Health Assessment Flashcards
Fowler’s Positions
High Fowlers: 80-90 degrees
Fowlers: 45-60 degrees
Semi Fowlers: 30-45 degrees
Low Fowlers” 15-30
Trendelenburg Positions
Trendelenburg: lower extremities higher than the head
Reverse: Lower extremities lower than the head
Modified: Lower extremities and head are above the heart
10 minute assessment
Concise, timely and realistic head to toe assessment; able to notice abnormalities quickly with ongoing practice
Focused Assessment
In-depth assessment about an actual or potential problem focusing on 1 or more body systems, classify further as initial and ongoing
AKA System-specific assessment
Comprehensive Assessment
Provides a holistic information, an overall information of body systems and functional abilities; emotional status; culturual and spiritual beliefs; psychosocial situation; family and community dynamics
Done during admission (initial) assessment
Inspection
Techniques of Physical Assessment
Uses sense of sight with the aid of lighting equipment
Use sense of hearing and smell
Use throughout the physical examination
Pay attention to details (color, size shape, position, symmetry, sounds, odor)
Palpation
Techniques of Physical Assessment
Use sense of touch (light and deep palpation)
Use sensitive parts of the hand to detect different characteristics: Dorsal surface for temp; palm of hand for vibration; thumb at the shin for pitting edema’ finger pads and palmar surface for masses, size pulses, texture and tenderness; fingertips for skin turgor
Percussion
Techniques of Physical Examination
Use sense of hearing
Sound is produced by fingertip tapping through body tissues
Direct and Indirect
Percussion Sounds
Lung: Resonance
Scapula: Flat
Liver: Dull
Stomach: Tympanic
Auscultation
Techniques of Physical Assessment
Sense of hearing
Listen to sounds produced within the body, aided or unaided
Direct and Indirect
General Survey
Appearance & Behavior
Vital Signs
Height and Weight
BMI
Weight. x (height x 2) x 703
Pallor
Unusual Paleness due to reduced oxygen level in the blood
easily observed in the face, buccal mucosa, conjunctivae, nailbeds
For a dark individual, skin becomes yellowish brown/ashen gray
Cyanosis
Bluish Discoloration due to increased amount of deoxygenated blood
Observed in the lips, nail beds, conjunctivae, palms
for dark individuals, assess on areas with less pigmentations
Vitiligo
Loss of pigmentation
Jaundice
Yellowish tinge
Erythema
Redness
Hyperhidrosis
Excessive perspiration
Bromhidrosis
Foul-smelling perspiration
Temperature
Use dorsal surface of the hand
Stage 1 pressure ulcer - skin is warm, erythema is non blanching
Vascularity
Compare PAD (peripheral arterial Disease) vs. CVI (chronic venous insufficiency) in terms of patient's limb skin color and changes Compare hematoma, ecchymosis, purpura and petechiae
Vascularity
Compare PAD (peripheral arterial Disease) vs. CVI (chronic venous insufficiency) in terms of patient's limb skin color and changes Compare hematoma, ecchymosis, purpura and petechiae
Peripheral Artery Disease Skin
Color: Pale Temp: Cool Leg Hair: Absent Edema: None to Mild Sensation: changes Pulses: Deficit Pain when elevating Leg: worsens
Chronic Venous Insufficiency Skin
Color: Bronze Brown Temp: Warm Leg Hair: May be present Edema: Typical Sensation: Normal Pulses: Normal Pain when elevating leg: Improved
Turgor
Grasp a fold of skin on the back of the forearm or sternal area with fingertips and release
Normally skin lifts easily and snaps back immediately while poor skin turgor stays pinched (late sign of dehydration)
Good: Instant Recoil - no dehydration
Poor: 2 Seconds - some dehydration
Tenting: >2 seconds - severe dehydration
Edema
Fluid Buildup in the tissues, direct trauma or venous return impairment
To assess pitting edema, press edematous area firmly with the thumb for several seconds and release
Degree/Depth:
+1 = 2 mm
+2 = 4mm
+3 = 6mm
+4 = 8mm
Primary Lesions
Macule, papule, pustule, vesicle, nodule, tumor, wheal
Secondary Lesions
Scar, keloid, crust, fissure, erosion, excoriation
Skin Cancer
A: Asymmetry ( unevenness)
B: Border (irregularity)
C: Color (black to bluish brown)
D: Diameter (greater than the size of a pencil eraser >6mm)
E: Evolution )mole changing in size, shape or color
Assessing the Head
Palpate the cranial bones: Frontal, parietal, temporal, occipital; note for any deformities
Inspect Facial Features: Note for asymmetry by comparing one side to the other
Inspect the scalp: Separate the hair into 3 areas with a comb and inspect the scalp for any lesions
Palpate the frontal and maxillary sinuses: For frontal sinuses apply pressure with thumb pushing it up on the bony prominence under the brow; maxillary sinus apply pressure on zygomatic bone
Palpate temporomandibular joint: ask patient to open and close mouth while palpating
CN V-Trigeminal
Motor
Instruct to clench teeth and relax; let patient open his mouth while you push it back as patient holding it against all resistance
*Checking the motor nerve- muscle of the jaw, temporalis, masseter and pterygoid
CN V-Trigeminal
Sensory
Wisp cotton on patients face, instruct patient to say now if he felt the wisp; do the same procedure but this time use sharp/dull or hot/cold items; assess for corneal reflex
*Checking sensory nerve to skin of the face
CN VII-Facial
Motor
Look for asymmetry as you instruct patient to smile, frown, show teeth, puff out cheeks, raise eyebrows; instruct patient to close his eye and attempt to open it but letting patient resist the force
*Muscle of facial expression
CN VII-Facial
Sensory
Instruct patient to identify if salty or sweet on front of tongue
*sense of taste
Myopia
Nearsightedness
Presbyopia
Age related far sightedness
Hyperopia
Farsightedness
CN II- Optic
Visual Acuity
Instruct patient to focus on your nose as he covers his “OD” (right eye) and hold your finger at arm length pointing top, middle and bottom on both sides (do the same with the “OS” left eye)
Visual Field
Using a ophthalmoscope check for the eye fundus
CN III-Oculomotor
Raising of the upper eyelid - abnormal drooping of the eye lid over the pupil is an impairment of the 3rd cranial nerve called ptosis
PERRLA
Pupils are equally round, reactive to light and accommodation
Normal Size: 2-4 mm in bright light and 4-8mm in the dark
6 Cardinal Field of Gaze
CN III- Oculomotor
CN IV- Trochlear
CN VI - abducens
Using the star pattern, instruct patient to follow the penlight only with his eyes watch for jerking movement of the eye (nystagmus)
Cover and uncover test to check for strabismus, a crossed eye (esotropia)
CN VIII- Auditory
Whisper Test;
Weber’s Test - bone conduction test and lateralization (Place vibrating tuning fork on the middle of the patient’s head and ask patient where sound localizes)
Rinne Test - Comparing air from bone conduction (Place vibrating tuning fork on the mastoid process until it can no longer be heard; place tuning fork in front of the ear canal; ask patient if he hears any vibration
Romberg Test - ask patent to stand with feet together and arms on the side, frist with eyes open then with eyes closed; stand close to patient to prevent fall
CN I- Olfactory
Occlude each nostril and let patient identify the odor
CN IX-Glossopharyngeal
CN X- Vagus
Sensory and Motor: With a tongue depressor touch the back of the pharynx and watch for the palate to rise (gag reflex and swallowing Motor: Instruct patient to say "ah" observe for the palate to rise symmetrically, uvula remains at the middle Sensory IX (pharynx and back of tongue) Motor IX (superior pharyngeal muscle) Sensory X (pharynx) Motor X (middle and inferior pharyngeal muscle)
CN XII _Hypoglossal
Ask patient to stick out tongue move from side to side
Thyroid Gland
Inspect: Instruct patient to swallow
Palpate: Place your hands at the midline, palpate by rolling hands laterally towards the SCM
Auscultate: Listen for bruit if thyroid gland is palpable (use bell of stethoscope)
Carotid Artery
Inspect: Position patient in bed 30 degrees and have him turn his head slightly away from the artery being observed, note pulsation
Palpate: Gently palpate one side at a time with index and middle fingers
Auscultate: using the bell of the stethoscope, listen for bruit
Jugular vein
Position patient supine in bed, check for jugular vein distention; then elevate the head of the bead at 30-44 degrees observe the vein. Normally vein is flat, if still distended, it is an indication of fluid overload (Right sided heart failure)
CN XI-Spinal Accessory
Assess Trapezius Muscle- place hand on shoulder instruct patient to push your hand up with his shoulder while you push down
Assess SCM Muscle- ask to turn head towards the side of your hand note the strength and contraction of the opposite SCM muscle
Lymph Nodes
- Occipital
- Postauricular
- Preauricular
- Retropharyngeal
- Submandibular
- Submental
SCM - Cervical (Superficial and Deep) - Clavicle
Level of Consciousness - Glasgow Coma Scale
Eyes Open - spontaneously = score of 4 (patient is awake and alert)
Best Verbal Response (Oriented - score of 5) Patient is oriented x 4 (Name, day, where and why)
Best Motor Response - obeys commands = score of 6
Decorticate
Abnormal posturing, stiffening of the body with arms flexed towards chest, fists clenched, wrist and fingers bent
Decerebrate
Abnormal body posture, arms and legs are extended, toes downward, head and neck arched backward
Mini-Mental State of Examination (MMSE)
Measure patients orientation, registration, attention and calculation, recall, language and praxis
Aphasia (impairment of language ability) -
Receptive - Not able to understand written or verbal speech
Expressive - understands written or verbal speech but not able to speak
Examples: Ask patient to repeat the sentence after you “No ifs, ands or buts” (Receptive or expressive)
Give patient a piece of paper and say “take this paper in your right hand, fold it in half and put on the floor” (receptive)
Parts of Brain affected in Aphasia
Frontal (intellectual function) and Temporal Lobe
Broca’s Area - Expressive
Wernicke’s Area - Receptive
Proprioception
Ability to sense position, location, orientation, movement of the body as well as its parts and equilibrium
Grasp Patients toe, holding the toe with your thumb and finger alternate moving the toe up and down, ask patient to state when the toe is up or down
Cerebellar Testing
Ask patient to move hand downward (pronation) and upward (Supination) in rapid movement
Position finger in space facing patient, instruct patient to touch your finger with their finger, then the tip of their nose, reposition your finger after each touch, repeat process and do same with other hand
Ask patient to move the heel of one foot up and down along the shin of the other leg
Posterior Thorax
Inspect: Have a mental picture of chest wall landmarks, inspect for skin and symmetry as patient takes deep breath
Palpate: For tenderness bulging, retraction and crepitus; evaluate for tactile fremitus
Check for Respiratory Excursion: Place hand at the level of the 10th rib in a fanning fashion, instruct patient to take a deep breath and assess for symmetry as your hand moves back and forth
Percuss: Using the middle finger of non-dominant hand and index finger of dominant hand - sound should be “Resonance”
Auscultate same area percussed (8points)
- *Same for Lateral Thorax
- *Anterior Thorax - place thumb along costal margin for respiratory excursion
Kidney Assessment
Percuss: Costovertebral angle with hand in a fist (direct method) or place non-dominant hand over the angle and percuss with your dominant hand in a fist (Indirect)
Bronchial
Normal breath Sounds
present over the large airways in the anterior chest near the second and third intercostal spaces; these sounds are more tubular and hollow-sounding than vesicular sounds, but not as harsh as tracheal breath sounds. Bronchial sounds are loud and high in pitch with a short pause between inspiration and expiration; expiratory sounds last longer than inspiratory sounds
Bronchovesicular
Normal Breath Sounds
heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration.
Vesicular
Normal breath Sounds
soft, blowing, or rustling sounds normally heard throughout most of the lung fields. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.
Ronchi
Adventitious Breath Sounds
Loud, low-pitch, rumbling, snoring sound, cleared by coughing
Crackles
Adventitious Breath Sounds
High pitch crackling, bubbly sound, heard during inspiration, not cleared by coughing
Wheezing
Adventitious Breath Sounds
High Pitch, musical sound, heard over inspiration and expiration, louder on expiration
Systole (S1)
Cardiac Cycle
Closure of the Mitral and Tricuspid causing the 1st heart sound
Diastole (S2)
Cardiac Cycle
Closure of the aortic and pulmonic causing the 2nd heart sound
During diastole, coronary arteries are perfused
Cardiac Assessment
Palpate and Ausculate 5 Landmarks
Aortic- 2nd ICS right of the sternal border
Pulmonic- 2nd ICS left at sternal border
Erb’s Point- 3rd ICS near the midline
Tricuspid- 4th ICS near the midline
Mitral- 5th ICS left midclavicular line (Point of maximum impluse)
Murmur (Valvular Stenosis/Regurgitation)
Abnormal Heart Sounds
Mitral stenosis - diastolic murmur
Mitral Regurgitation - systolic murmur
Congested Heart
Abnormal Heart Sounds
Producing S3 sound (heart failure)
Enlarged Heart
Abnormal Heart Sounds
Producing S4 sound (cardiomyopathy)
Pulse Sites
Temporal Carotid Femoral Dorsalis Pedis Apical Brachial Radial Popliteal Posterior Tibial
Breast Inspection
Inspect breast size and symmetry; observe for masses, retraction, dimpling or flattening; note for inverted nipple, any discharges or bleeding
Palpation: Have patient sit with arms extended and muscle relaxed, palpate lymph nodes along the axillary area as well as the upper and lower clavicular ridges; lying supine, palpate the entire breast using finger pads; note for masses that are hard, fixed non tender, irregular; compress nipple with thumb and index for any discharges
Abdomen Assessment
Inspect: Position supine with knees bent, check for contour and skin; look for pulsation; ask patient to cough and inspect for hernia
Auscultation- using diaphragm of stethoscope, begin at the RLQ continuing clockwise listen for bowel sounds; use the bell, auscultate 1 inch above the umbilicus (aorta); 1 inch to each side (renal arteries); 2 inches down (iliac arteries); then another 1 inch down (femoral)
Percussion: using indirect method, percuss the entire abdomen starting from the RLQ (dullness = liver; tympanic = stomach and intestine)
Liver Palpation/Percussion
Palpation: Ask Patient to take a deep breath and hold, place non dominant hand at the back while dominant hand palpates to find the lower margin of the liver and label; may also use hook method
Percussion: To find the upper margin of the liver, percuss the lung until you hear dullness and label
** The size of the liver at the right midclavicular line is between 6-12 centimeters
Spleen Palpation/Percussion
Palpation: Ask Patient to take a deep breath and hold; place non dominant hand at the back while dominant hand palpates the left costal margin
Percussion: Instruct to turn at right side, percuss the area note the change from resonance to tympanic, dullness if spleen is enlarged
range of Motion
Flexion/Extension Internal Rotation/External Rotation Abduction/adduction Supination/Pronation Dorsiflexion/Plantar Flexion Inversion/Eversion
Rating Muscle Strength
5 - Full ROM against gravity with full resistance - Normal
4 - Full ROM against gravity with moderate resistance - Good
3 - Full ROM with gravity - Fair
2 - Full ROM without gravity (passive motion) - Poor
1 - Palpable muscle contraction but no movement - Trace
0 - No muscle contraction - Zero
Kyphosis
Abnormal upper back curvature
Scoliosis
Sideway curve of the spine
Lordosis
Spine curves significantly inward
Papanicolaou (Pap) Smear
Nurse inserts a vaginal speculum to assess vaginal wall and cervix for any cancerous lesions
Testicular Cancer
Mostly among men aged 18-34, painless enlargement of one testis with a palpable small, hard lump on the front or side of testicle
