Health Assesment Flashcards
Before you begin
Age group considerations
Organization of the assessment is a must if you go from dirty to clean always clean stethascope and wash hands
Neuro specific health assessment components
Level of consciousness and orientation
Pupil response and cardinal age
Smile and show teeth, raise eyebrows
Tongue to roof of the mouth out side to side
Shoulder strength with resistance
HGTW
FLEXION AND EXTENSION BUE AND BLE
Level of consciousness
Single most important part of the assessment
Clue to see of deteriorating condition
Alert, lethargic, obtunded, stuporous/ semi-comatose, comatose
Name and date of birth, where are you, and what brought you to the hospital
Alert
Attentive, follows commands, if asleep wakes promptly remains attentive
Lethargic
Drowsy slow to respond
Obtunded
Difficult to arouse needs constant stimulation
Stuporous/semicomatouse
Arouses only to vigorous stimuli like pain
Comatose
No response to verbal or nonverbal or noxious stimuli no movement except deep tendon reflex
Cranial nerves
12 pairs
Sensory motor or both
Not all of the cranial nerves are always tested
Listed in order of testing not numerical value
Testing cranial nerves iii IV AND VI
Pupil response with pen light to see pupils dialate
Use tip of pen and have patient follow with their eyes and with an H motion
Testing cranial nerve VII
Ask patient to smile and show teeth
Wrinkle forehead
Testing cranial number 12 `
Put tongue on the roof of mouth
Stick tongue out and move it from side to side
Testing cranial nerve XI
Place hands on shoulders and ask patient to shrug them up and down
Testing motor function
Hand grasp and toe wiggle
FLEXION and extension with resistance
All done bilaterally BUE BLE
Done to make sure everything is working properly
Respiratory components of assessment
Anterior and posterior lung sounds
Clubbing
Auscultation of the lungs
Vesicular
Bronchovesicular
Bronchial
Vesicular
Periphery of the lungs Soft and breezy sounds
Bronchovesicular
Closer to the sternum is like a blowing sounds
Bronchial
Over the trachea largest and loud and high pitched
Abnormal or adventitious sounds
Crackles or rales
Rhonchi
Wheezes
Pleural friction rub
Crackles or rales
Can be fine or coursed
Call them crackles because they sound like rice crisps
They are caused by fluid
Can be cleared with a cough
Rhonchi
Due to large secretions in the air way sounds like flapping
Can be cleared with a cough so the airway will be cleared
Wheezes
High pitched musical sounds so we can hear them over all of the lungs commonly heard in the exhale but in severe cases can be heard inhale
Can be caused by respiratory illness
Pleural friction rub
Sounds like stehascope rubbing against cloth
Why we use stethascope on skin
No fluid and something could be rubbing against tissue
It is very painful
Abnormal respiratory patterns
Bradypnea
Tachypnea
Apnea
Hyperpnea
Kussmauls
Cheyne strokes
Bradypnea
Slow breathing
Tachypnea
Breathing fast
Hyperpnea
Breathing more deeply and faster than usual
Kussmaul breathing
Fast and deep breaths that occur in response to metabolic acidosis
Cheyne-strokes
Breathing disorder characterized by cyclical episodes of apnea and hyperventilation
Pattern of auscultation
1 starting on the left
Clubbing of the nails
Can occur when the blood is consistently low oxygen in the blood. Also people who live in places with high elevations this can happen
Cardiac specific health assessment components
Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for Edema
Heart sounds
LUB S1
DUB S2
LUB
Systole or s1 and is the sounds associated with the mitral and tricuspid valves
DUB
S2 or diastole and is the sounds associated with the aortic and the pulmonic valves closing
Pauses between heart sounds
There are natural pauses between s1 and s2 but the pauses between s2 and s1 is longer
Location of heart sounds
Aortic
Pulmonic
Tricuspid
Mitral
Aortic
Right base and the second intercostal space to the right of the eternal border
Pulmonic
Left bases and second intercostal space to the left of the eternal border
Tricuspid
Left lateral sternal border and fifth intercostal space to the left of the sternal border
Mitral
Apex and midclavicular line at the fifth intercostal space
Pulses
Carotid
Brachial
Radial
Ulnar
Apical
Femoral
Popliteal
Dorsalis pedis
Assessment of pulses
Carotid
Radial
Apical
Dorsalis pedis
Carotid
One at a time bilaterally
Radial
Bilaterally at the same time
Apical
With a stethoscope for two beats
Dorsalis pedis
Bilaterally at the same time
Pulse points
0,1+,2+,3+,4+
0 pulse point
Absent non palpable
1+ pulse point
Diminished palpable very weak
2+ pulse point
Strong normal
3+ pulse point
Full increased
4+
Bounding can feel it very strongly
Doppler
Hand held device
Most often used for pedal pulses If we can not feel it by hand
If we use the Doppler make sure to document it every time