health and physical assessment of adults Flashcards
What does SOAP stand for?
subjective, objective, assessment and plan
How to obtain the information?
Health history- chief complaint, history of present illness, general state of health, social history, family history, domestic violence
Mental status exam
Cognitive level
Physical exam
What do you ask in social history?
drugs, tobacco, alcohol, sex practice, tattoos, piercing, traveling history, work environment to assess occupational hazard
What do you ask in family history?
Disease in blood related relatives and spouse
What to ask in mental exam?
Appearance- grooming, hygiene, dressing, posture, body movement
Behavior
- level of consciousness (are they alert and aware; are they interacting with the environment)
- facial expression and body movement (eye contact; is there facial and body movement appropriate for the situation)
- Speech ( cohesive; can they articulate and appropriate)
What to ask in cognitive level of function
12-2
Is health history subjective or objective
subjective
Is physical exam subjective or objective?
objective
What is the order of the physical exam?
Inspect, palpate, percussion and auscultation
except the abdominal
Difference between light and deep palaption?
Light is for surface problem using one hand and 2-3 finger and deep use one hand on top of the other and use all the fingers to place pressure
Types of percussion?
learn
resonance, hyper resonance, tympani, dullness, and flatness
is vitals included in the physical exam
yes
also radial pulse, height and weight
How to check for cyanosis, jaundice, bleeding and inflammation in dark skin?
cyanosis- the conductive will be pale, the lip and tongue will be grey, the nail bed, palm and sole will be blue
jaundice - the sclera is yellow and the mucous membrane
Bleeding - discoloration and edema; compare with unaffected side
Inflammation- taut, warm and shiny
What do you recommend for skin assessment?
ABCDE
Asymmetry Border irregularity Color variance Diameter greater than 6 mm Evolve in color, size or shape
Assessment of head?
Inspect size, symmetry, shape, tenderness, mass
Palpate the temporal artery, the maxillary and frontal sinus
Inspect the temporomandibular joint: ask to move jaw side to side
any crepitus, tenderness or limited range of motion is problem
tests cranial nerve number 5 - trigeminal
Assess the face?
tenderness, edema, involuntary movement, shape, size and symmetry
Assess the neck?
symmetry of the accessory muscle, palpate the trachea ( should be in the middle and not deviated), the thyroid gland ( when patient swallows the gland should move up, palpate with anterior and posterior approach usually not palpable, if then auscultate for bruit)
Test cranial nerve 11 (accessory nerve)
shrug shoulder for trapezius and move chin to side against resistance for sternocleidomastoid
Objective assessment of the eye?
assess eyebrow for symmetry, eyelid for ptsosis or drooping, eyelashes for equal distribution, exophthalmus for bulging of eye and enopthalmus for sunken eyes
What are all the eye exams?
snellen test near vision confrontation test corneal light reflex cover uncover 6 cardinal position/diagnostic position test color vision
what is the snellen test?
assess for distant vision/vision acuity
the client must be standing 20 feet away from the chart
can wear contact lense or glasses but not reading glasses
numerator is the person denominator is the normal eye or others
What nerve does the snellen test assess for?
optic nerve (nerve 2)
What is the near vision test?
handheld device held 14 inches from the patient that includes various sizes of print or ask the patient to read the magazine
cover the eye not being used
normal result is 14/14
testes cranial nerve 2
what is the confrontation test
examines for peripheral vision
client covers one eye and looks straight ahead while the nruse covers the opposite eye
the nurses advances finger or small object from periphery from several direction
the client should see the object at the same time as the nurse
tests for cranial nerve 2
what is the corneal light reflex?
assess for parallel alignment of the axes of the eye
each eye tested separately
nurse hold penlight 12 inches from the patient and reflect the light at the middle of the two eye; there should be a reflection (red dot) on the cornea at the same position on both eye
the patient is looking straight ahead
What is the cover uncover test
checks for slight degrees of deviated alignment; assess for strabismus (when the eye does not align with each other)
the patient will cover one eye and look straight ahead
the uncovered eye should have steady fixed gaze
what is the 6 cardinal test
tests the 6 muscle sattaching the eyeball to the orbit and serves to direct the eye in point of interest
head is still and moves both eyes following a object
which nerves do the 6 cranial test assess for?
3, 4 and 6
trochlear, abducens and oclomotor
what is the color vision test
uses the ishihara chart in which a number or letter needs to be picked out of a complex and colorful picture
diagnosis of red-green color blindness not blue
how should the pupils be
round and equal
constriction upon light and dilation in darkness
light being shone which causes constriction is called direct light
light not being shown with constriciton is called consensual
How should sclera be?
sclera should be white
in dark skin people they may have yellow scelera which is normal with dots
how should cornea be
transparent, shiny, smooth and bright
cloudy can indicate accident or injury
opthalmoscopy or fundoscopy
patient in dark room to dilate the pupil
assess for external structures and interior of the eye
the instrument is held in the right hand if right eye is being tested
client looks ahead
the instrument is 12-15 inches away
as instrument is directed at the eye a red glare is seen in the pupil; if not then it means opacity of the lens
how should optic disc, general background, macula and retinal vessels be
optic disc is round or oval, yellow cream orange to redish pink color
the general background the light to dark brown red
the retinal vessels should be visible without engorgement
the ma
What do you assess in the ear?
size,shape, symmetry, pain, redness
What do you assess in the external auditory meatus?
cerumen, pus, redness, pain, swelling
how is sound transmitted?
bone or air conduction
what is conductive hearing loss
when there is a physical obstruction of sound waves
what is sensorineural hearing loss
defect of the cochlea or 8th cranial nerve
what is mix hearing loss
mix of conductive and sensori
what is the wisper test?
the examiner stands 1-2ft away from the client
the client the other ear
the examiner will cover mouth and whisper 2 syallabul wods
the client will state if they herd it
if the client did not that means there is fluid accumulation
what is the watch test
tests of client can hear high acuity sounds
examiner will hold ticking watch 5 inches away from the testing ear
what is tuning fork test
measures hearing on the basis of bone or air conduction
what is a otoscopic exam
tests the ear
pull pinna up and back
how does the normal external canal look?
pinkish intact without any lesions
there can be wax and hair
how does the tympanic membrane look
it should in intact without any perforation or lesions
should be transparent, opaque and pearly grey
cone. of light reflex is 5 oclock on the right and 7 on the left
if membrane is retracted or bulging then the edges of the light reflex will diffuse
The otoscope is never introduced blindly
into the external canal because of the
what is the vestibular assessment
assess for any imbalance in the air
Test for fallin aka rombergs
-client will close eyes and place feet together, slight sway or normal but excessive sway is positive rombergs
Past pointing
client sits down in front of the examiner and closes eyes and sticks both the index finger out
the examiner places index finger below the client, the client raises arms and places them back down when the examiners fingers are
Gaze Nystagmus
Client stares 30 degrees away and examiner looks for twitching
Dix-hallpike
Examiner turns client head 40 degrees and lies him down and check for nystagmis for 30 seconds
how to check patency of the nostrils
close one nose and ask client to breath in and out through the other
What is the rating of the tonsils?
(0 is surgically removed; 1 + is tonsils hidden within pillars; 2 + is tonsils extending to the pillars, 3 + is tonsils extending beyond the pillars, 4 + is tonsils extending to the midline)
what should you recommend for dental care?
fluoride water
What are the adventitious lungs sounds?
fine crackles medium crackles coarse crackles wheezing rhonchi pleural rub
What is fine crackles?
High pitch popping noise that comes at the end of the inspiration
Caused by: P, asthma, heart failure and restrictive pulmoary disease
medium crackles?
Medium pitch popping sounds that comes in the middle of the inspiration .Worse than fine crackles.
Same condition as fine
Coarse crackles
Low-pitched, bubbling or gurgling sounds that start early
in inspiration and extend into the first part of expiration.
Not cleared by cough.
Same as above, but condition is worse or
may be heard in terminally ill clients with
diminished gag reflex. Also heard in
pulmonary edema and pulmonary fibrosi
wheezing
High-pitched, musical sound similar to a squeak. Heard
more commonly during expiration, but may also be heard
during inspiration. Occurs in small airways.
Heard in narrowed airway diseases such as
asthma
rhonchi
Low-pitched, coarse, loud, low snoring or moaning tone.
Actually sounds like snoring. Heard primarily during
expiration, but may also be heard during inspiration.
Coughing may clear
Heard in disorders causing obstruction of
the trachea or bronchus, such as chronic
bronchitis
Pleural rub
A superficial, low-pitched, coarse rubbing or grating
sound. Sounds like 2 surfaces rubbing together. Heard
throughout inspiration and expiration. Loudest over the
lower anterolateral surface. Not cleared by cough.
Heard in individuals with pleurisy
(inflammation of the pleural surfaces)
What are the voice sounds?
Done with lung disease is suspected
Broncophony - ask to say ninety nine
nurse should hear muffle, soft, indistinct sounds
Egophony- say eeeee, nurse should hear eeeee
Whispered- whisper 1 2 3 nurse should hear faint, muffled and almost inaudible
Auscultation of the heart?
Auscultate heart rate and rhythm; check for a pulse deficit (auscultate the apical heartbeat while palpating an artery) if an irregularity is noted. c. Assess S1 (“lub”) and S2 (“dub”) sounds, and listen for extra heart sounds, as well as the presence of murmurs (blowing or swooshing noise that can be faint or loud
How to check the peripheral vascular system?
BP Symmetry of arterial pulse Carotid pulse (one at a time) Listen for bruits Measure calf circumference and check for pretibial edema
Palpate superficial inguinal nodes
Check arteries of the extremities
Check the breast
palpate with three fingers and also check the axillary nodes (should not be palpable)
Order of the abdomen assessment
inspect, ausculatate, percussion and palapate
How to auscultate abdomen
After inspection start the auscultation
Listen to all 4 quadrants starting with RLQ(hypo, hyper or normoactive)
Listen for 5 mins before stating absent sounds
Auscultate aorta, renal arteries, femoral and iliac to listen for bruits
how to percuss the abdomen
predominantly tympani; dull over the liver and the spleen
Measure liver and spleen and make sure no pain from the kidney
what is in the muskuskeletal assessment
only inspection and palpation
assess active and passive ROM
grade the muscle strenght
Assess neurological system
- Assess cranial nerves
- Level of consciousness, pupils, coordination, reflex and sensory function
- Note mental and emotional status
- record vitals
How to assess level of consciousness? (neuro)
Determine behavior
alert, confused, delirium, unconsciounsess, stupor and coma
In extreme levels use glascow coma scale
light touch if appropriate
How to assess pupils?
neuro
size, equality, and reaction to light (brisk, slow and fixed)
brisk is rapid which is normal
How to assess motor function ?
neuro
. Assess for voluntary and involuntary, strenght movements and purposeful and nonpurposeful movements. c. This component of the neurological examination may be performed during assessment of the musculoskeletal system
How to assess cerebellar function ?
neuro
rombergs test, assess as clients walks in straight line
How to assess coordination function ?
neuro
Assess by asking the client to perform
rapid alternating movements of the
hands (e.g., turning the hands over
and patting the knees continuously)
The nurse asks the client to touch the nurse’s finger, then his or her own nose; the client keeps the eyes open and the nurse moves the finger to different spots to ensure that the client’s movements are smooth and accurate. c. Heel-to-shin test: Assist the client into a supine position, then ask the client to place the heel on the opposite knee and run it down the shin; normally the client moves the heel down the shin in a straight line.
how to assess sensory function ( neuro)?
Assess pain by applying sharp object
Assess light touch
Position sense- kinethesia; move tow or finger up and down and ask which one was moved
Stereognosis: Tests the client’s ability to
recognize objects placed in his or her
hand
Graphesthesia: Tests the client’s ability
to identify a number traced on the
client’s hand
Two-point discrimination: Tests the
client’s ability to discriminate 2
simultaneous pinpricks on the skin
Plantar reflec- a. A cutaneous (superficial) reflex is tested
with a pointed but not sharp object.
b. The sole of the client’s foot is stroked
from the heel, up the lateral side, and
then across the ball of the foot to the
medial side.
c. The normal response is plantar flexion
of all toes.
Bruzinki and kernigs sign for meningial irritation
DTR- biceps, triceps, ptella and achillies
