Health Assessment Review

Question 1

Physical Assessment Components

(Inspection, Palpation, Percussion, Auscultation)

Answer 1

• Inspection:
  
  • Use of sight to assess for size, color, share & symmetry.
• Palpation:
  
  • Use of touch to assess for temperature, turgor, texture, moisture, vibrations, shape, size. Use dorsal surface of hand to assess temperature. Assess most tender areas last.
• Percussion:
  
  • Tapping a person’s skin to assess for location, size, density of tissues
• Auscultation:
  
  • Listening with a stethoscope to assess pitch, loudness, quality & duration of body sounds.

Question 2

Vital Signs: Pulse

What to assess?

How to take radial/apical pulse?

What is a pulse deficit?

Answer 2

Assess: Rate, rhythm (regular or irregular), equality (right vs. left side), and strength (0-4+)

Radial: Palpate using the index, middle & 4th finger on the wrist closest to the thumb.

Apical: Auscultate using the diaphragm of the stethoscope at the fifth ICS at left MCL

Pulse deficit = apical pulse - (minus) radial pulse; need two people to perform; one takes the apical pulse for a full minute; the other person takes the radial pulse for a full minute at the exact same time; the numbers should be the SAME; an actual pulse deficit is NOT an expected finding; it means that not every heart beat/ventricular contraction is not getting to the periphery.

Note: For an irregular pulse, count for a full minute.

Question 3

Vital Signs: Blood Pressure

Key Points

Answer 3

• BP cuff sizing: The BP cuff width should be 40% of arm circumference. Bladder should surround 80% of arm circumference. If it is too large = false low reading. If it is too small = false high reading.
• Do not take BP on an arm with a patient who has a PICC line, a mastectomy or an AV fistula. Prefer not to take the BP on a side with an IV line if possible.

Question 4

Pulse

Expected Rate, Rhythm & Strength

Answer 4

• Rate:
  
  • Adults - 60-100 bpm
    
    • Bradycardia (<60)
    • Tachycardia (>100)
• Rhythm:
  
  • Regular
• Strength:
  
  • 0 = absent
  • 1+ = diminished
  • 2+ = normal
  • 3+ = strong
  • 4+ = bounding/unable to obliterate w/ pressure

Question 5

Orthostatic Hypotension

When & how to assess?

Answer 5

When to assess?

• When ordered by provider &/or when patient reports syncope, certain medications (ex., antihypertensive meds) or if hypovolemic.

How to assess:

• Have patient lie in supine 5-10 minutes; take BP & pulse in supine.
• Sit patient up, 2-3 minutes; take BP & pulse
• Have patient stand up, wait 2 minutes; take BP & pulse
• Monitor for dizziness, weakness, fatigue.

Question 6

Pain Assessment

Components of Pain Assessment

Answer 6

• Location of pain?
• Quality of pain (patient’s word):
  
  • Nociceptive pain (described as “aching” or “throbbing”)
  • Neuropathic pain (described as “shooting” or “burning”)
• Intensity of pain (pain scale)
• Timing (onset, duration, frequency)
• Accompanying symptoms (e.g., nausea)
• What relieves pain?
• What makes pain worse?

Question 7

Eye assessment: What to assess?

Answer 7

Conjunctive pink? Sclera white?

PERRLA (pupils are equal, round, reactive to light & accommodation)

• Check for accommodation by asking the patient to focus on a distant object (pupil dilates), then to a near object (pupil constricts).

How to check for consensual response?

• Shine a penlight into the patient’s right eye.
• Expected finding: Both the left “and” the right eye constrict.

Question 8

S/S of Hypoxia are…

Answer 8

Apprehension, restlessness (often an early sign ), inability to concentrate, decreased level of
consciousness, dizziness, behavioral changes, fatigue, and agitation.

Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia.

Question 9

Respiratory:

Expected Rate

Pulse Oximetry

Answer 9

• Rate (Adults):
  
  • 12-20 breaths/minute
  • Bradypnea (RR < 12)
  • Tachypnea (RR > 20)
• SpO2: 95-100%
  
  • Low 90s is expected for COPD patients.

Question 10

Abnormal Lung Sounds

Answer 10

• Crackles (fine):
  
  • High-pitched crackling/popping sound; take several strands of hair (if your hair is long enough :)) and rub them back & forth right at your ear. That is what fine crackles sound like. Indicates are moving through collapsed alveoli.
• Crackles (coarse):
  
  • Low-pitched bubbling/popping sound. Indicates air moving through collapsed alveoli.
• Wheezes:
  
  • High-pitched, muscial, squeaky; indicates air moving through narrowed passageways
• Rhonchi:
  
  • Low-pitched, continuous, snoring-like sounds; indicates air moving through fluid-field airways
• Pleural friction rub:
  
  • Loud, grating, scratching sounds; indicates inflamed pleura
• Absent breath sounds

Question 11

Anatomy of Lungs

(Lobes & Apex vs Base)

Answer 11

• Lobes:
  
  • 3 on right lung
  • 2 on left lung
• Apex of lung:
  
  • At top
• Base of lung:
  
  • At bottom (Note: the heart is opposite - apex at bottom & base at top of heart)

Question 12

AP to Transverse Diameter

Answer 12

• Normal AP diameter is 1:2
• 2:2 diameter called a barrel chest; sometimes seen with patients who have chronic COPD or other obstructive pulmonary diseases

Question 13

Posterior Chest Auscultation

Answer 13

Auscultate all lung sounds using the diaphragm (see picture; using the “S” pattern; are bilateral breath sounds equal & clear?)

Question 14

Neck Vessels

Inspection, Palpation, Auscultation

Answer 14

• Inspection:
  
  • Assess for jugular venous distention (JVD):
    
    • Position patient at 30-45 degree angle & inspect the jugular with penlight.
    • Note visible pulsations or signs of JVD.
• Palpation:
  
  • Palpate each carotid artery (one at a time!).
  • 4+ (0-4+ range) = “unable to obliterate with pressure; which is expected finding
• Auscultation:
  
  • Use bell to listen for bruits (swishing sound, not expected finding).
    
    • Ask patient to inhale, exhale & hold breath while you listen.

Question 15

Where are all the palpable pulses locations in the body?

Answer 15

Question 16

Heart Auscultation

Answer 16

• Auscultation:
  
  • Auscultate with both bell & diaphragm
  • Identify rate/rhythm, S1 & S2 sounds; listen for extra hear sounds, murmurs at 5 locations (APETM):
    
    • Aortic valve: 2nd ICS, RSB
    • Pulmonic valve: 2nd ICS, LSB
    • Erb’s Point: 3rd ICS, LSB
    • Tricuspid valve: 4th ICS, LSB
    • Mitral valve (point of maximal impulse/PMI): 5th ICS, left MCL.
• Normal Heart Sounds:
  
  • https://youtu.be/FtXNnmifbhE

Question 17

S1 & S2 Heart Sounds

Answer 17

• S1 heard best at 5th ICS, LSB (PMI)
• S2 heard best at 2nd ICS, RSB

Question 18

Heart: Auscultation Sites

Answer 18

“All People Enjoy Times Magazine”

Question 19

• *When inspecting/palpating/auscultating the apical impulse, the nurse knows to assess at this
  landmark: **

Answer 19

Apical pulse occupies the 5th intercostal space, at the left midclavicular line. (Varies slightly with individuals.)

Question 20

Name the Structures on This Picture

Answer 20

A. Aortic area

B. Pulmonic area

C. Erb’s point

D. Tricuspid area

E. Mitral area

1. 1st ICS
2. 2nd ICS
3. 3rd ICS
4. 4th ICS
5. 5th ICS

Question 21

Where is the base/apex of the heart?

Where is the base/apex of the lungs?

Answer 21

The apex of the heart (see picture) is at the bottom of the heart. That is where the PMI (point of maximal impulse) is located. The base of the heart (see picture) is at the top of the heart.

The apex of the lungs (not denoted in picture) is actually at the top of the lungs; and the base of the lungs is located at the bottom of the lungs.

Question 22

Anatomy & Blood Flow of the Heart

Answer 22

• Know blood flow (oxygenated & deoxygenated blood), chambers & valves

Question 23

Musculoskeletal System

Inspection/Palpation, Spinal Curvatures, ROM, Muscle Strength

Answer 23

• Spinal Curvatures:
  
  • Scoliosis, kyphosis, lordosis
• ROM of all joints:
  
  • Specify
• Muscle Strength:
  
  • 0-5 range; strength should be equal bilaterally

Question 24

Range of Motion of All Joints

Answer 24

• Flexion
• Extension
• Hyperextension (neck, waist, wrist)
• External rotation (hip, shoulder)
• Internal rotation (hip, shoulder)
• Abduction
• Adduction
• Circumduction (shoulder, hip, ankle)
• Supination
• Pronation
• Inversion
• Eversion
• Dorsiflexion & planter flexion (ankle)

Question 25

Level of Consciousness

Alert, Lethargic, Obtunded, Stuporous, Comatose

Answer 25

• Alert:
  
  • Awake, alert, responds to questions approppriately, follows commands
• Lethargic:
  
  • Drowsy but easily awakened by calling name in a normal voice; responds to questions or commands but falls asleep when not stimulated
• Obtunded:
  
  • Difficult to arouse; requires vigorous shaking or shouting; confused, slow to respond, requires constant stimulation for cooperation.
• Stuporous:
  
  • Unconsciousness most of the timne; responds only to vigorous shaking or painful stimulis; inappropriate verbal response (mumbling or groaning).
• Comatose:
  
  • Completely unconscious, unresponsive to pain, abnormal posturing may be present.
  • Decorticate:
    
    • Arms flexed & internally rotated, legs extended & rotated inward.
  • Decerebrate:
    
    • Head arched back; arms & legs extended.

Question 26

Glasgow Coma Scale

Answer 26

Score between 3 & 15; less than 8 = severe head injury &/or coma; between 9-12 = moderate injury; 15 = fully alert.

Assessment:

• Eye opening:
  
  • 4 = Spontaneous
  • 3 = In response to voice
  • 2 = In response to pain
  • 1 = No eye opening
• Verbal response:
  
  • 5 = Coherent & oriented
  • 4 = Incohorent/disoriented
  • 3 = Inappropriate words
  • 2 = Sounds; no words
  • 1 = No vocalization
• Motor response:
  
  • 6 = Follows commands
  • 5 = Local reaction to pain
  • 4 = General withdrawal from pain
  • 3 = Decorticate posture
  • 2 = Decerebrate posture
  • 1 = No motor response

Question 27

Anatomy of GI Tract

Answer 27

• Difference between esophageal & pyloric sphincter.
• The order of the small intestines:
  
  • Duodenum, jejunum, ileum
• The order of the large intestines:
  
  • Ascending, transverse, decending, sigmoid colon

Question 28

Locations of all organs in abdomen (r/t quadrants)

Answer 28

Question 29

Abdomen:

Inspection, Auscultation, Palpation

(didn’t include percussion; nurses typically don’t percuss)

Answer 29

• Inspection:
  
  • Assess for contour, for lesions, scars, striae, distention, symmetry
• Auscultation:
  
  • Auscultate bowel sounds in all 4 quads:
    
    • Use bell to listen for bruit over abdominal aorta
• Palpation:
  
  • Palpate to asess for muscle guarding, rigidity, masses, tenderness
  • Palpate tender areas “last”.

Question 30

Bowel Sounds

Answer 30

• Normal:
  
  • High-pitched clicking, gurgling, cascading sounds that occur irregularly (5-30 time/min)
• Hypoactive:
  
  • Diminished bowel sounds; listen for 5 minutes before determining the patient has absent bowel sounds
• Hyperactive:
  
  • Loud growling or gurgling sounds (“borborygmus”) which indicate increase motility

Question 31

Skin - Color Assessment

Answer 31

• Pallor:
  
  • Anemia, shock, local arterial insufficiency
• Cyanosis (blue):
  
  • Deoxygenated hemoglobin due to CV or respiratory disorders
• Erythema (red):
  
  • Inflammation, fever, polycythemia, alcohol intake
• Jaundice (yellow):
  
  • Elevated bilirubin levels due to liver or blocked bile duct, hemolytic anemia
• Brown discoloration:
  
  • Addison’s disease (bronzed appearance), venous status dermatitis

Question 32

Explain the grading scale for pitting edema.

Answer 32

• 1+ Mild pitting; slight indentation; no perceptible swelling of the leg
• 2+ Moderate pitting; indentation subsides rapidly
• 3+ Deep pitting; indentation remains for a short time; leg looks swollen
• 4+ Very deep pitting; indentation lasts a long time; leg is grossly swollen and distorted

Question 33

Define & pronounce diaphoresis

Answer 33

Profuse sweating

Question 34

Explain the grading scale for assessing the force or “amplitude” of an artery.

Answer 34

0 = absent

1+ = weak “thready”

2+ = normal

3+ = increased

4+ = full, bounding (unable to obliterate with pressure; carotid artery is typically 4+)

Question 35

Define rebound tenderness.

Answer 35

After the nurse pushes down on an area of the abdomen, they lift their hand up quickly, causing the structures indented by the palpation to rebound suddenly. Pain on the release of pressure confirms the patient has rebound tenderness. May indicate inflammation of the peritoneum.