Health Assessment Flashcards
Primary Health Promotion
Protection to prevent occurrence of disease
Example: immunization, nutrition, exercise
Secondary Health Promotion
Early ID of disease before It becomes symptomatic to hold the progression of pathological process.
Example: Screenings, self-exams ie. scoliosis, skin cancer, mammogram
Tertiary Health Promotion
Minimize severity and disability from disease through appropriate therapy for chronic disease. Example diabetes management, cardiovascular rehab)
Types of Assessments (CPESS)
-Comprehensive (head to toe/physical)
-Problem Based (severe cough)
-Episodic
-Shift (f/up)
-Screenings (disease detection)
Subjective Data
Symptoms reported from patient
Objective Data
Signs observed, felt,, heard, or measured.
Clinical Manifestations
Presenting signs and symptoms
Biological Data
Name, DOB, Gender, Race, Martial Status, Occupation
Reason for Seeking Care
If ill, Hx of present illness, including OLDCARTS
Present Health Status
Scale poor-excellent, Ht/wt, allergies, meds
Present Health History
Childhood illness, injuries, surgeries, hospitalization, immunization, last exams
Family History
Including: Integumentary, Head, Eyes, Ears, Nose, Mouth, Neck, Breast, Heart, Peripheral Vascular, Respiratory, GI, Urinary, Genitalia, Musculoskeletal,CNS, Endocrine,
Personal & Psychosocial Status/Hx
Mental health, support system, health promotion, drugs,tobacco, alcohol use
ROS
Integumentary, Head, Eyes, Ears, Nose, Mouth, Neck, Breast, Heart, Peripheral Vascular, Respiratory, GI, Urinary, Genitalia, Musculoskeletal,CNS, Endocrine,
ISBAR
I- Self Intro
S- Situation
B-Background
A-Assessment
R-Recommendations
Culture
Knowledge, beliefs, art, morals, laws, customs specific to a group of people
Ethnicity
Shared culture characteristics, languages, and beliefs Example (Filipino, Viet, Mexican)
Race
Asian, Caucasian, Hispanic, Black
Mental Status
Degree of intellectual, emotional, psychological, and personal competence. Involves memory, calculating, communication, judgment & reasoning.
Standard Drink
-12 oz of regular beer
-8-9 oz of malt liquor
-5 fl oz of table wine
-1.5 shots of spirits
Screening Tools
-PHQ-9 (Depression)
-C-SSR (Columbia-Suicide Severity Rating Scale)
-COWS (Drugs, Clinical Opiate Withdrawal Scale)
-AUDIT (Alcohol Use Disorders ID Test)
-SADQ (Severity of Alcohol Dependence Questionnaire)
-Human Trafficking
CLAS
Culturally and Linguistic Appropriate Services. Eliminate racial and ethnic disparities
A&Ox4
Awake, Alert, and Oriented to Person, Place, Time, and Event
Prone
Lying on stomach with hands flexed under head over a pillow
Area Assessed: Musculoskeletal
Supine
Laying on your back
Area Assessed: Head, Neck, Anterior Thorax & Lungs, Breast, Axilla, Heart, Abdomen, Extremities, Pulses
Sim’s
On your stomach with one leg up
Area assessed: Rectum and Vagina
Semi-Flower’s
Elevated to at least 30 degrees
Normal VS: Infant
HR: 100-160
Respiratory Rate: 30-53
BP:
-Systolic: 72-104
-Diastolic: 37-56
Normal VS: Toddler
HR: 98-140
RR: 22-37
Systolic: 86-106
Diastolic: 42-63
Normal VS: School-Age Child
HR: 75-118
RR: 18-25
Systolic: 97-115
Diastolic: 57-76
Normal VS: Adolescent
HR: 60-100
RR: 12-20
Systolic: 110-131
Diastolic: 64-83
Normal VS: Adult
HR: 60-100
RR: 12-20
BP: <120/<80
Assessment
A systematic method of collecting and analyzing data of for the purpose of planning patient centered care
3 levels of health promotion
Working out, eating healthy, sleeping, taking vitamins
Culture Competence
Adapting to your clients culture, acknowledge own biases and avoid stereotypes, non biased care
Ways to increase cultural sensitivity
learn about different cultures, respect opinions, and ask questions
CSSRS
Columbia Suicide Severity Rating Scale
COWS
Clinical Opiate Withdrawal Scale
CIWA & SADQ
Clinical Institute Withdrawal Assessment for Alcohol-Revised
Severity of Alcohol Dependence Questionnaire
PHQ-9
Patient Health Questionnaire for Depression
Nursing Proccess
A-Assessment
D-Decision
P-Process
I-Implementation
E-Evaluation
L.E.A.R.N
Listen, Explain, Acknowledge, Recommend, Negotiate
Mental Status
Degree of competence that a person shows in intellectual, emotional, psychological, and personality. A&Ox4
Mental Health
How the patient is doing, able to realize and recognize their own abilities and cope with normal stressors.
Interpersonal violence
Human trafficking screening tool
Open Ended Question
Done at the beginning of the exam if you or patient needs to describe something
Close Ended Questions
Short quick answers for medical history
Directive Questioning
Answer to a specific question such as “what is your eye color?”
Strategies to make Pt comfortable during challenging moments in an interview
-be comfortable
-“many patients use illicit drugs”
Personal and Psychosocial Status
“Have you had any thoughts of harming yourself or others? Do you feel safe at home and in your relationships?”
Health History Components
Biographical Data, Chief Complaint, Mental Status, Hx of present illness, Present Health Status, Past Health History (illnesses, surgery, immunizations, last ann phy, & menstrual cycle), Psychosocial Status (family and social relationships, support system, tobacco, illicit drugs, & alcohol use, ROS
Stethoscope
Auscultation do the heart and other organs & body cavities
Pulse Ox
O2 saturation
Otoscope
Ear Light
Opthalmoscope
Eye Light
Rine & Weber Test (Hearing) CN VIII
Tuning Fork
Rine: On Bone, evaluate bone and air conduction
Weber: Top of the head, evaluate lateralization of sound
Snellen Chart (optic) CN II
Test for distance in vision stand 20 feet away
Jager/Rosenbaum (optic) CN II
For reading (nearsightedness) Hold 14 inches away
Pen light
PERLA and to look in body cavities
PERRLA
Pupil Equally Round, Reactive to Light and Accommodating
Accommodation (oculomotor) CN III
Pupils React to Distance
Consensual Response (oculomotor) CN III
Cover half the face, shine light on one eye, check other eye for dilation
Goniometer
Check degree of flex ion or extension of joints
Calipers
Skin Fold thickness & body fat
IPPA
-Inspection: Visually Inspect patient
-Percussion: Evaluate size, boarders and consistency of internal organs, detect tenderness, fluid in body cavity
-Palpation: Use of Hands to feel texture, size, shape, consistency, location of certain body parts and identity painful or tender areas
Auscultation- Listening to sounds in the body, intensity, pitch, duration, and quality
Palpation Types
Palmar surfaces of fingers and finger lands are more sensitive than fingertips, ulnar surface of the hand is most sensitive to vibration, dorsal is better for temperature
Direct Percussion
Striking finger or hand directly against patients body
Indirect Percussion
Two Types:
Fist
Fingers
Tympanic Percussion Tone
Heard over the abdomen & stomach (tympanic, loud, Hugh, medium, drum like)
Hyperresonant Percussion Tone
Heard in inflated lungs (emphysema), very loud, very low, longer, booming
Dull Percussion Tone
Heard of the liver, medium, medium high, medium, thudlike
Flat Percussion Tone
Bone and Muscle, Flat, Soft, High, Short, Extremely Dull
Resonant Percussion Tone
Lungs, Loud Intensity, Low Pitch, Long Duration, Hollow Quality
Reasons for falsely altered BP readings
High BP, Thyroid Issues, Cardiac Output, Peripheral Vascular Resistance, Volume of Circulating Blood, Age, Sex, Race, Diurnal Rhythm, Meds, Smoking, Diet
Describe the Purpose BP
Purpose: Checks the force of blood circulating through our system
Force of blood pressing against the arterial wall
Systolic Pressure
Max pressure exerted on arteries when ventricles contract or eject blood from the heart
Diastolic Pressure
Minimum pressure exerted by the vessels, ventricles relax and fill with blood
Partial Pressure
Difference between systolic and diastolic pressure. Ranges from 30-40 mm Hg
Routes to Measure Temperature
Oral- Common and Accurate way.
Rectal- Invasive but Inaccurate
Tympanic- Ears
Axillary- Fold of the Arm
Temporal- Temple of head across the forehead
Purpose of Measuring HR
Indicate patients health status check for any illnesses
Methods of Measuring HR
Carotid- Sternocleidomastoid muscle in front of the neck
Apical-Chest (Peds)
Radial- Wrist (Thumb)
Ulnar-Wrist (Pinky)
Femoral-Base of Hip/Leg
Popliteal- Behind Knee
Dorsalis Pedis- Top of foot btwn first & second toe
Posterior Tibial- Behind the Tibia bone on the foot
Sitting Position
Areas Assessed: Head, Neck, Back, Posterior Thorax and Lungs, Breast, Axilla, Heart, VS, upper extremities
Rationale: Expansion of Lungs and better visualization of symmetry
Limitations: Pt may be unable to sit. Use supine position in bed HOB elevated
Supine Position
Lying on Back
Areas Assessed: Head, Neck, Anterior Thorax and Lungs, Breast, Axilla, Heart, Abdomen, Extremities, Pulses
Rationale: Most Relaxed Position. Easy access to pulse site
Limitations: Pt w/ respiratory problems, SOB. Raise head of bed
Dorsal Recumbent
Supine Position with hands raised above and under head, knees propped and feet flat facing outward on the table
Areas Assessed: Head and Neck, Anterior Thorax, Lungs, Breast, Axilla, Heart, Abdomen
Limitations: unable to stay in position for long
Lithotomy Position
Supine Position with waist at edge of bed, legs raises and propped on stand
Area Assessed: Female Genitalia & Genital Tract
Rationale: Max exposure of genitalia and facilitates insertion if vaginal speculum
Limitations: Embarrassing and Uncomfortable. Drape patient to keep them covered
Sims Position
On stomach with left knee slightly raised
Areas Assessed: Rectum and Vagina
Rationale: Flexion of hip improves exposure of rectal area
Limitations: Joint deformities hinders patients mobility
Prone Position
Laying on stomach arms directly on head
Areas Assessed: Musculoskeletal System
Rationale: Asses extension of hip joint only
Limitations: Pt w/ respiratory problems
Lateral Recumbent Position
Laying on side
Areas Assessed: Heart
Rationale: Detects murmurs
Limitations: Pts w/ respiratory problems
Knee Chest Position
All fours, thighs upright position with hips raised above body level
Areas Assessed: Rectum
Rationale: Max exposure of rectal area
Limitations: Embarrassing and Uncomfortable. Minimize time and keep pt covered
Actions to take with abnormal VS
Retake vitals, Compare with Baseline, Consult Dr.
Respiratory Measurement Across Life Span
Men, Infants, Children: Breathe using abdomen, diaphragmatically
Women: using chest, thoracic
Assessing Respiratory Rates and Breathing
Rhythm: Regular, Irregular, Regularly Irregular (infants)
Depth: Excursion of chest wall
-Deep: full lung expansion with full exhalation
-Shallow/Normal: small volume of sir movement in and out of lungs
Effort: Labored or Unlabored
Quality: Clear & Quiet, Wheezing, Whistling
Amplitude (Force) Ratings:
Easily Palpable, smooth, and upstroke
Ratings:
0+ Absent (dead)
+1 Diminishes, barely palpable
+2 Normal
+3 Full Volume (walking upstairs)
+4 Bounding, Hyperactive
Screening Tools for Pain:
Wong Baker: Kids, Faces, 3 years or older
Numeric Rating Scale (NRS): Adolescent, Adults, scale 1-10, cultural barriers
Faces Pain Scale Revised (FPSR): Kids, Faces, 6 years or older
Face, Legs, Activity, Cry, Consolability (FLACC): Non verbal pt unable to report self pain
Appropriate inspection techniques
Present pain scale, Be Gentle, Look for clear signs, OLD CARTS, ICE
OLDCARTS
ONSET: When did the pain begin? Begin Gradually or Suddenly?
LOCATION: Where do you feel the pain? Can you point to the pain?
DURATION: Is the pain constant or does it come and go? How often does it occur and last?
CHARACTERISTICS: Describe the pain? Sharp, Burning, Aching, Cramping, Throbbing?
AGGRAVATING FACTORS: What makes the pain worse? Does the pain seem worse when you feel depressed or anxious?
RELATED SYMPTOMS: When do you experience the pain? Do you notice any symptoms at the same time? Increased HR, SOB, Sweating, Rapid Breathing, Nausea
TREATMENT: What have you done to alleviate the pain? How do you cope?
SEVERITY: Describe the intensity, strength, or severity of the pain. How severe do you let it get before seeking pain relief?
**Ask pt about response to pain. Anger, Crying, Frustration.
Examination of the Head: Expected Findings
-Normocephalic: Uniform shape, size, and intact
-Affect Facial Expressions
-Intact skin, scalp, and hair
-Face: Symmetrical, Skin matches rest of body, No bumps, mumps, lumps, or masses
CN V Trigeminal: Motor, Jaw Opening, Clenching, Chewing
CN VII Facial: Facial Expressions
Examination of Head: Abnormal Findings
-Skull:
Microcephaly: Abnormally Small Head
Macrocephaly: Abnormally Large Head
Acromegaly: Abnormal Growth of Face, Feet, Hands
-Asymmetrical
-Infestation, Scaliness, Hair Loss
-Uneven Skin
Examination of Neck: Normal Findings
-No bumps, mumps, or lumps on Trachea, Thyroid Gland, or Lymph nodes
-Trachea is in the middle of the neck
-Range of Motion: Flexion, Extension, Lateral Bend, Lateral Rotation
-Muscle Strength
CN XI Spinal Accessory: Motor, turning head, shrug shoulder w/ and w/o resistance
Examination of Neck: Abnormal Findings
-Lumps, Mumps, and Masses that are also firm and not movable
-Limited Range of Motion
-Muscle Weakness and Tenderness
-Bruit Sounds in the arteries (turbulent flow in diaphragm)
Examination of Eyes: Normal Findings
-Symmetry of Eyebrows, Eyelashes, Eyes
-Outer Canthus is aligned with Pina of ear
-No discoloration or discharge of conjunctiva, lacrimal puncta, cornea, iris
-Blinking
-White Sclera
-Traction of Direction
-Dilation of Pupil
-Light reactivity
CN II Optic: Sensory, Visual activity and fields
CN III Oculomotor:
~Motor, Raise eyelid, traction
~Parasympathetic, Pupillary Constriction, Change in lens shape
Examination of Eyes: Abnormal Findings
-Flakiness, loss of eyebrows, eyelashes, scaling
-Alignment is off
-Asymmetrical
-Abnormal shape and bulging
-Discoloration and Discharge
-Failed Consensual, Accommodation, and Pupil Dilation
Examination of Ears and TM: Normal Findings
-Able to respond during conversation
-No infection from earrings or piercings and quantity
-External Ear Symmetry and Shape
-No discharge, odor, or discoloration
-No lumps, bumps, or masses
CN VIII Vestibulocochlear: Sensory, Hearing and Equilibrium (balance)
~TM:
-Flat and pearlescent in color
-Malleus: umbo and short process intact
-Asses for cone of light (reflux)
Examination of Ears & TM: Abnormal Findings
-Hard of Hearing
-Tenderness
-Low Set Ears (Down syndrome) or Asymmetrical
-Darwin Tubericle
-Abnormal bumps, lumps, masses, or tags
-Ear Pit
-Bloody or clear discharge
~TM
-Absence or distortion of landmarks (umbo light canal)
-Discolored TM
Examination of Nose: Normal Findings
-Patency
-Symmetry, No discharge, skin is smooth and intact
-Septum and Nasolabial folds are intact and symmetrical
-Nares not flaring or narrowed
-No pain or tenderness around frontal and maxillary sinuses
-Pig nose: Septum,Turbinates, Lateral Walls, and meatus are intact and pink, clear mucosa
CN I Olfactory: Sensory, smell reception and interpretation
Examination of the Nose: Abnormal Findings
-Deviated Septum
-Perorated Septum
-Inflammation of the internal nose
-Abnormal secretions (color, odor, consistency,crust)
-Epistaxis (nose bleed)
-Obstruction of airflow
-No patency
-Asymmetrical nares nasolabial folds
-Tenderness or Pain during Palpation
Examination of the Mouth and Throat: Normal Findings
-Pink lips, symmetrical vertically and laterally, smooth and have linear markings, vermillion border
-Teeth (32 or 28) condition, color, alignment
-Able to clench teeth, pink & healthy gums (observe under dentures)
-No lesions, odors, discharge
-Salivary Glands (submandibular, sublingual, parotid p) are pink and vascular
-Tongue movements and resistance
-buccal mucosa, tonsils, and pillars are pink and symmetrical
-Tongue: able to visualize dorsal, ventral taste buds
CN V Trigeminal: jaw opening and clenching
CN VII Facial:
Motor: Labial Speech and Portray Emotions
Sensory: Taste
Parasympathetic: Secretion of saliva and tears
CN IX Glossopharyngeal:
Motor: Swallowing & Speech sounds
Sensory: Sensation of nasopharynx, gag reflex, taste
Parasympathetic: Secretion of Salivary Glands & Carotid Reflex
CN X Vagus:
Motor: Voluntary swallow and phonation (speech sounds)
Parasympathetic: Secretion of digestive enzymes
CN XII Hypoglossal: Tongue movement, articulation, and swallowing
Examination of the Mouth and Throat: Abnormal Findings
-Cleft Lip
-Missing Teeth, Denture Care
-Oral Lesions
-Discoloration on the outside and inside of mouth
-Limitations in mouth movements (tongue, facial expressions, swallowing, speech)
-Exudate from pharynx and tonsils
-Nodules on both palates
-Irregular patches on tongue
Problems & Diseases: Head
-Psoriasis
-Alopecia
-Brain Tumors
-Bell’s Palsy: Half face is frozen
-Stroke: Half or whole cannot move
Problems & Diseases: Eyes
-Glaucoma
-Nearsightedness & Farsightedness
-Strabismus (lazy eye)
-Conjuctivits
Problems & Diseases: Nose
-Epitaxies
-Chronic Sinus Problems
-Deviates Septum
Problems & Diseases: Ears
-Conductive Hearing Loss
-Obstructed Canal
Problems & Diseases: Mouth and Throat
-Dysphagia (difficulty swallowing food or liquid)
-Strep Throat
-Tonsillitis
-Deviated Trachea
Problems & Diseases: Neck
-Swollen Lymph nodes
-Unable to shrug shoulders
-Limited ROM
-Pregnant women: enlarged thyroid
Head Palpation
Gently, look at hair and line for infestation, scaliness, hair loss, bumps.
Infants: Measure Head, Fissures close around 2 yo.
Temporal Arteries should be smooth and not tender. NOTE PULSATION.
Neck and Throat Palpation
-Trachea
-Thyroid Gland, (Anterior: flex neck slightly forward, Posterior: fingers on either side of trachea SWALLOW TEST )
-Lymph nodes (sub mental, sub mandibular, preauricular, postauricular, occipital, anterior & posterior cervical, deep & superficial cervical, supraclavicular, infraclavicular)
Eye Palpation
Palpate when eyes are closed & lacrimal puncta
Mouth Palpation
Visually inspect teeth, mucosa, lips, gums, and tongue
Nose Palpation
-Front and Maximal Sinus
-Use pen light to inspect inside
CN Tests: Head
CN V Trigeminal:
Sensory: Cotton ball to various locations of face with pt eyes closed
Motor: Place clean hand on pt face over master muscle and clench jaw
CN VII Facial:
Have patient make smile, frown, raise eye brows, puff cheeks, close eyes
CN Test: Neck
CN XI Accessory: Shrug shoulders with and w/o resistance
CN Test: Eyes Visual Acuity
CN II Optic: Distant Vision, Use Snellen Chart & Nearsightedness, Jaeger Chart, Confrontation
-Ask pt if they wear glasses or corrective lenses
Have patient stand at 20 ft away. Cover one eye and read from 20/20 if patient is able to read more than 50%, move down to smallest line they can read. If less than 50%, move up to the next line they can see. Switch eyes and perform same steps.
-If needed use Jaeger chart. Ask patient what’s the smallest line they can read while holding card 14 inches away from eye
-Confrontation test: Get close to patient, cover same eye. Assess peripheral vision.
CN Test: Eyes Oculomotor, Light Reflection of Cornea
CN III:
~Hirschberg Test (Middle Eye Test)
-Stare straight ahead and shine penlight toward bridge of nose.
CN Test: Eyes, Oculomotor, EOM
CN III Oculomotor, CN IV Trochlear, CN VI Abducens
~EOMS, Extra Ocular Eye Movement:
-SIX Cardinal Fields of Gaze
Have patient fixate on pen and without moving their head, make a snowflake with pen
CN Test: Eyes, Oculomotor. PERRLA
CN III Oculomotor: PERRLA (Pupils Equally Round Reactive to Light and Accommodating)
-Inspect if Pupils are Equal and Round
~Corneal Light Reflex (Hirschberg):
-Have patient stare straight ahead and shine light in the middle of the eyes. LOOK FOR LIGHT REFLECTION IN BOTH EYES
~Consensual Response: Pupil react to light
-Place hand in middle of the face, shine light in one, then check the other eye for dilation of pupil (eye with no light). Do for both eyes.
~Accommodation: Pupil react to distance
-Have patient fixate on a distance object then focus back to pen. Check for constriction when focused on far object and dilation when focusing on near object
Red Reflex
Use Opthalmoscope to check RED REFLEX.
-Shine light in pupil while looking through viewing lens. See red glow
Eye Coordination
Light Reflection or Cover Uncover Test
CN Test: Ears
CN VIII: Vestibulocochlear Sensory and Equilibrium
Weber: Bone Conduction
-Use tuning fork and place on midline of skull. Ask patient which ear sound is louder. Normal should be equal bilaterally
Rinne:
-Use tuning fork place on bone behind ear and begin counting till they can’t hear, then switch fork facing the ear and continue count. Normal is 2:1 Ratio
Whisper Test & Finger Rub Test
CN Test: Mouth and Throat
CN IX Glossopharyngeal, CN X Vagus
-Have patient say “ahh”. Use tongue depressor if needed, Look for rise and fall of uvula
CN VII Facial
-Taste test with eyes closed
CN IX Glossopharyngeal, CN X Vagus, CN XII
-Swallow test by standing behind patient, fingers on either side of trachea. Should move freely during swallowing
CN Test: Neck
CN XI Spinal Accessory
-Have patient shrug shoulders with and without resistance
CN Test: Nose
CN I: Olfactory
-Sniff Test, have patient close eyes, nostril at a time
