CNM Purple Big Book: General Health Assessment and Health Promotion 2013 Flashcards
ROS endocrine focus
Menses, breasts, pregnancy, thyroid, menopause
ROS genitourinary
In uterine exposure to DES if born before 1971
Uterine or ovarian problems
History or symptoms of STI or pelvic infection
History or sx of vaginal infections
History of abnormal Paps - date, abnormality, tx
Hx or sx of UTI
Sx of urinary incontinence
Concluding question
Is there anything else I need to know about your health in order to provide you with the best health care?
Prevalence
Existing level of disease
Incidence
Rate of new disease
Tympani
Loud, high-pitched, drum-like sound, eg, gastric bubble, gas-filled bowel
Resonance
Loud, low-pitched, hollow sound, eg. Healthy lungs
Dull
Soft to mod, mod-pitched, thud-like sound, eg liver, heart
light palpation is used to identify…
~1 cm deep
muscular resistance
areas of tenderness and
large masses or areas of distention
deep palpation
~4cm deep
used to delineate organs and
to identify less obvious masses
underweight
BMI <18.5
normal weight
BMI 18.5-24.9
Overweight
BMI 25-29.9
Obesity
BMI 30-39.9
Extreme obesity
BMI 40 or greater
waist circumference provides msmt of abd fat as independent prediction of risk for
DM II, dyslipidemia, HTN, and CVD in individual with BMI 25-39.9
in adult femaile, incr relative risk is indicated at a waist circumferece greater than
35 in
Primary lesions
occur as an initial, spontaneous rxn to an internal or external stimulus
(macule, papule, pustule, vesicle, wheal)
Secondary lesion
result from later evolution or trauma to a primary lesion
ulcer, fissure, crust, scar
Thyroid nl PE
palpable with no masses or tenderness, rists symmetrically with swallowing
Lymph node HEENT locations
preauricular, postauricular, occipital, tonsilar, submandibular, submental, superficail cervical, posterior and deep cervical chains, supraclavicular
Lymph node PE wnl
<1 cm, nontneder, mobile, soft, discrete
snellen chart used for what kind of vision
central
rosenbaum card used for what vision
near vision
impaired near vision
presbyopia
impaired far vision
myopia
Tragus tenderness may indicate
otitis externa
mastoid process tenderness may indicate
otitis media
Tympanic membrane PE wnl
intact, pearly gray, translucent, with cone of light at 5:00 and 7:00, umbo and handle of malleus visible; no bulging or retraction
decreased tactile fremitus
emphysema, asthma, pleural effusion
increased tactile fremitus with…
lobar pneumonia, pulmonary edema
crackles
intermittent, nonmusical, brief sound
rhonchi
low-pitched, snoring qulaity
wheezes
high-pitched, shrill quality
pleural friction rub
grating or creaking sounds
transmitted voice sounds/vocal resonance (bronchophoney, egophoney, whispered pectoriloquy) indicate
fluid or a solid mass in lungs
physiologic split S2 heard during
inspiration
s1 heard best at
apex
S2 heard best at
base
fixed split S2
heard in inspiration and expiration; may be heard with atrial septal defect or right ventricular failure
increased S3
early diastole, low-pitched;
may be normal in children, young adults, and in late pregnancy; not nml in older adults
increased S4
late diastole, low-pitched;
may be normal in well-trained athletes and older adults;
heard with aortic stenosis and hypertensive dz
murmurs
systolic murmur may be physiologic (pregnancy) or pathologic (diseased valves);
diastolic murmur usually indictes valvular dz
murmur of mitral valve stenosis
early/late diastole, low-pitched, grade I-IV; heard loudest at apex without radiation; no respiratory phase variation
normal lymph nodes
<1cm, non-tender, mobile, soft and discrete
uterine size, nullip and parous
nulliparous: 5.5-8 cm long
parous 2-3 cm larger
ovarian size during reproductive years
3cm x 2 cm x 1 cm
CBC nl findings adult female
4.2-5.4 million/mm3
low CBC values
hemorrhage, hemolysys, dietary deficiencies, hemoglobinaopathies, bone marrow failure, chronic illness, medications
high CBC values
dehydration, diseases causing chronic hypoxia such as congenital heart dz, polycythemia vera, medications
H/H
rapid indirect measure of RBC count
nl H/H non-pregnant female
37-47%
nl H/H pregnant female
=/> 33% first and third trimesters
=/>32% second trimester
Hgb
measurement of total hgb (which carries oxygen) in the blood
nl hgb non-pregnant
12-16 g/dL
nl hgb pregnant
=/> 11 g/dL first and third trimester
=/> 10.5 g/dL second trimester
Low H/H due to
anemia, hemoglobinopathies, cirrhosis, hemorrhage, dietary deficiency, bone marrow failure, renal dz, chronic illness, some cancers
High H/H due to
erythrocytosis, polycythemia vera, severe dehydration, severe COPD,
Heavy smokers or those living at higher elevations may also have higher hgb.
Red blood cell indices
provide info re size, weight and Hgb [ ] of RBCs, useful in classifying anemias
Mean corpuscular volume (MCV)
average volume or size of a single RBC
nl MCV
80-95 mm, normocytic
Microcytic/abnormally small MCV
seen in iron deficiency anemia and thalassemia
Macrocytic/abnormally large MCV
seen with megaloblastic anemias such as vitabin B12 deficiency and folic acid deficiency
Mean corpuscular hemoglobin (MCH)
average amount or weight of Hgb within RBC
nl MCH
27-31 pg/cell
causes for abnormal MCH
same as MCV
Mean corpuscular hemoglobin concentration MCHC
average [ ] or % of Hgb within a single RBC
nl MCHC
32-36 g/dL, normochromic
decreased [ ] or hypochromic
seen with iron deficiency anemia and thalassemia
WBC with differential
provides information useful in evaluating individual with infection, neoplasm, allergy or immunosuppression
nl WBC (adult)
5000-10,000/mm3
increased WBC
seen with infection, trauma, inflammation, some malignancies, dehydration
decreased WBC
seen with some drug toxicities, bone marrow failure, overwhelming infections, immunosuppression
WBC may be elevated but a normal finding in
late pregnancy and labor
neutrophils
increased with acute bacterial infections and trauma.
Increased immature forms (band or stab cells) referred to as a “shift to the left”,
seen iwth ongoing acute bacterial infection
basophils and eosinophils
increased with allergic rxn and parasitic infections.
NOT increased with bacterial or viral infection
lymphocytes and monocytes
increased with CHRONIC bacterial and
ACUTE viral infxns
Peripheral blood smear
microscopic examination of smear of peripheral blood to examine RBCs, platelets, and leukocytes
platelet count
used to evaluate abnl bleeding or blood clotting
Nl platelet (adult)
150,000-400,000
low platelets (thrombocytopenia)
hypersplenism, hemorrhage, leukemia, cancer chemotherapy, infection
high platelet count (thrombocytosis)
some malignant disorders, polycythemia vera, rheumatoid arthritis
Urinalysis
dipstick and/or microscopic evaluation of urine.
includes eval of appearnace, color, odor, pH, protein, specific gravity, leukocyte esterase, nitrites, ketones, crystals, casts, glucose, WBCs, RBCs
nl U/A
no nitrities, ketones, crystals, casts or glucose. clear, amber yellow, aromatic. pH 4.6-8.0 protein 0-8mg/dL specific gravity (adult) 1.005-1.030 leukocyte esterase negative WBCs 0-4 per high power field RBCs at 2 or less
Blood glucose used for
diagnosis and eval of DM
fasting glucose
NPO (except water) x 8hr
nl (adult) <100
impaired 100-125
diagnostic for diabetes 126 or higher
Two-hour postprandial glucose during OGTT
sample obtained 2 hours after a glucose load of 75g
nl = <140 mg/Dl
impaired glucose tolerance 140-199
dx of DM = 200 or more
ADA criteria for dx of DM
sx of DM plus random non-fasting glucose of 200 or more.
fasting glucose of 126 or more
2-hr postprandial 200 or more
repeat testing on subsequent day to confirm dx
ADA recommends using fasting glucose rather than OGTT for screening
HbA1C
NOT for dx of DM
Gold standard for measurement of long-term glycemic control in individuals with DM
reliable tool for evaluating need for drug therapy and monitoring effectiveness of therapy
Good diabetic control HbA1c
<7%
BUN and creatinine
used in evaluation of renal fxn
BUN
indirect measure of renal and liver fxn
nl BUN
10-20 mb/dL
increased BUN
hypovolemia, dehydration, reduced cardiac function, GI bleeding, starvation, sepsis, renal dz
decreased BUN
liver failure, malnutrition, nephrotic syndrome
serum creatinine
indirect meausre of renal fxn
nl serum creatinine
0.5-1.1 mg/dL
increased levels creatinine
renal disorders, dehydration
decreased creatinine
debilitation and decreased muscle mass
Lipid profile
determines risk for coronary heart dz and eval of hyperlipoproteinemia.
Includes total cholesterol, triglycerides, HDL, LDL.
Fast 12-14 hr prior to test
Total cholesterol nl level
<200 mg/dL
may be elevated in pregnancy
triglycerides nl
35-135 mg/dL
may be elevated in pregnancy
HDL
removes cholesterol fro mperipheral tissues and transports to liver for excretion
nl HDL
40 mg or greater
low HDL assoc with
incrased risk for heart and peripheral vascular disease
LDL
cholesterol carried by LDL can be deposited into peripheral tissues
nl LDL
<130 mg/dL
high LDL assoc with
increased risk for heart and peripheral vascular dz
Thyroid stimulating hormone (TSH)
used to dx hyperthyroidisim, primary hypothyroidism, differentiat primary from secondary hypothyroidism, and to monitor thyroid replacement or suppression therapy
nl TSH
0.4-4.7 mU/mL
increased TSH
seen with primary hypothyroidism and thyroiditis
decreased TSH
seen with secondary hypothyroidism, hyperthyroidism, suppressive doses of thyroid medication
free thyroxine (FT4)
used in dx of thyroid dz
nl FT4
0.58 - 1.64 ng/dL
increased FT4
hyperthyroidism and acute thyroiditis
decreased FT4
hypothyroidism
nl Total thyroxine (T4)
4.5-12.0
T4 measurement affected by
increases in thyroxine-binding globulin (TBG)
causes for increased TBG
pregnancy, OCP use, estrogen therapy
universal donor blood type
O neg because no antigens on RBCs
universal blood type recipient
AB positive because no antibodies to react to transfused blood
rubella titer indicating immunity
1:10 or greater
high titers of rubella
1:64 or greater, may indicate current infection
Rubella IgM antibody titer
used if preg woman has suspicious rash; IgM antibodies appear 1-2 days after onset of rash; disappear 5-6 wks after infection
how soon are HIV antibodies detectable in 95% of infected individuals?
withing 6 months of infection
PCR used for
to confirm indeterminate Western blot result OR negative results in persons with suspected HIV infxn
which test if suspect recent HIV infxn before development of immune response?
HIV plasma RNA.
A + test should be confirmed with subsequent intibody testing to document seroconversion
Hepatitis B (HBV) test
HBsAg (antigen) rises shortly before onset of clinical sx, peaks during first week of sx, and returns to nl by the time jaundice subsides
HBsAg
indicates active HBV infection: individual is infectious. Person is carrier if antigen persists
HBsAb
antibody appears 4 weeks after disappearance of surface antigen.
Indicates end of acute infectious phase, and signifies immunity to subsequent infection.
Also used to denote immunity s/p hep b vaccine
Tuberculosis: purified protein derivative (PPD) test
usually + w/i 6 wks after infection.
does not indicate active/dormancy of infxn
CDC def of + PPD
high risk pop: 5mm induration or greater
moderate risk pop: 10 mm induration or greater
gen pop: 15 mm induration or greater
+PPD
once + rxn, usually persists for life
false neg PPD
incorrect admin (needs to be intradermal) or immunosuppression
false pos PPD
may result if individual had prior vaccination with bacillus of Calmette and Guerin (BCG) vaccine
PPD test CONTRAINDICATED
if hx of BCG vax or active TB since severe local rxn can occur
daily fat intake
20-35% of calories
daily saturated fats
<10% of calories
daily trans fats
as low as possible
daily cholesterol intake
<300 mg/day
daily sodium intake
<2300 mg/day ~1 tsp
one drink equivalents
12 oz beer, 5 oz wine, 1.5 oz hard liquor
14-18 yr old daily calium intake
1300 mg/day
19-50 yr old daily calium intake
1000 mg/day
51 yr old daily calium intake
1200 mg/day
vit D intake daily
adults 400-600 IU/day
according to National Osteoporosis Foundation: calcium/vit D intake
50 yr: 1200 mg/day, 800-1000 IU
sources of calcium
milk, yogurt, soybeans, tofu, canned sardines/salmon with edible bones, cheese, fortified cereals and OJ, supplements
sources of vit D
fortified milk, egg yolks, saltwater fish, liver, supplements, regular exposure to direct sunlight without sunscreen
folate requirements for women of childbearing age
0.4 mg/day (400 microgm/day)
folate requirement if hx of neural tube defect or sz disorders or insulin-dependent DM
may benefit from 4 mg (4000 micorgm/day)
sources of folic acid
dried beans, leafy green vegetables, citrus fruits and juices fortified cereals
Most multivitamins include 0.4 mg folic acid
iron requirements for non-pregnant women
14-18 yr: 15 mg/dL
19-50 yr: 18 mg/dL
>51 yr: 8 mg/dL
sources of iron
meat, fish, poultry, fortified cereals, dried fruits, dark green vegetables, supplements
concerns with vegetarian diets
plan to avoid deficiencies in protein calcium, iron, vit B12, vit D
Physical Activity Guidelines for Americans
engage in at least 150 min of moderate-intensity or 75 min vigorous intensity aerobic physical activity each week
Performed for at least 10 minutes per episode
Spread throughout the week
HR in moderate intensity exercise
achieves 50-69% of maximum HR
Max HR = 220 minutes minus age
ex aerobic physical ctivity
brisk walking, running, bicycling, jumping rope, swimming
amt of muscle strengthening activites/wk
2 or more days each week
of moderate or high intensity involving all major muscle groups
ex: weight lifting, exercises with elastic bands or use of body weights (push ups, tree climbing) for resistance
bone strengthening activity
running, brisk walking, weight training, tennis, dancing
BSE breast self exam
ACS: teach, but not necessary
ACOG: perform monthly
CBE clinical breast exam
ACS: q 3 yrs from 20-39 yr old
q year age 40+
ACOG: periodic eval, yearly or as appropriate >18 yr
q year age 40+
Mammograms
ACS: q year age 40+
ACOG: q 1-2 yrs age 40-49, then yearly
MRI
ACS: 20% (high) LR = mammo+MRI yearly start age 30
ACOG: <15% LR = not recommended
ACOG: combination of yrly mammogram and MRI in women with BRCA gene mutation beg age 25 or younger based on earliest age of onset in family
breast cancer risk assessment tools
BRCAPRO,
Claus model
Tyrer-Cuzick model
Paps
ACS: begin approx 3 yr after beg vag intercourse or by 21 yr old
up to 29 yr: yearly if smear, q 2 yr if liquid-based
30 yr+: if 3 consecutive nl Pap, may do q 3 yr unless hx of in utero DES exposure, HIV infectio or immunosuppression
ACOG: begin at age 21
21-29 yo: q 2 yr
30+ yo: neg Pap, neg HPV = no more than q 3 yr
Chlamydia screening
CDC: yearly for all sexually active females 25 yo or younger
Blood Pressure
at least every 2 years for adults
Cholesterol screening
NCEP:
Fasting lipid profile: q 5 yrs beginning age 20
(total cholesterol, LDL, HDL, triglycerides)
Total cholesterol levels
240 mg/dL = high
LDL levels
<130 = desirable
130-159 mg/dL = borderline high
160-189 mg/dL = high
190 mg/dL = very high
HDL levels
60 mg/dL = High = protective against CHD (desirable)
Triglyceride levels
200 mg/dL = High
CHD risk factors for women
> 55 yr old
family hx of premature CHD (male relative <40 mg/dL
DM
Fecal occult blood test recommendations
ACS & ACOG: yearly beginning at age 50
Sigmoidoscopy recommendations
ACS & ACOG: q 5 yrs beginning age 50 -OR- colonoscopy q 10 yrs -OR- double contrast barium enema q 5 yrs More frequent testing and starting at younger age if risk factors including IBS and personal or fam hx of colonic polyps or colon cancer
Plasma glucose recommendations
American Diabetic Association Fasting plasma glucose q 3 yr starting 45 yo More frequent if risk factors including: BP >140/90 DM in first-degree relative African American Asian Hispanic Native American obesity at >120% or greater of desirable weight OR BMI =/>27 hx of gestational DM or baby weighing >9 lb at birth HDL 250 mg/dL
Thyroid function screening
USPTF: routine screening for thyroid function is NOT warranted in asymptomatic individuals
ACOG: TSH periodically for women with an autoimmune condition or strong family hx of thyroid dz
Tuberculosis screening
CDC, ACOG: perform on all individuals at high risk
vision screening
by ophthalmologist
q 3-5 yrs for AA 20-39 yo
q 2-4 yr 40-64 AND q 1-2 yr >65 regardless of race
Yearly for DM regardless of age
dental screening
routine detnal care and preventive services including oral cancer screening at least once every year
Bone Mineral Density screening
screen all women >65 for osteoporosis/osteopenia with BMD test
Screen POSTmenoparusal women <65 yo WITH risk factors
high risk groups for whom HBV is recommended
individuals with multiple sex partners, are household contacts or sex partners of those with HBV infection; injection drug users; healthcare workers or otherwise at occupational risk; inmates of long-term correctional institutions
3-doses: now, 1 mo, 6 mo
At what age is influenza vac recommended?
Yearly after age 50.
What groups of younger individuals is yearly flu vax recommended?
Those with pulmonary, CV, or other chronic medical disorders and those who may transmit flu to them. Also to any woman who will be in 2nd/3rd trimester during flu season.
Who can use LAIV?
Healthy nonpregnant individuals under 50 years old.
Pneumococcus vax recommendations.
All immunocompetent individuals x1
<64 if living conditions are high risk for pneumonia.
Rubella vax recommendation
All nonpregnant women of childbearing age who lack documented evidence of immunity or evidence of vax after 12 months old
C/I to rubella vax
Pregnancy (and don’t get preg for four weeks)
Immunocompromised unless HIV
Hypersensitivity to neomycin
When in preg may Td be given?
2nd/3rd trimesters
Varicella vax given how?
two doses 4-8 wks apart
C/I to varicella vax
pregnancy (and don’t become pregnant for 4 wks after vax)
hx of anaphylactic rxn to neomycin
immunocompromised indivuduals
zoster vax recommendation
all individuals 60 yr or older regardless of prev hx of herpes zoster (shingles) or chickenpox
Hep A vax recommendation
if living or traveling in country with high Hep A levels, IV drug users, occupational exposure risks, food handlers, individuals with chornic liver dz or clotting factor disorders
2 doses 6 mo apart
HPV vax
age 11 or 12
now, in 2 months, and 6 mo after first
can be given anytime 13-26
meningococcal vax
one dose: all kids 11-18yrs
college freshmen in dorms
those with anatomic or fxnal splenia
if traveling to regions where meningococcal dz is hyperendemic or epidemic
Major side effects to nicotine replacements
Patch: local skin reaction
Gum/lozenge/inhaler: mouth and throat irritation
Spray: nasal irritation
all: HA, dizziness, nausea
C/I to nicotine replacement
serious cardiac arrhythmias severe angina recent myocardial infarction concurrent smoking Pregnancy category D
Buproprion major side effects:
insomnia
dry mouth
nausea
skin rash
C/I for bupropion
seizure disorder eating disorder use of MAOI concomitant use of other forms of bupropion Pregnancy cat B not recommended during bf
Varenicline tablets
reduces nicotine withdrawal sx; blocks effect of nicotine if individual resumes smoking; nicotinic acetylcholine receptor partial agonist
Major s/e of varenicline
n/v changes in dreaming constipation gas neuropsychiatric sx
C/I to varenicline tablets
precautions with psychiatric disorders and renal impairment
Pregnancy cat C
not recommended during bf
Client education for varenicline
initiate med 1 week before smoking cessation
concomitant use of nicotine replacement may increase s/e
discontinue med and report any agitation, depression, and suicidal ideation
female sexual dysfunction
Must cause personal distress to be considered a sexual dysfunction
May be persistent or recurrent, lifeong or acquired, generalized or situational
Etiology may include relationship factors, medical conditions, medication side effects, psychological factors, sexual abuse hx
vaginismus
involuntary contraction of musculature of the outer third of the vagina that interferes with vaginal penetration
Differential dx, other medical conditions that may account for s/s of aging
Hypothyroidism Glaucoma, cataracts Chronic cardiac and pulmonary disorders Depression Alzheimer's disease
anthropometry
measurement of the human individual
arcus senilis
opaque ring at margins of cornea with decreased tear production
in ageing, what changes are there to the thorax?
rib cage less mobile
increased A-P diameter
in aging individuals, what abdominal changes are there?
decreased muscle tone
may have less pain with abdominal pathology
in aging individuals, what neurologic changes happen?
slower reaction time
may have decreased response to pain stimuli
What happens to lab values in the aging person?
There is no significant change in the absence of disease process
What happens to glucose levels as a person ages?
decreased glucose tolerance common in older people - fasting glucose levels increase after age 50
what is the cutoff for mammography screening?
ACS and ACOG currently do not have cut off age
Labs for women after age 65
Yearly: dipstick u/a mammography fecal occult blood test Q 1-3 yrs: Paps Q 3-5 yrs: cholesterol TSH Q 5 yrs: sigmoidoscopy -OR- Q10 yrs: colonoscopy
