Fundamentals Health Assessment Flashcards
What is a Brief General Assessment
10 minute assessment, concise, timely, and realistic head to toe assessment.
What is Ongoing/Follow-up Assessment?
assessment done at regular intervals
What is a Focused Assessment
In depth assessment of a specific health issue, usually involves 1 or more body system.
Used to address the immediate concerns.
What is a Comprehensive Assessment?
Provides a holistic information, an overall information of body systems and functional abilities, emotional status, cultural + spiritual beliefs, psychosocial situation, family + community dynamics.
Done during admission (initial) assessment
Includes collection of subjective data, complete vital signs
What is Emergency Assessment
Focused on ABC’s
Performed mostly in acute settings ( ED, ICU)
Enviromental needs as a patient
Privacy and adequate draping (hospital gown)
Room temperature should be comfortable
Warm blankets if needed
Enviromental needs as a Nurse
Soundproof room with adequate lighting
Easy to maneuver examination table
Equipment arranges for easy use
Fowler’s Position
High Fowler’s (80o - 90o)
Fowler’s (45o – 60o)
Semi Fowler’s (30o - 45o)
Low Fowler’s (15o - 30o)
Trendelenburg Position
Trendelenburg (Lower extremities higher than the head)
Reverse (Lower extremities lower than the head)
Modified (Lower extremities & head are above the heart)
What is Biographical Data
note preffered language and any cultural barriers
Reason for Seeking Health Care
Try to record whatever the patient has to say in the pts exact words
Ex: “I’ve been coughing for 1 week”
History of Present Health Concern
Explore the symptoms, let the patient describe and explain their symptoms
Past Health History
It includes past diseases, surgeries, hospitalizations, immunizations, list of medications, preventative screenings, these data alert the nurse to certain risk factors
*advise pt of due screenings
Family History
Provide info about diseases and conditions for which the patient may be at risk; can provide clues to patient’s current health issues (eg: family members with infectious disease or any environmental hazards at home)
Functional Health Assessment
assess pts ADL’S, pt independent ADL’s
Psychosocial and Lifestyle Factors
Assess support system (interpersonal relationship and resources), level of activity + exercise, sleep + rest, nutrition, values, beliefs, self esteem, self concept, sexual history and orientation, mental health status + family violence
Review of Systems
series of questions about all body systems, maybe incorporated into the physical assessment of each regions
Inspection
uses sight, smell, hearing
Use throughout the physical examination
Pay attention to details( color, shape, size, position, symmetry, sounds, odor)
Palpation
Uses sense of touch
Types of palpation: Deep, Light
Use sensitive parts of the hand to detect different characteristics
What part of hand to assess for skin temperature
Dorsal (back of hand)
What part of hand to assess for vibration on skin?
Palm of the hand
What part of hand to assess for masses, size, pulses, tenderness?
Pinger pads, and palmar surface
Percussion
Uses sense of hearing, sound is produced by fingertip tapping through body tissues
Types of percussion
Direct and Indirect
Resonance sound found where?
Lung
Flat sound found where?
Scapular
Dull sound found where?
Liver
Tympanic sounds found where?
Stomach
Standing position
used to assess posture, balancem and gate
Supine Position
facilitates abdominal relaxation
Assesses vital signs, head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
Sims Position
Lies on either side w? the lower arm below the body & upper arm flexed at the shoulder and elbow, both knees are flexed, w/upper leg more acutely flexed.
Assesses rectum or vagina
Lithotomy position
pt in dorsal recumbent position with the buttocks at the edge of the examining table + heels in stirrups
Assesses female genitalia and rectum
Sitting
Allows visualization of the upper body, facilitates full luung expansion.
Used to assess vital signs, head, neck, anterior + posterior thorax, lungs, heart, breasts, upper extremities,
Dorsal Recumbent Position
pt lies on back w legs seperated, knees flexed and soles of feet on bed
Assesses head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses.
** Should NOT be used for abdominal assessment bc it contracts abdominal muscles.
Prone
Assesses the hip joint and posterior thorax
Knee-Chest
assess anus and rectum
Dull or Thudlike sound
normally heard over dense surfaces as heart or liver
Dullness replaces ressonance when fluid or solid tissue replaces air-containing lung tissue, such as pneumonia, pleural effusion, and tumors
Hyperresonant
Louder-lower-pitched
Normally heard when percussing the chests of children or thin adults, or in hyperinflated lungs such as COPD, OR DURING ACUTE ASTHMA attack
An area of hyperresonance on one side of the chest may =pneumothorax
Tympanic
Hollow, high drumlike sounds
normally heard over stomach, but heard over chest indicates excessive air in the chest, such as in pneumothorax
Auscultation
Use sense of hearing, by listening to sounds produced within the body, aided or unaided
Types of Auscultation:
Direct and Indirect
General Survery
General appearance, behavior, vital signs, height and weight
Ex: how does pt walk? Initial look of pt
How to calculate BMI
{wt in lbs x 703/ Ht in Inches ^2}
The Skin (Color)
ivory to light pink, brown or olive skin
Pallor
Unusual paleness
Easily observe in face, buccal musosa, conjunctivae, nail beds
For dark individual, skin becomes yellowish brown/ashen gray
Cyanosis
Bluish Discoloration
Observe in the lips, nail beds, conjunctivase, palms
For dark individual, assess on areas of less pigmentation
Pallor v Cyanosis
Pallor= DECREASE in oxygen level in the blood
Cyanosis= INCREASE in amount of deoxygenated blood
Vitiligo
Loss of pigmentation
Jaundice
Yellowish Tinge
Liver or gallbladder
Erythema
Redness
Sign of Inflammation
Hyperhydrosis
Excessive perspiration
Bromhidrosis
foul-smelling perspiration
Stage 1 Pressure ulcer
Skin is warm, erythema is NON BLANCHING
Texture of skin
smooth, soft and flexible
Older = skin is wrinkled and leather
Peripheral Artery Disease
Pale, cool temp
No leg hair
none to mild edema
changes in sensation
pulse deficit
pain worsens when elevating
regular wound edges
distal
sometimes necrotic
Chronic Venous Insufficiency
Brown, bronze, warm
may have leg ahir
typical edema
normal sensation
normal pulses
pain improved when elevating
wet wound
irregular wound edges
usually ANKLE
Turgor
Grasp a fold of skin over the front of chest or under the clavicle, back of forearm, or sternal area and release
Normal skin turgor
skin lifts easily and snaps back immediately
Poor skin turgor
2 seconds- some dehydration
Tenting
> 2 seconds= severe hydration
How to assess infant skin turgor
abdomen or thigh
Edema
Fluid buildup in the tissues, direct trauma or venous return impairment
How to assess pitting edema
press edematous area firmly with the thumb for several seconds and release
Primary Lesion
macule, papule, pustule, vesicle, nodule, tumor, wheal,
Secondary lesions
scar, keloid, crust, erosion, excoriation,
Skin Cancer Assessment
Asymmetry= uneveness
Border=irregularity
Color=black to bluish brown
Diameter= greater than the size of a pencil eraser (>6mm)
Evolution= mole changing in size, shape, or color
Nail Blanch Test
Capillary refill
apply gentle firm quick pressure with the tumb to nail bed, and observe the return of pink color (perfusion)
Brisk Cap Refill
<3 seconds
Sluggish Cap Refill
> 3 seconds
Clubbing
Change in angle (>180 degrees) between the nail and nail base, normally 160 degrees
What does nail clubbing indicate
Hypoxia
Palpate the crainial bones
frontal, parietal, temporal, occipital; note for any deformities
Inspect the facial features
not for asymmetry by comparing one side to the other
Inspect the Scalp
seperate the hair into 3 areas with a comb and inspect the scalp for any lesions
Hydrocephalus
Spinal fluid not draining properly
Infant frontalis is not closed properly
Adult cases= Increase in ICP
Acromegly
Increase production of growth hormone
Only seen in adults
Alopecia
Medical term for baldness
Causes= DHT derivative of testosterone
Palpate the fronal and maxillary sinuses
for frontal sinuses, apply pressure with tumb pushing it up on the bony prominences under the brow
For MAxillary sinuses, apply pressure on zygomatic bone
Palpate temporomandibular joint
ask pt to open and close his mouth with palpating the TMJ
CN V
Trigeminal
Assess CN V motor
clench teeth and relax; open mouth while you push it back as pt holding against resistance.
Assess CN V Sensory
Wisp cotton on pts face, instruct pt to say now if he felt it
do same w sharp/dull hot/cold items
Assess for corneal reflex as well
CN VII
Facial
Assess CN VII Motor
look for asymmetry as pt smile, frown, show teeth, puff out cheeks, raise eyebrows; pt close his eye and attempt to open it but letting patient resist the force
Assess CN VII Sensory
pt identify salty or sweet on front of tounge (sense of taste)
Macular degeneration
loss in centeral vision
Glaucoma
loss of peripheral vision
Cataract
lens cloudiness/opacity
Retinal Detachment
retinal falls, like a curtain covering your vision, floaters
Myopia
image apears in front of the retina
near sited
Hyperopia
Far sighted
image appears behind the retina
Presbyopia
for sighted w older adults
result of normal aging
Astigmatism
cornea lengthens to a football shape
Cones
daytime vision
colors
Rods
nighttime vision
CN II
Optic
Assess CN II
Visual acuity w snellen chart
Assess CN II Visual Field
pt cover one eye, follow pen light up, down, side, side
CN III
Oculomotor
Assessing CN III
Raising upper eyelid
PERRLA
Ptosis
abnormal drooping of the eyelid over the pupil is an impairment of the 3rd cranial nerve
CN III CN IV CN VI
oculomotor
Trochlear
Abducens
6 cardinal field of gaze
CN VIII
Auditory
Whisper Test
ask pt to cover his right ear, you whisper on the other 1-2 ft away, let pt repeat what you said
CN I
Olfactory
Assess CN I
occlude each nostrol and let pt identify the odor
CN IX
Glossopharyngea;
CN X
Vagus
Assess CN IX & X (sensory & Motor
with a tounge depressor touch the back of pharynx and watch for the palate to rise (gag reflex and swallowing)
Assess CN IX & X Motor
intruct the pt to say “ah” observe for the palate to rise symmetrically, uvula remains at the middle
Assess CN IX sensory
instruct the pt to identify if sour or bitter on BACK of tounge (sense of taste)
Assess CN X (sensory & motor)
listen to pt talking (speech)
Sensory X
pharynx, larynx, viscera
Motor X
Larynx
The longest and only cranial nerve that wanders from the brain stem to the organs of the neck, thorax & abdomen is
CN X vagus nerve
CN XII
hypoglossal
Assess CN XII
ask pt to stick tongue out, moe from side to side
How to inspect the thyroid gland
observe the thyroid gland by instructing pt to swallow
How to palpate the thyroid gland
place your hands at the midline, palpate by rolling hands laterally towards the SCM
Auscultate the thyroid gland
listen for bruit if thyroid gland is palpable
Awake & Alert
fully awake; oriented; responds to all stimuli
Lethargic
appears drowsy or asleep but makes spontaneous movement; aroused by gentle shaking and saying pts name
Stuporous
unconscious most of the time,has no spontaneous movement, must be shaken or shouted to arousal; inappropriate verbal response; responds to painful stimuli
Comatose
cant be aroused, even with use of painful stimuli
Glasgow coma scale (GCS)
is objectively describe the extent of impaired consciousness in all types of acute mediccal and truma patients
Eye open coma scale
score of 4 pt is awake and alert
Score of 5
best verbal response pt is oriented x4
Score of 6
bbest motor response obeys commands
