Health Assessment Part 1
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| Subjective data | Obtained from the client – primary source – if can’t communicate, ask secondary source of family members/people nearest them - Not measurable or observable, but what the patient tells us.
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| Example of subjective data | “I’m short of breath”, “My pain is 10/10”, “I feel sick to my stomach”, “His skin doesn’t look so red today”.
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| Objective data | Measurable & observable – we gather it as healthcare workers - other than client – facts, figures, etc.
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| Example of objective data | ”The patient walked 5 feet without assistance”, “He vomited X amount of emesis.”
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| Subjective or Objective – Feelings, perceptions, and self-report of symptoms? | subjective
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| Subjective or Objective – Blood pressure measurement? | objective
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| What is in medical record? | Medical history, labs, test results, current physical findings, and primary health care provider’s treatment plan.
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| Purpose of client interview? | Gather and provide information, ID problems & concerns, “chief complaint”, Why here? subjective data gathering and build rapport.
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| During assessment, where would you most likely gather the most subjective data? | Client interview/health history.
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| PMH | Past Medical Heath
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| ROS | Review of systems – a systematic method for collecting data on all body parts.
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| 5 Techniques for assessment | Inspection, palpation, auscultations, olfaction, and percussion
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| You typically hear the first heart sound best when auscultated where? | left 5th ICS along midclavicular line.
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| What do we palpate the skin for? | temperature, moisture, texture, turgor, tenderness, and thickness.
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| What do we palpate the abdomen for? | tenderness, distention, or masses
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| light palpation | 1 cm in depth
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| deep palpation | 4 cm in depth
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| The most sensitive area are palpitated | last
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| Percussion involves tapping the body with | the fingertips to produce a vibration that travels through body tissues.
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| Tympani sound is | drum-like, high pitch – ex: gastric bubble
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| Resonance sound is | hollow, low pitch – ex: healthy Lungs
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| Hyperresonance sound is | booming, very low pitched ex: Emphysemic lung tissue
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| Flatness sound is | very dull, high pitch – ex: muscle, bone
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| Dullness sound is | thud-like, medium pitch – ex: Liver, spleen, heart
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| Frequency | the number of sound wave cycles generated per second by a vibrating object.
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| Loudness | the amplitude of a sound wave. Auscultated sounds are loud or soft.
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| Quality | sounds of similar frequency and loudness from different sources - blowing or gurgling
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| Duration | the length of time that sound vibrations last
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| Go for the place of most concern first | focus assessment
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| The physical examination is made up of | individual assessments for each body system.
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| Sitting | head, neck, thorax – full expansion of lungs – symmetry of upper body parts - disadvantage: hard for client with weakness.
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| Supine | flat on back – to auscultate abdomen, femoral pulse, heart, abdomen - disadvantage: hard to breathe
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| Dorsal recumbent | on back with knees bent and together - abdominal area – relaxes ab muscles
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| Lithotomy | female genital and tract-embarrasing
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| Sims | lying on side with one leg flexed – exposes rectal and vaginal area – good for rectal exam or vaginal exam. Inflection of the hip and knee needed, so hard for hip patients. Used for enema.
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| Prone | flat on abdomen – musculoskeletal system – they can flex knees and hips – not good for respiratory patients.
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| Lateral recumbent | lying on their side with both knees slightly bent – on “left-lateral recombant” side for heart – good for murmurs
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| Knee-chest | rectum – embarrassing
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| Semi-fowler | 30 – 45degree angle while lying on back
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| Fowler | 90 degree angle while lying on back
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| What are some of the things to assess in a general survey? | age, gender, distress, posture, gait, hygiene, speech, affect.
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| First part of physical assessment is? | vitals
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| Assessment of the skin reveals changes in | oxygenation, circulation, nutrition, local tissue damage, and hydration.
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| Skin produces which Vitamin | D production
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| Melanoma | an aggressive form of skin cancer
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| Normal brown skin appears to be yellow-brown and normal black skin appears to be ashen gray when? | When patient is cyanotic.
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| If pallor is present, the mucous membranes will be | ashen gray
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| Assessment of cyanosis in dark-skinned client requires observation of | areas where pigmentation occurs the least (conjunctiva, sclera, buccal mucosa, tongue, lips, nail beds, and palms and soles)
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| Localized skin changes, such as pallor or erythema (red discoloration), indicate | circulatory changes
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| A | Asymmetry – same on each side or different?
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| B | Border – ragged edges, border irregularity
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| C | Color – Solid? Multi-colored? Brusing?
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| D | Diameter – How big?
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| E | Elevation – bigger than smaller?
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| Indurated | hardened
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| A decrease in turgor predisposes the client to | skin breakdown
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| Petechiae | dots that show broken blood vessels especially when they are thrombocytopenic – hemorrhages in the skin layer.
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| Spider angionomas | big nose with lots of spider veins
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| Macule | freckle or Petechia – flat area less than 1 cm in size that is discolored.
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| Patch | large amount of macules grouped together – larger than 1 centimeter. – birthmarks or Mongolian spots.
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| A birthmark would what kind of skin lesion? | A patch
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| A Mongolian spot would be what kind of skin lesion? | Patch - Look like bruises and occur a lot in infants and can be mistaken for child abuse.
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| Papule | something solid, elevated, and less than a centimeter- or a mole.
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| A nevus would be what kind of skin lesion? | Nevus = mole – a papule
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| Nodule | solid, elevated, and greater than a centimeter – can be hard or soft. – wart would be one.
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| What kind of skin lesion would a wart be? | A nodule
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| Tumor | 1-2 cm - Could describe as dime-size, quarter-size, etc. Usually centimeters is used.
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| Wheal | an elevated red area. Usually has fluid inside of the tissue. Mosquito bite or hives
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| A mosquito bite would be what kind of skin lesion? | wheal
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| Hives would be what kind of skin lesion? | Wheal because they are fluid filled
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| Cyst | fluid filled cavity in the subcutaneous area. Usually soft
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| Vesicle | an elevated cavity containing free serous fluid – less than a centimeter - Chickenpox, herpes.
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| Chickenpox would be what kind of skin lesion? | Vesicle
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| Pustule | pus filled, elevated cavity. Pimple
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| A pimple would be what kind of skin lesion? | Pustule
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| Ulcer | Deep loss of skin surface that extends into dermis and bleeds/scars – venous stasis ulcer.
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| Bulla | Blister – larger than 1 cm. Superficial in the epidermis.
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| Atrophy | Thinning of skin w/loss of normal skin furrow – skin is shiny and translucent
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| senile keratosis | thickening of skin
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| cherry angiomas | (ruby red papules
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| Primary Lesions | Occurring as initial spontaneous manifestations of a pathological process such as an insect bite.
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| Secondary Lesion | Resulting from later formation or trauma to a primary lesion such as a pressure ulcer.
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| When you detect a lesion, inspect it for | color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized.
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| Name some primary lesions | macules and nodules - come from some stimulus to the skin
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| Name a secondary lesions | ulcer - occur as alterations in primary lesions
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| Basal cell carcinoma | almost never spreads to other parts of the body
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| Squamous cell carcinoma | more serious than basal cell and develops on the outer layers of sun-exposed skin - may travel to lymph nodes
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| 4 Levels of edema | Mild-1, moderate-2, deep-3, very deep-4
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| Anasarca | severe generalized edema
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| Normocephalic | Head round and symmetric and appropriate for size of body.
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| Microcephalic | small sized skull
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| Macrocephalic | large head bones
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| Hydrocephalus | infants - large head results from congenital anomaly or the buildup of cerebrospinal fluid in the ventricles.
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| Enlarged jaws and facial bones resulting from ___, a disorder caused by excessive secretion of growth hormone. | acromegaly
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| Puffy around eye could indicate ___. | heart failure
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| Trachea should be | mid-line, no lumps, thyroid gland normal
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| Listen to the thyroid for | bruits
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Created by:
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