: Systolic 100-130 mm Hg; Diastolic 60-80 mm Hg.

Circulatory System Functions

  • Functions: Transport oxygen/nutrients, defend against infection, maintain pH.

  • Normal blood pH: 7.34-7.44 (slightly alkaline).

Blood Components

  • Plasma: Comprises 55% of total blood volume; mostly water.

  • Red Blood Cells (RBCs): Carry oxygen, formed in the bone marrow, responsible for oxygen transportation.

  • White Blood Cells (WBCs): Primary defense against infection, classified into granulocytes and agranulocytes.

  • Thrombocytes (Platelets): Involved in clotting, lifespan of 8 days.