Health Assessment 2220 Exam 1 Flashcards
What does health assessment include?
encompasses the entire person such as physical, intellectual, spiritual, environmental, sociocultural, and emotional
How to conduct health assessment
gathering information about health status of pt current and past history, health history subjective, and physical assessment objective
types of health assessments
initial/comprehensive, focused/episodic, emergency, and time lapsed
initial/comprehensive assessment
full head to toes exam conducted on admission
focused/episodic assessment
specific to injury/complain of pt and is conducted after comprehensive exam focused on pt chief complaint (ex: ABD pain requires ABD exam)
Emergency Assessment
life threatening problems need to be noted and solved immediately; focused on ABCs then secondary complaints; rapid head to toe exam/trauma assessment conducted (ex: stabbings, anaphylaxis, SOB)
Time lapsed
interval assessment such as taking vital signs every 4 hours or every so many days a pt requires a check up
Types of assessment techniques in order
Inspection, palpation, percussion, and auscultation
Order of assessment for abdominal exam
Inspection, auscultation, percussion, palpation (palpating prior to auscultation can create abnormal bowel sounds)
inspection assessment
what do you see, hear, smell? what size, color, shape, position, symmetrical?
palpation assessment
feeling of the pt body using palmar surface and fingers for sensitivity, ulnar surface for vibration, dorsal surface for temperature; whats the temp., skin turgor, texture, moisture, vibration, shape?
light palpation
1cm (0.5”)
moderate palpation
1cm-2cm (0.5-0.75”)
deep palpation
2cm (1”)
percussion assessment
tapping of pt body listening for different sounds that are produced (hollow vs. dense)
direct percussion
directly tapping on surface of pt
blunt percussion
using the ulnar surface of fist and thumping your own other hand against pt
indirect percussion
tapping finger on own other finger/hand against pt
auscultation assessment
listening to pt organs and bodily systems with stethoscope
use for diaphragm
to hear higher pitched sounds such as lung sounds, bowel sounds, and normal heart sounds
use for bell
listen to lower pitched sounds such as murmurs or bruits
is bell pressed lightly or firmly when auscultating
lightly
diaphragm pressed lightly or firmly when auscultating?
firmly
what are you listening for when auscultating?
quality of sounds such as pitch (high or low), loudness (soft or loud), duration (short,medium, or long), quality (description of sound)
tips for ausculation
examine from the right of pt, warm stethoscope, close eyes for better attention, auscultate on bare skin
general survey importance
begins moment of contact, provides clues to overall health, first impression give cues for what needs attention, establishes pt baseline, includes vitals, H&W
What to observe for in general survey
(11) 1. signs of distress, 2. stature/build, 3. speech patterns, 4. Significant others accompanying, 5. Dressing/grooming, 6. posture/gait/coordination, 7. LOC, 8. Eye contact, 9. vision/hearing problems, 10. nutritional state, 11. affect
example general survey
pt is 56 Y male construction worker appears healthy and stated age
pt AOx4, cooperative and shwoing no signs of distress
HT 6’1” Wt 202lbs
T- 97.6 P-82bpm RR 16/min BP 122/78 R arm sitting
The importance of an interview
establishes trust
Health history
biographical data, reason for seeking care, present health or history of present illness, past health, family history, functional assessment & ADLs/psychosocial
chief complaint
reason pt is seeking care in their own words
present health or HPI
location, character/quality, severity/quantity, timing, setting, aggravating/relieving factors, associated/radiating factors, pt perception; OPQRSTI
Past health
childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, OB history, immunizations, last exam, allergies, current meds
family history
age and health/cause of death of blood relatives; presence of heart disease, cancer, HTN, CVA, diabetes, cancer, blood disorders, obesity, psychiatric
subjective data
symptoms that pt describes; clinician cannot see these and relies on pt word (pain, health history
objective data
what can be seen through a general survey and physical examination
interviewing techniques
(5) validating- validates correctness of what nurse heard, clarifying- using question to decipher the truth or if something is unclear, reflecting- repeating what pt has said or describing feelings to elaborate, sequencing- used to place events in chronological order to identify cause and effect, directing- obtain more information or introduce something new
open ended questions
used to start conversation and obtain information (ex; what concerns do you have about treatment?)
close-ended questions
helpful for seeking specific information or clarification (ex: how many times do you take this medication?)
communicating with children
be responsive to nonverbal communication, get at eye level, be gentle and calm, use understandable language, use structured play
communicating with critically ill
assume they can hear you, explain what you are doing and provide cues about day/night, call bell within reach
sources for assessment
reviewing medical records, patient interview, family interview, other providers
phases of interview
introduction-purpose of interview, how long it will take, expectations, ensure confidentiality, working- open-ended questions for obtaining info and close-ended for direct questions, closing- summary of the interview
functional assessment
self esteem/self-concept: personal identity, body image, role-performance, activity: are they active or sedentary, sleep/rest: adequate sleep, nutrition/elim.: good diet and bowels, stress/adaptations: stressors in life d/t job or family and what coping skills, intimate partner violence: safe at home or stating domestic violence
older adult assessment tool
SPICES: sleep disorders, problems with eating, incontinence, confusion, evidence of falls, skin breakdown
non-verbal communication
physical appearance and facial expressions (how you present to the pt), posture (get at eye level), gestures, tone of voice and touch (be careful with touch)
equipment used for assessments
opthalmoscope for eyes, odoscope for ears, stethothscope for lungs, hear, BP, heart sounds, bowel sounds, pulse ox for sat
when are vital signs taken?
admissions, discharge, change in status, every 1-4-8 hours (depending on floor)
normal ranges
BP- 120/80, HR-60-100, RR- 12-20, Sat. 95-100 , Core temp. 35.9-38 C or 96.7-100.4F
What can affect vitals
pain
most accurate temp.
rectal (98.7-100.5)
least accurate temp.
axillary
ways to measure core temp
tympanic and rectal (rectal usually 1 degree F higher than oral)
how to take BP
using sphygmomanometer and stethescope, aneroid (calibrated 2mmHg), needle at 0
incorrect BP readings
too small of cuff = higher reading and too large cuff= lower reading; pt has not rester (5 min), consumption of caffeine, smoked, arm not at heart level, pt not quiet
factors affecting temperature
circadian rhythm (lowest temp in AM and peak around 4-8PM), age (older = lower core temp.), sex progesterone during ovulation increases temp. (~0.5-1F), environmental temp or consuming warm drink (wait 15 min), increase in metabolic rate (exercise, stress, illness)
oral route temp
most common; blue one for mouth; wait 15-30 minutes after iced or hot drink
contraindications to oral temp
kids <5 years, confused/unconscious pt, comatose pt, pt with seizure disorders, pt after oral/nasal surgery, pt receiving O2
tympanic membrane route
measures core temp (usually 1F higher than oral), good for young, confused/unconscious pt
contraindication for tympanic membrane temp.
pt with ear drainage, external ear infection (middle ear infect. is fine), or scars on tympanic membrane
temporal
non-inasive, quick, reliable
contraindications to temporal artery route temp.
do not measure over scar tissue, open lesions, or abrasions
axillary route
used when both oral and rectal are contraindicated, not used when accuracy required, usually 1 F lower than oral
core temp measurements
tympanic membrane and rectal
rectal temp. route
measures core temp., the most accurate, 1 degree higher than oral, use lubricant, insert in direction of umbilicus 1.5 inch
contraindication of rectal temp
pt with diarrhea, bowel surgery, rectal diseases, heart disease or after cardiac surgery, neutropenic pt, pt with spinal cord injury, throbocytopenia
factors that afect respirations
(12 factors) age (d/t lung capacity), sex (males lower RR d/t capacity), altitude (increased elevation = increased RR), stree/anxiety (stimulates SNS increasing R), exercise (increase O2 demand increasing RR), medications (narcs depress Resp. drive and stimulants increase), acid-base balance (hyperventilate to release CO2), brain lesions (cheyne stokes), respiratory disease (can affect rate, depth, pattern), pain (incease RR but decreases depth), anemia (decreased O2 carrying which increases RR), fever (increases metabolic rate which increases RR)
when counting respirations
do not announce, count to 15 sec and multiply by 4; if irregular count for 1 minute
Pulse factors
W>M, pulse decreases with age (infant pulse varies with breathing), SNS increases HR and PNS decreases HR, fever stress, disease, activity increase HR, beta blocker slow down HR, atropine increase HR
pulse sites
superficial temporal (forehead), external maxillary (in front of ear), carotid ( at a time), brachial, ulnar, radial, femoral (groin), popliteal (behind knee), posterior tibial (medial posterior to ankle), dorsalis pedis (top of foot)
where to palpate on unresponsive
carotid
pulse deficit
difference between apical and pulse rates (femoral or radial); not every beat is generating enough blood flow for peripheral pulse
when count pulse for 60 seconds
irregular rhythm
factors affecting BP
age (increase with age d/t decreased elasticity; wider pulse pressure with age), circadian rhythm (lowest in AM; varies 5-10), sex (w lower than M until menopause), food intake (increases after food), exercise 9increases during exercise), weight (increased BP with increased weight), emotional state (anxiety, pain, fear, excitement, increases BP by stim. SNS), body position (lower in prone/supine), race (higher in African Americans), meds (diuretics decrease BP, oral contraceptives increase BP)
Normal BP
120/80 and below
Prehypertension
120-129/80
stage 1 HTN
130-139/80-89
stage 2 HTN
140+/90+
HTN crisis
180+/and or 120+
Why is normal BP important
HTN is one of leading causes for cardiovascular disorders like MI, stroke, renal failure,\; end organ damage of brain, heart, kidneys
orthostatic hypotension
decrease in SBP of 20 or more and decrease of DBP of 10 or more within 3 minutes of standing compared to supine/sitting; d/t vasodilation (HR compensates by increasing)
need for O2
less than or equal to 90%
inaccurate sat readings
HGB too low, poor Peripheral circ. movement, CO (higher affinity for binding), thick nails, dark nail polish
Valves of heart and location
Tricuspid valve (from right atria to right ventricle, pulmonary valve (right ventricle to right pulmonary artery), mitral valve (left atrium to left ventricle), aortic valve (left ventricle to aorta)
auscultate aorta
2nd intercostal space, RSB
auscultate pulmonary artery
2nd intercostal space, LSB
auscultate Erbs point
3rd intercostal space, LST
auscultate tricuspid valve
4th intercostal space, LSB
auscultate mitral valve
5th intercostal space, mid clavicular line
PMI
point of maximal impulse is 5th intercostal space mid clavicular line; apical pulse
S1 sounds
closing of AV valves (mitral and Tricuspid); ventricular systole begins
S2 sounds
closing of Semilunar valves (pulmonary and aortic); diastole begins
diastole
period between S2 and S1
systole
area between S1 and S2
what are you feeling at the PMI
ventricular recoil
documenting pulses
rate, rhythm, and quality; location; amplitude (0-+3)
pulse amplitudes
0- absent pulse, unable to palpate, +1- diminished pulse, +2- brisk, normal pulse, +3- bounding pulse
how to find/auscultated weak or difficult pulses
use a doppler
pack years documenting
15 years of smoking 2.5 packs a day = 37.5 pack year
BMI
ratio of weight to height
underweight
less than 18.5 BMI
normal weight
18.5-24.9 BMI
overweight
25-29.9 BMI
obese
30-39.9 BMI
extreme obesity
40+ BMI
Cardiovascular exam
signs and symptoms, lifestyle habits, medications, family history, smoking history
signs and symptoms of CV
fatigue, dyspnea, chest pain, SOB, leg cramping, foot sensation (pins and needles), wound healing (slow), edema, arrythmias or palpitations
lifestyle habits for CV
alcohol consumption, smoking, exercise, diet
family history for CV
HTN, DM, murmurs, CHD, CVD (cardiovascular disease), dyslipidemia (dysfunctional lipids), obesity, LQTS (long QT syndrome)
smoking history
type of tobacco or nicotine, when started and stopped, pack years, smoking cessation
risk of lung cancer for former smokers
risk is back to those of non smokers after 15 years
HDL vs. LDL
HDL keeps arteries clear of plaques; LDL forms plaques causing hardening and narrowing
Lipid lab numbers
triglycerides <150mg/dL
Total CHOL <200mg/dL
LDL <100mg/dL
HDL >60mg/dL
Cardiopulmonary Inspection
skin color (general, lips, nailbeds); body position (upright or tripod); finger clubbing (from chronic hypoxia); nasal flaring (hypoxia sign); anxiousness or restlessness
Central cyanosis
blue lips and due to low arterial O2, cap refill < 3 sec (normal)
peripheral cyanosis
normal arterial O2, prolonged cap refill > 3 sec
edema
caused by capillaries leaking fluid; scale is +1-+4 (2mm, 4mm, 6mm, 8mm (pitting))
causes for edema
hear failure, kidney failure, liver failure, weakness/damage to veins in legs, inadequate lymphatic system, long term protein deficiency, increased cell membrane permeability
skin turgor
hydration status; pinched skin should return to normal otherwise it results in tenting
location for turgor test
forearm, sternum, sub-clavicular, abdomen In children (do not use back of hands for older adults)
types of pain
acute vs chronic
acute pain
last less than 6 months (rapid onset), mild - severe, triggers autonomic nervous system (increase HR, BP, and RR), disappears after underlying cause is resolved
chronic pain
lasts beyond normal healing period, minimum of 6 months, can be unrelenting and severe or consistent or comes and goes
sources of pain
cutaneous/ superficial (skin wound), somatic (tendon, ligament, nerve, bone, blood), visceral (organ pain), referred pain (originates somewhere but is felt elsewhere), neuropathic (pins and needles; disease/lesion of CNS or PNS), intractable pain (resistant to interventions) psychogenic pain (no reason for pain)
pain assessment
COLD ERA and OLDCARTS
COLD ERA
character of complaint/ pain, onset of symptoms, location, duration or pain, exacerbated by what, relieved by what, associated symptoms
OLDCARTS
onset, location, duration, character, aggravating factors/associated symptoms, relieving factors, treatment, severity
pain rating scales
Wong baker (faces), 0-10 distress scale, abbey pain scale, nonverbal pain scales (dementia pain scales), FLACC pain scale (2 months-7 years)
medical asepsis
hand hygiene and wearing gloves; reduce number of pathogens; keeping clean
types of PPE
gloves, gowns, masks, eyewear
gowns
prevent soiling of blood/bodily fluids
masks
prevent inhalation of large particle aerosols and small droplet nuclei; discourage touching eyes, nose, mouth
eyewear
protect eye membrane from splash contamination
N95
filtering facepiece respirator; filters out 95% of particles; needs to be fit-tested, can reuse for 5 days
donning PPE
wash hands, put on gown, put on mask, put on goggles/face shield, put on gloves (outside of pt room)
doffing PPE
(untie gown ties if fasten in front then…), remove gloves, then goggles/face shield, then gown, then mask, then wash hands
HAI
healthcare associated infections
Types of HAIs
CAUTI, SSI, VAP, CLABSI, MRSA, C-Diff, VRE, CRE
CAUTI
catheter associated UTI
SSI
surgical site infections
VAP
ventilator associated pneumonia
CLABSI
central line associated bloodstream infections
MRSA
methicillin resist and staphylococcus aureus
C-diff
gram pos. bacillus (anaerobic); diarrhea; contact enteric precautions (gloves and gowns); use soap d/t spores
types of precautions
contact (direct or indirect), airborne, droplet
types of indirect contact
vector (living creature ex: insect) and fomite (inanimate object)
how to create correct precaution measures
standard precautions + transmission based
standard precautions
blood, all bodily fluids EXCEPT sweat, non-intact skin, mucous membrane
contact/contact enteric (intestines) definition and PPE
gown, gloves, handwashing before, disposable equip or clean with chlorhexidine;
contact and contact enteric precautions
private room if possible, dedicated equip., door can be open, disposable cleaning supplies, transport- protect surfaces, instructions to visitors are susceptibility and PPE
droplet precautions definition and PPE
mask, gown, gloves; infections spread by large particle droplets (ex: rubella, mumps, diptheria)
droplet precautions
private room if possible, dedicated equipment, door can be open, transport of pt- mask and tissue receptacle, instructions of visitors- susceptibility and PPE
airborne precautions defintion and PPE
TB, varicells, rubeola; resppirator, gown, and gloves (room may have HEPA
airborne precautions
private room (neg. pressure and sealed), dedicated equipment, door closed, pt transport requires mask, instruct visitors susceptibility and PPE
Reverse (neutropenic) isolastion
private room, dedicated equip., door closed, no standing water in room, no plants/flowers, healthy providers. transport of pt needs mask, visitors should not visit if sick, where proper PPE
5 steps of infection prevention
stop at the source, block portal of exit (cover motuh when cough), interrupt mode of transportation (wash hands), protect portal of entry (mucous mebranes), increase defense (vaccines)
infectious agent
BACTERIA, fungi, virus, parasite
reservoir/host
natural habitat of organism (human, animal, inanimate object)
portal of exit
sputum, emesis, stool, blood
means of transmission
aerosol, droplet, contact
portal of entry
mucous membranes, nonintact skin, GI tract, GU tract, respiratory tract
susceptible host
immunosuppressed, elderly, chronically ill, trauma/surgery
stages of infections
incubation (pathogen proliferating), prodromal (person is most infectious with vague and nonspecific symptoms), full stage (specific signs and symptoms of disease), convalescent (recovery from infection)
gram positive bacteria
1 large cell wall that does stain; easier to kill
gram negative bacteria
double phospholipid cell membrane; harder to kill; does not stain
broad spectrum vs. narrow spectrum antibiotic
broad kills both whereas narrow kills 1
exogenous transmission
entering body from environment
endogenous transmission
become infected with own bacteria (micoflora)
fungal infections
spread by direct skin contact or indirectly from contaminated floors or soils
