Health Assessment Flashcards
What type of data do you collect, validate and analyze during health assessment?
- Subjective
- Objective
Subjective Data
Information based on patient experiences and perceptions
Objective
Measurable and directly observed
Health assessment includes two components:
- Health History
- Physical Assessment
Health history
collection of subjective information about the patient’s health status
Physical assessment
collection of objective data about changes in the patient’s body systems
Types of Health Assessments- 4 types
- Comprehensive
- Ongoing Partial
- Focused
- Emergency
Comprehensive Health Assessment
Conducted upon admission to health care facility
Ongoing Partial Health Assessment
Conducted at regular intervals
Focused Health Assessment
Conducted to assess a specific problem
Emergency Health Assessment
Conducted to determine life threatening or unstable conditions
Considerations When Performing Health Assessment:
- Lifespan considerations
- Cultural Considerations and Sensitivity
- Patient Preparation
- Environmental Preparations
Factors to Assess During a Health History
- Biographical data
- Reason for seeking health care
- History of present health concern
- Past Health History
- Family Health History
- Functional Health
Preparing the Environment for Physical Assessment:
- Hand Hygiene
- Prepare the Examination Table
- Provide a gown and drape for the patient
- Are there any precautions beside standard
- Gather the supplies and instruments needed
- Provide a curtain or screen if the area is open to others
- Provide a comfortable room temp.
Equipment Used During a Physical Examination:
- Thermometer
- Sphygmomanometer
- Scale
- Flashlight or penlight
- Stethoscope
- Metric tape measure and ruler
- Eye chart
- Watch with a second hand
Positions used during Physical Assessment: There are eight
- Standing
- Sitting
- Supine
- Dorsal Recumbent
- Sim’s
- Prone
- Lithotomy
- Knee-chest
Techniques used during a Physical Assessment (say in order)
- Inspection
- Palpation
- Percussion
- Ausculation
Inspection Assesses
size
color
shape
position
symmetry
Palpation Assesses:
temperature
turgor
texture
moisture
vibrations
shape
Percussion assesses
location
shape
size
density of tissues
Auscultation assesses
the four characteristics of sound:
pitch
loudness
quality
duration
General survey includes
General appearance
vital signs
height, weight, waist circumference
calculating BMI
Physical Assessment includes: 10 things
- Integument
- Head and Neck
- Thorax and lungs
- Cardiovascular and peripheral vascular systems
- Breasts and axillae
- Abdomen
- Female and male genitalia
- Anus, rectum, prostate
- Musculoskeletal system
- Neurologic system
Integument (Skin) Assessment Subjective data includes:
History of rashes, lesions, bruising, allergies
Exposures to sun, chemicals
Piercings or tattoos
Degree of mobility
Nutritional status
Skin Language Terminology
Erythema
Ecchymosis
Petechaie
Cyanosis
Jaundice
Pallor
Diaphoresis
Turgor
Edema
Erythema
redness (pertaining to skin)
Ecchymosis
Collection of blood in
subcutaneous tissue (pertaining to skin)
Medical term for a bruise
Petechiae
Hemorrhagic spots/capillary
bleeding (pertaining to skin)
Cyanosis
bluish or grayish color (pertaining to skin)
Jaundice
yellow color (pertaining to skin)
Pallor
Paleness (pertaining to skin)
Diaphoresis
Excessive perspiration (pertaining to skin)
Turgor
Elasticity (pertaining to skin)
Edema
excess fluid (pertaining to skin)
Two types of skin lesions
- Primary Lesions
- Secondary Lesions
Primary Lesions - 9 types
- Macule
- Papule
- Vesicle
- Pustule
- Bulla
- Cyst
- Nodule
- Plaque
- Wheal
Macule
a flat, circumscribed area; can be brown, red, white, tan
Is a primary lesion
Papule
An elevated, palpable, firm, circumscribed area generally less than 5 mm in diameter
Is a primary lesion
Vesicle
an elevated, circumscribed, superficial, fluid-
filled blister less than 5 mm in diameter
Is a primary lesion
Pustule
An elevated, superficial area that is similar to a
vesicle but filled with pus
Is a primary lesion
Bulla
A vesicle greater than 5
mm in diameter
Is a primary lesion
Cyst
An elevated, circumscribed area of the skin filled
with liquid or semisolid fluid
Is a primary lesion
Nodule
An elevated, firm, circumscribed, and palpable
area greater than 5 mm in diameter; can involve all skin layer
Is a primary lesion
Plaque
An elevated, flat-topped, firm, rough, superficial papule greater than 2 cm in diameter; papules can coalesce to form plaques
Is a primary lesion
Wheal
An elevated, irregularly shaped area of cutaneous edema; wheals are solid, transient, and changeable, with a variable diameter; can be red, pale pink, or white
Is a primary lesion
Secondary Lesions include- 4 things
- Crust
- Excoriation
- Lichenification
- Scale
Crust
a slightly elevated area of variable size; consists of dried
serum, blood, or purulent exudate
Is a secondary lesion
Excoriation
Linear scratches that may or may not be denuded
Is a secondary lesion
Lichenification
Rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching (eg, chronic eczema and lichen simplex)
Is a secondary lesion
Scale
Heaped-up keratinized cells; flakey exfoliation; irregular;
thick or thin; dry or oily; variable size; can be white or tan
Is a secondary lesion
Skin, Hair and Nails Objective Assessment: when INSPECTING look for
Color, shape
Lesions (use descriptive terms)
Bruising, lacerations, wounds
Distributions
Clubbing
ABCDE for skin cancer screening
Skin, Hair and Nails Assessment Objective: When PALPATING FEEL for
Temperature
Texture, moisture
Turgor
Edema
Palpable lesions
Capillary lesions
Capillary refill (Normal is <3 seconds)
ABCDE for Skin Cancer Screening
Asymmetry
Border
Color
Diameter
Evolving
Assessing for Melanoma: Assymetry
If a line is drawn through a mole, the two halves will not match
Assessing for Melanoma: Border
The borders of an early melanoma tend to be uneven
The edges may be scalloped or notched
Assessing for Melanoma: Color
A number of different shades of brown, tan, or black could appear
A melanoma may also become red, white or blue
Assessing for Melanoma: Diameter
Melanomas usually are larger in diameter than the size of the eraser on your pencil, but may sometimes be smaller when first detected
What does HEENT stand for?
Head
Ears
Eyes
Nose
Throat
What is SUBJECTIVE data having to do with HEENT
Changes in vision or hearing
History of allergies, chronic illnesses
Exposure to harmful substances or smoking
History of infection or trauma
Pain
Dental care practices
What is OBJECTIVE data having to do with HEENT.
Only Head, Face and Nose for now
Inspection
Shape of head
Size of head
Symmetric and Proportionate
Nasal turbinates
Cranial Nerve I: Olfactory
Terms to document NORMAL findings of head (size and shape)
Normocephalic, symmetric
Terms to document NORMAL findings of nose
Nares moist and darker red than oral mucosa
No evidence of swelling, bleeding, or discharge
reports sense of smell
What is OBJECTIVE data having to do with HEENT.
Only Head, Face and Nose for now
Palpation
Masses, symmetry of head
Frontal and maxillary sinuses
Nasal patency
Cranial Nerve V: Trigeminal nerve
Cranial Nerve VII: Facial
Cranial Nerve V:
Trigeminal Nerve
TMJ assessment (move jaw from side to side clenching teeth and assessing pain and sensation
Cranial Nerve VII
Facial
Ask pt to smile, frown, puff cheeks, etc,
Assessing for symmetry and function
Cranial Nerve I
Olfactory Nerve- smell
Nasal patency
Ask pt to occlude one nare and blow out the other side
“patency” means clear and open
Normal findings having to do with Head, Face, Nose Objective Assessment
No pain upon palpation of sinuses
No masses
Nares patent
What is OBJECTIVE data having to do with HEENT.
Only Ear now
Inspection
Inspect external ears for shape, size, lesions, cerumen, foreign bodies
Internal inspection: Tympanic Membrane
What is OBJECTIVE data having to do with HEENT.
Only Ear now
Palpation
Ear and mastoid process
OBJECTIVE Assessment of Ear hearing includes
Whisper Test
What happens if pt fails whisper test
If pt fails, utilize Weber and Rinne Test
Assessment of Ear with Whisper test assesses what nerve?
Cranial Nerve VIII- Acoustic Nerve
Normal findings of Objective Ear Assessment
No evidence of cerumen, foreign bodies, pain
Ears are aligned and symmetric
TM pearly gray with no erythema
Patient passes Whisper Test
OBJECTIVE Assessment of Eyes: Inspection
Inspect:
Eyelids eyelashes, eyebrows
(distribution, symmetry, alignment)
Cornea
Conjunctiva
Sclera
Direct and Consensual Light Reflex
Extraocular Movements
Visual acuity checked with Snellen Chart
Convergence
Eye Assessment Objective: Acronym
PERRLA
Pupils
Equal
Round
Reactive
Light
Accommodation
Direct and Consensual Light Reflex- How to test it?
Direct Light Reflex: Shine light in one eye- does it constrict
Consensual Light Reflex: Shine light in the same eye- the other eye should constrict as well
What nerve does direct and Consensual Light Reflex test?
Checks Cranial Nerve III Oculomotor Nerve
Extraocular movements in Eyes- How do you test it?
Follow finger with eye.
Move in six cardinal fields of gaze
(box shape and back to center each time)
What are you looking for when testing for Extraocular movements and are doing the 6 cardinal fields of gaze?
Nystagmus
Looking to see if eyes are moving in parallel to each other
Are the eyes moving in the right direction
Any pain?
Extraocular movements assess what cranial nerves?
Checks
Cranial Nerve III (oculomotor)
Cranial Nerve IV (Trochlear)
Cranial Nerve VI (Abducens)
Which nerve does the visual acuity test assess for?
Cranial Nerve II: Optic
This test is done with Snellen Chart
Normal Findings of Objective Eye Assessment
Clear without erythema
Symmetrical
No swelling or exudate
PERRLA
EOMs: Eyes move together, parallel, without evidence of nystagmus
Abnormal findings of Objective Eye Assessment:
Glaucoma
Cataracts
Nystagmus
Any of the above not appearing on exam
Throat Assessment OBJECTIVE:
Inspection:
Ask pt to open mouth and use tongue blade and penlight to look inside mouth
Assess lips, gingiva, teeth, oral mucosa, tongue, hard and soft palates for color, moisture, lesions and swelling
Make pt go “ahh”
Ask pt to stick tongue- note symmetry or deviation from midline
What cranial nerves are assessed when a pt goes “ahhh”
This assesses:
Cranial Nerve IX
Cranial Nerve X
When a pt sticks out tongue, what cranial nerve are you assessing for?
Cranial Nerve XII Facial
When a pt is sticking their tongue out, what about that should you note? (Not talking about nerve type)
Note symmetry or deviation from midline
How to inspect the Thyroid
Inspect the thyroid anteriorly
What landmarks should you locate when inspecting the Thyroid during the thyroid assessment?
Locate landmarks of the Thyroid cartilage, and the cricoid cartilage
How to observe/palpate the Thyroid during Thyroid Assessment?
Observe/palpate left and right by displacing tissue to midline and repeating for other side;
palpate also when patient swallows
Subjective Component of Thorax and Lung Assessment:
Dyspnea
History of trauma or lung surgery
Number of pillows used when sleeping
Cough, chest pain, allergies
Exposure to chemicals
Smoking
Thorax and Lung Assessment:
Order of technique when doing looking for objective data: know the order!
Inspection
Palpation
Percussion
Ausculation
Where should you be doing the techniques (ex; palpate, inspect, etc..) on the body?
Anteriorly and Posteriorly
What are we INSPECTING for anteriorly and posteriorly for lungs and thorax?
Work of breathing, accessory muscle use
Anterior and Posterior diameter
Deformities, rashes, lesions
Symmetry
When we are PALPATING for thorax and lung assessment, what are we assessing for?
We are palpating anteriorly and posteriorly
systematically palpate assessing for moisture, masses, tenderness, vibration, symmetry
Respiratory expansion
Tactile fremitus
Tactile Fremetis
Assessment of vibration
If increased, can be pneumonia or mass; decreased can be obesity, fluid, COPD, asthma
Thorax and Lung Assessment
What is the purpose of Percussion in this assessment?
Percussion differentiates between bone, organs, and tissues.
Percussion determines if tissues are filled with air, fluid, or solid.
What are the sounds of percussion?
Resonant
Flat
Dull or thudlike sounds
Hyperresonant sounds
Tympanic sounds
Sounds of Percussion: Resonant
low pitched, hollow heard over normal lung tissue
Sounds of Percussion: Flat
heard over solid areas such as bone
Sounds of Percussion: Dull or thudlike sounds
Heard over dense areas such as organs
When would dullness replace resonance during percussion of thorax and lungs?
Dullness replaces resonance when fluid or solid tissue replaces air containing lung tissue such as pneumonia, pleural effusions, or tumors
Sounds of Percussion: Hyperresonant sounds
louder and low pitched
Who might have hyperresonant sounds?
children, and very thin adults or persons with hyperinflated lungs - COPD, acute asthma attack.
An area of hyperresonance on one side of the chest may indicate pneumothorax
Sounds of Percussion: Tympanic Sounds
Hollow, high, drumlike sounds.
Normally heard over the stomach. Indicate excessive air in the chest such as in pneumothorax
Objective Thorax and Lung Assessment
Auscultation
Assessed systematically listening for breath sounds that are equal and clear
Determining the different sounds based on location
Assessing for adventitious sounds
Listen for full ventilation
Normal Breath Sounds are also called:
Bronchial
Bronchiovesicular
Vesicular
Abnormal (adventitious) sounds are called:
Wheeze
Rhonchi
Crackles
Stridor
Friction rub
SUBJECTIVE Information to collect during Cardiovascular Assessment
History of chest pain, palpitation, dizziness
Swelling in ankles or feet
Medications
Personal or family history
Type and amount of exercise
Objective information to collect during cardiovascular assessment: What are the techniques to follow to collect OBJECTIVE information?
- Inspection
- Palpation
- Auscultation
What is part of the Neck Vessel Assessment in the Cardiovascular Assessment? (What techniques do you use)
Inspection
Palpation
Auscultation
How should you inspect patient during neck vessel inspection?
Inspection:
Supine with patient at 30-45 degree angle
How should you palpate pt during Neck Vessel assessment?
Palpate one carotid at a time
How should you be auscultating during neck vessel assessment?
Use bell of stethoscope
Normally, you should not hear anything
You are listening for bruit
During the Cardiovascular Assessment, how should you inspect (not talking about Neck vessels now):
Inspection:
With pt in supine position
Inspect precordium for contour, pulsations, and lifts or heaves (rise along the border of the sternum with each heart beat)
Observe the apical impulse at the 5th intercostal space midclavicular line
During the Cardiovascular Assessment, how should you palpate (not talking about Neck vessels now):
Use the palmar surface of hand with four fingers held together
Palpate precordium for pulsations
Proceed in a systematic manner
Palpate the apical impulse in the mitral area (note size, duration, force and location in relationship to the midclavicular line)
For Assessment of Peripheral Vascular System, what is the SUBJECTIVE data you should be collecting?
Ask pt:
History of swelling
Perfusion issues
Cardiovascular Disease
Smoking
Diabetes
For Assessment of Peripheral Vascular System, how should you collect OBJECTIVE data?
Inspect
Palpate
What should you be inspecting for the objective data when assessing the peripheral vascular system?
Inspect extremities, bilaterally for redness (erythema), lesions, hair distribution, edema, varicosities
What should you be palpating when collecting objective data while assessing the peripheral vascular system?
Palpate for pulses:
Brachial
Radial
Ulnar
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Abdominal Assessment: SUBJECTIVE information to collect
Abdominal pain, indigestion, nausea
Nutrition
Changes in bowel habits
Appetite
Alcohol ingestion
Menstrual history
What is the order to collect OBJECTIVE data during Abdominal Assessment?
- Inspection
- Auscultation
- Percussion
- Palpation
OBJECTIVE information to collect during Abdominal Exam: Inspection
When inspecting note:
Skin color
Contour
Pulsations
Umbilicus
Lesions
Masses
OBJECTIVE information to collect during Abdominal Exam: Ausculation
When auscultating note:
Bowel sounds- abnormal or normal
Vascular sounds: bruits
When auscultating during the abdominal exam, what are considered normal sounds
Normal: gurgling every 5-30 seconds
When auscultating during the abdominal exam, what are considered ABNORMAL sounds?
Hyperactive
Hypoactive
Absent
When auscultating during the abdominal exam, what are hyperactive sounds?
Is an abnormal bowel sound
Hyperactive: diarrhea, early bowel obstruction
When auscultating during the abdominal exam, what are hypoactive sounds?
Is an abnormal bowel sound
Hypoactive: Post-op or late bowel obstruction
When auscultating during the abdominal exam, what are absent sounds?
Is an abnormal bowel sound
No bowel sounds for 5 minutes- obstruction
OBJECTIVE information to collect during Abdominal Exam: Percussion
Systematically- comparing both sides
Gas filled has tympanic sound
Fluid and solid have dull sound
OBJECTIVE information to collect during Abdominal Exam: Palpation
Light palpation
Deep palpation
Assess for tenderness, palpable organs , guarding, rebound tenderness
Breast assessment: SUBJECTIVE data to collect
Ask about pain
Ask if they do self examinations of the breast
Lumps
Swelling
Discharge
Menstruation- changes in breasts during this time
Hormones
Recent mammogram
OBJECTIVE data to collect during Breast Assessment
Inspect breasts in different positions
Assess for lumps, symmetry. pulling
Palpate in clockwise motion using pads of three fingers to assess for masses in breast and axillae
Most common place for breast cancer?
Tail of Spence
When should women be doing their breast self examinations?
The week after their menstrual periods
SUBJECTIVE information to collect during MALE genitalia assessment
History of infections
Difficulty with urination
Discharge
Testicular self exam
Erectile dysfunction
Sexual History
OBJECTIVE information to collect during MALE genitalia assessment
Inspection of anatomy
Urinary meatus
if uncircumsized, document and retract foreskin
Should be erythema, tenderness, masses, tensions
When is the best time for men to do their testicular self exam?
Once a month after a warm shower
SUBJECTIVE information to collect during FEMALE genitalia assessment:
Menarche, menstrual history, sexual history, infections, pain with intercourse, OB history
SUBJECTIVE information to collect during musculoskeletal assessment
Trauma, arthritis, neurologic disorders
History of pain or
swelling in muscles or
joints
Frequency and type of
exercise
Dietary intake of
calcium
Smoking, exercise, and
diet history
OBJECTIVE information to collect during FEMALE genitalia assessment:
Inspection of anatomy, should be free of erythema, swelling, lesions, discharge.
Internal exams are for advanced practice nurses
OBJECTIVE information to collect during musculoskeletal assessment: Inspection
Inspect for:
Symmetry of muscles
spinal curves (scoliosis, lordosis, kyphosis)
OBJECTIVE information to collect during musculoskeletal assessment:
Palpation
palpate or tenderness for edema
What are the three things you check for during OBJECTIVE data collection of musculoskeletal assessment?
Inspection
Palpation
Range of Motion
What are you checking for range of motion for during musculoskeletal assessment?
Range of motion of major joints
Neck
Shoulders
Elbows
Wrists
Hip
Spine
Knees
Legs
Feet
How to grade muscle strength while collecting objective information during musculoskeletal assessment?
Grade muscle strength 0-5
What does 0 muscle strength mean
no contraction
What does 1 muscle strength mean
muscle flicker
What does 2 muscle strength mean
muscle can move, not against gravity
What does 3 muscle strength mean
movement possible against gravity, not against resistance
What does 4 muscle strength mean
movement possible against gravity and some resistance
What does 5 muscle strength mean
muscle contracts normally against full resistance
Neurologic Assessment SUBJECTIVE info to collect
History of numbness, tingling, seizures, trembling
Headaches or dizziness
Trauma to head or spine
History of HTN or stroke
Changes in vision, hearing, taste, or smell
History of diabetes or cardiovascular disease
Alcohol and medications
Neurologic Assessment OBJECTIVE info to collect
Mental status
Cranial nerve function
Cerebellar function
Motor and Sensory function
Deep tendon reflexes
What is included in mental status when collecting objective info for neurologic assessment?
Mental status: Level of consciousness, level of awareness, behavior, appearance, memory and language
What is included in Cerebellar function when collecting objective information for neurologic assessment?
Cerebellar function: Gait assessment (Walk regular, heels, toes), Romberg
What is included in Motor and Sensory function when collecting objective information for neurologic assessment?
Motor and Sensory function: rapid alternating movements; light touch, sharp and dull