Health Assessment Flashcards
before you begin
- age group considerations: will have to explain for kids, kids are also scared more often of HCWs
- organization of the assessment: want to do the same way so you don’t forget, can always come back and do something if forget but if go from dirty to clean need to change gloves, wash hands
(abdominal assessment has specific order, everything else is flexible)
level of consciousness
- single most important neuro assessment component
- often first clue of deteriorating condition
testing level of consciousness (LOC)
- alert: attentive, follows commands, if asleep - wakes promptly and remains attentive
- lethargic: drowsy but awakens, slow to respond
- obtunded: difficult to arouse, needs constant stimulation (say name or remind them to stay awake)
- stuporous/semi-comatose: arouses only to vigorous/noxious stimuli (unpleasant, nailbed pinch/pressure, sternal rubbing), may only withdraw from pain
- comatose: no response to verbal or noxious stimuli, no movement except deep tendon reflex
cognitive awareness
is the patient oriented to person, place, time and event?
aka mentation
- oriented x4
- ask name, dob, where are you right now, what brought you here, what year
testing cognitive awareness
- what is your name and date of birth? (person)
- where are you right now? (place)
- what brought you here? (event)
- what year/day is it? (time)
cranial nerves
- 12 pairs
- sensory, motor, or both
- not all cranial nerves are always tested
- listed in order of testing, not numerical value
just have to know what thing tests what nerve
testing cranial nerves 3, 4 and 6
do take glasses off, hold pupil guide on forehead and see what size pupils they have, test pupil response, accommodation (ask them to watch light and hold foot away and bring closer) and cardinal gaze
pupil response:
- examine size and shape of pupils and compare to scale
- start at ear with penlight and move in toward nose
- note change in size and speed of reaction
- with penlight off, move penlight close to and away from pupils
cardinal gaze:
- use tip of unlit penlight
- have patient follow with eyes only
- about 9-12” from face, move the end of penlight in an H motion
testing cranial nerve 7 (smile w/teeth, wrinkle forehead or raise eyebrows)
- ask patient to smile and show teeth
- ask patient to wrinkle forehead or raise eyebrows
testing cranial nerve 12 (xii) (tongue)
- ask patient to touch the roof of mouth with tongue
- protrude tongue out of mouth
- move tongue from side to side
testing cranial nerve 11 (xi)
- place hands lightly on patient shoulders
- ask patient to shrug shoulders (with little bit of resistance)
testing motor function
will complete as part of neuro and musculoskeletal assessments
- hand grasp and toe wiggle (HGTW): put 2 fingers forward and ask patient to grasp them, have them push back on open palms with open palms, push forward
- flexion and extension with resistance: flex and extend feet with your palm on bottom and then top of foot
- all done bilaterally on BUE and BLE
neuro components of assessment
- level of consciousness and orientation
- pupil response and cardinal gaze
- smile and show teeth, raise eyebrows
- tongue to roof of mouth, out, side to side
- shoulder strength with resistance
- HGTW
- flexion/extension BUE and BLE
auscultation of the lungs
normal sounds:
- bronchial: over trachea, loud, high pitched, hollow quality (largest space)
- bronchovesicular: closer to the sternum, blowing sounds
- vesicular: periphery of the lungs, soft and breezy sound
abnormal or adventitious sounds
- crackles or rales: can be fine or coarse, rice krispy sound, high pitched, heard at the lung bases, most common cause is fluid collection
- rhonchi: rumbling coarse sounds heard over trachea and bronchi, due to large secretions in the airway, usually clears with cough
- wheezes: high pitched musical sounds, can hear over all the lung fields, most commonly heard with exhale, although in really severe cases can hear on inhale as well, caused by narrowing of airways, ex: asthma and COPD, lung disease, resp. illness
- pleural friction rubs: one of number 1 reasons we listen to stethoscope over the skin and not on clothing bc sounds like cloth rubbing, between fleural cavity and lungs there is fluid and sometimes there is an adhesion and fluid isn’t there so lungs rub
abnormal respiratory patterns
- bradypnea (slow)
- tachypnea (fast)
- apnea (no breathing)
- hyperpnea (more deeply and faster)
- Kussmaul’s
- Cheyne-Stokes
pattern of auscultation
- 7 anterior and 10 posterior
- always start on patient’s left, listen to inspiration and exhalation, move to next position
- 7th position is there because extra lobe in lungs
- only do deep breaths for posterior 7, 8, 9, 10
- anterior goes top left, across 2, down 3, across 4, down 5, across to right 6 then up for 7th
- posterior goes to top left, across, down, across, down 5, across 6, down 7, across 8, down 9, across 10
nail shape
- examine BUE shape
- put nails in half-heart position to check for clubbing
- clubbing most commonly indicates low oxygen levels
respiratory components of assessment
- anterior and posterior lung sounds
- clubbing
heart sounds
- lub: systole or S1, sound associated with the closing of the mitral/tricuspid valves
- dub: diastolic or S2, sound associated with the closing of the aortic/pulmonal valves
- there are natural pauses between S1 and S2 as well as between S2 and S1 but there should be a longer pause between S2 and S1
(lub and dub is one heart sound?)
location of heart sounds
All Party Till Midnight
listen to 2 cycles, so lubdub lubdub for each place - typical unless having to listen bc took new medications
- aortic: right base, 2nd intercostal space to the right of the sternal border
- pulmonic: left base, 2nd intercostal space to the left of the sternal border
- tricuspid: left lateral sternal border, 5th intercostal space to the left of the sternal border
- mitral: apex, midclavicular line at the 5th intercostal space
pulses
use for assessment:
- carotid (neck)
- radial (wrist)
- apical (chest, heart sounds)
- dorsalis pedis (foot)
other places to feel pulse: (not included in assessment)
- brachial (blood pressure in arm)
- ulnar (other side of wrist)
- femoral (upper thigh)
- popliteal (behind knee)
assessment pulses
- carotid: one at a time, bilaterally
- radial: bilaterally at the same time
- apical: with stethoscope for 2 beats
- dorsalis pedis or pedal pulses: bilaterally at the same time
pulse points
pulse quality:
- 0: absent, non-palpable
- 1+: diminished, palpable, weak and thready
- 2+: strong, normal
- 3+: full, increased
- 4+: bounding
assessment via doppler
hand-held device, most often used for pedal pulses
- put on ultrasonic jelly to amplify sound
- most common on pedal pulses but if having trouble finding radial pulses, can use it
- don’t need doctor’s orders or anything, can just grab and use
- would want to document if used it in EMR: pedal pulses 0, doppler used to verify that they were there
