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Fundamentals Ch 4

Introduction to Health Assessment

Signs Vs. Symptoms Signs are objective data (as observed/measured by nurse) and symptoms are subjective data (as experienced/reported by patient).
What makes "signs" objective data? Can be seen, heard, measured and be verified by more than one person.
Is the Pain Scale subjective or objective? Objective (is has been qualified)
Is the "ability to stand" subjective or objective? Objective (can be observed by nurse)
What is "disease"? A disturbance of a structure or function of the body; a pathologic condition.
What is "Unknown etiology"? Diseases that have no apparent cause.
What are some originations of disease? Hereditary, congenital, inflammatory, degenerative, infectious, metabolic, neoplastic, traumatic and environmental.
What are some risk factors for the development of disease? any situation, habit, environmental condition, genetic predisposition, physiologic condition, and other that increases the vulnerability of an individual or a group to illness or accident.
What are the categories of risk factors? Genetic and physiologic, age, environment, and lifestyle.
What is a chronic disease? A disease that develops slowly and persists over a long period, often for a person's lifetime.
What is Remission? Partial or complete disappearance of clinical and subjective characteristics of a disease.
Organic vs. Functional Disease Organic disease results in structural change in an organ that interferes with its functioning. Functional Disease maybe be manifested as organic disease, but careful
What are the cardinal signs of infection and inflammation? erythema, edema, heat, pain, purulent drainage, loss of function
What are the two parts to the nursing health assessment? Health history (biographical data, chief complaint, history of present illness, past medical history, femily history, lifestyle) and physical exam.
What is the initial step in the assessment process? Nursing health history
What is the chief complaint? Reason for seeking health care, should be documented in patient's own words.
What is the PQRST method? Provacative/palliative Quality/quantity Region/radiation Severity Timing
What is the OLDCART method? Onset Location Duration Characteristics Aggravating/alleviating Related symptoms Treatments tried
What should be included in the past health history? Previous hospitalizations, allergies, immunizations, habits and lifestyle patterns, ability to person ADLs, patterns of sleep, exercise and nutrition
What is the objective of obtaining family history? To determine patient's risk for illnesses of a genetic or familial nature.
Review of Symptoms: what are the general constitutional symptoms? fever, chills, malaise, fatigability, night sweats; weight (average, preferred, present, change, appetite)
When do you do a comprehensive assessment? Upon initial examination (health history and complete physical exam)
What is a focused assessment? assessment of a specific problem
What is an emergency assessment? rapid focused assessment
What is an ongoing partial assessment? Ongoing assessment of already identified health problems to monitor changes at regular intervals.
What are the components of a head-to-toe assessment in order? The nurse begins with a neurological assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area legs and feet are examined in that order.
What is the supine position? Lying flat on back with legs extended, allows relaxation of the abdominal muscles.
What is the prone position? Lying flat on abdomen with head turned to one side, used to assess hip joint and posterior.
What is the Fowler's/Semi-Fowler's Position? Fowler's: semi-sitting 45-60 degrees, promotes cardiac and respiratory function Semi-Fowlers: about 30 degrees
What does PERRLA stand for? Pupils equal, round, reactive to light, and accommodation.
What are the different levels of orientation in a neurological assessment? Patient is oriented X 1 (person) X 2 (person and place) X 3 (person, place and time) X 4 (person, place, time and purpose)
Inspection, as it pertains to a physical assessment: Assessment of size, color, shape, position, and symmetry.
Palpation, as it pertains to a physical assessment: Assessment of temperature, turgor, texture, moisture, vibrations, and shape.
Percussion, as it pertain to a physical assessment: Assessment of location, shape, size and density of tissues.
Auscultation, as it pertains to a physical assessment: Assessment of the four characteristics of sound; i.e. pitch, loudness, quality and duration.
Cranial toward the head
Caudal toward the tail
Sudoriferous glands Sweat glands
Ceruminous glands gland that secrete earwax
Macule a flat cincumscribed area that is a change in the color of the skin < 1cm in diameter (freckles, flat moles or petechiae)
Papule An elevated circumscribed area > 1 cm in diameter (warts, lichen planus or moles)
Patch A flat irregularly shaped macule > 1 cm in diameter (vitiligo, port wine stains)
Plaque Elevated, firm and rough with a flat top surface > 1 cm in diameter (psoriasis)
Wheal Elevated irregularly shaped area of cutaneous edema with variable diameter (insect bites)
Nodule Elevated, firm, circumscribed and deeper in the dermis than a papule, 1-2 cm in diameter (lipoma)
Tumor Elevated and solid. >2cm diameter (neoplasm, lipoma, hemangioma)
Vesicle Elevated, circumscribed, superficial and filled with serous fluid <1cm in diameter (chicken pox, herpes zoster)
Bulla Vesicle > 1cm diameter (blister)
Pustule Elevated, superficial and filled with purulent fluid (acne, impetigo)
Cyst Elevated, circumscribed, encapsulated and filled with fluid or semisolid material (sebaceous cyst, cystic acne)
Telangiectasia Fine, irregular red lines produced by capillary dilation (rosacea)
Scale Heap of keratinized cells. Irregular with variation in size (dry skin)
Lichenification Rough, thickened epidermis secondary to persistent skin irritation (eczema)
Keloid Irregularly shaped, elevated and progressively enlarging scar formed during healing.
Scar Thick, fibrous tissue that replaces normal tissue following injury
Excoriation Loss of the epidermis; linear hollwed-out crusted area (abrasion)
Fissure Linear crack or break from the epidermis to the dermis (Athlete's foot)
Erosion Loss of part of the epidermis following rupture of a vesicle or bulla (chicken pox)
Ulcer Loss of epidermis and dermis. Varies in size (pressure sores)
Crust Dried exudate. Slightly elevated. Varies in size (scab)
Atrophy (pertaining to skin lesions) Thinning of skin surface and loss of skin markings (stretch marks)
ABCDE's of Malignancy in skin lesions A-Asymmetry (one half is different) B-Border is blurred or irregular C-Color is not uniform D-Diameter >6mm E-Evolution, changed or new lesions
Other risk signs in malignant skin lesions (ABCDEs continued) Color spreads into the surrounding skin, loss of pigment, itching, tenderness and bleeding without provocation.
Accessory Structure of the Eye Eyebrows, eyelashes, eyelids, lacrimal apparatus
Structures of the eyeball sclera, comea, iris, pupil, retina
Ptosis drooping upper eyelid
Exopthalmos protruding eyes
Diplopia double vision
Myopia nearsightedness
Hyperopia farsightedness
Strabismus independent turning of the eye
Miosis constricted and fixed pupils
Mydriasis dialated and fixed pupils
Anisocoria unequal pupil size
nystagmus involuntary, rapid, rhythmic movement of the eye
Presbyopia loss of accommodation to nearby objects as a result of age
Eye/pupil accommodation Pupils constrict when object is nearer, pupils should dilate when object is further away.
Eye convergence As object nears face, eyes start to cross.
Bones of the middle ear Malleus, Incus, Stapes
In a peripheral cardiovascular assessment, what do you look for upon inspection of the extremities? Color, temperature, lesions/ulcers, venous patterns/varicocities, and edema
In a peripheral cardiovascular assessment, what do you palpate for? Peripheral pulses (including rate, amplitude and symmetry), Perfusion (capillary refills should be <3 sec) Phlebitis and Homan's sign.
Borborygmi Stomach growling
Flatus Gas
Hematemesis Blood in emesis-either bright red or like coffee grounds
Dysphagia Difficulty swallowing
Odynophagia Pain with swallowing
Jaundice or icterus Yellow discoloration of the skin/sclera
Melena Black tarry stool
Hematochezia Stool with red blood
Peristalsis Wave-like contraction of the GI tract
Active bowel sounds 4-32 per minute
Absent bowel sounds no sounds for 5 minutes (minimum)
Ascites Edema of the abdomen
Dysuria pain or difficulty urinating
Hesitancy (with urination) difficulty starting or maintaining a urinary stream
Polyuria increase in urine volume >3 liters
Nocturia urinary frequency at night
Hematuria blood in the urine
Pyruia puss in the urine
dyspareunia pain with sexual intercourse
dysmenorrhea pain with menstruation
amenorrhea absence of menstruation
polymenorrhea frequent menstruation
metrorrhagia intermenstrual bleeding
menorrhagia increased amount or duration of menses
Active range of motion (ROM) Patient can independently move joints
Passive range of motion (ROM) The nurse moves joints.
Active-assistive range of motion (ROM) The nurse assists in moving joints with patient.
Dorsiflexion backward bending of the hand or foot
circumduction movement of the distal part of a limb to trace a complete circle
Eversion (foot) movement of the sole inward
Inversion (foot) movement of the sole outward
Abduction lateral movement away from the midline
Adduction movement toward the midline
flexion vs. extension flexion: state of being bent extension: state of being straight
hypertrophy excessive development of a tissue or organ
hypermyotrophy excessive development of muscular tissue
atrophy decrease in size of an organ or tissue/wasting
flaccidity weak or soft
contracture abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching
crepitus movement of air through tissue, commonly felt during ROM of joints
ambulation walking
gait manner or style of walking
tremor involuntary trembling
tic involuntary rapid/repetitive movement
Cranial Nerve I (Olfactory) Sense of smell
Cranial Nerve II (Optic) Central and peripheral vision, visual acuity
Cranial Nerve III (Oculomotor) Pupillary constriction, PERRLA, lid position
Cranial Nerve IV (Trochlear) EOMs down to the nose, observe for nystagmus
Cranial Nerve VI (Abducens) controls eye movement to the sides. ask the patient to look toward each ear and follow your fingers through the six cardinal fields of gaze.
Six cardinal fields of gaze 1.right and up 2. right 3. right and down 4. left and up 5. left 6. left and down
Cranial Nerve V (trigeminal) facial sensation, check sensation in forehead, cheek and jaw using a soft and dull object. check sensation of scalp, too. test motor function of temporal and masseter by assessing jaw opening strength
Cranial Nerve VII (Facial) controls facial movements and expression. assess patient for facial symmetry. have him wrinkle his forehead, close his eyes, smile, pucker his lips, show his teeth, puff out his cheeks. check hearing by rubbing your fingers together by each ear.
Cranial Nerve VIII (Acoustic) controls hearing. check hearing by rubbing your fingers together by each ear.
Cranial Nerve IX (Glossopharyngeal) & Cranial Nerve X (Vagus) Innervate tongue and throat (pharynx and larynx) and are checked together. assess the sense of taste on the back of the tongue, observe ability to swallow, ask the patient to say AHHH. the uvula should be in the midline and the palate should rise.
Cranial Nerve XI (Accessory) controls the neck and shoulder movement, test by asking the patient to raise his shoulders against your hands to assess the trapezius muscle. then turn his head against your hand to assess the sternocleidomastoid.
Cranial Nerve XII (Hypoglossal) innervates the tongue, ask patient to stick out tongue (it should be midline) look for problems with eating, swallowing or speaking.
Lethargic patient appears drowsy or is asleep most of the time, but can be aroused by gentle shaking and saying patient's name.
Stuporous unconscious most of the time, no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses but are less likely to be appropriate
Comatose cannot be aroused
Reflex Grades 0, 1+, 2+, 3+, 4+ 0=no response, 1+=somewhat diminished, 2+=normal, 3+=brisker than average, 4+=very brisk, hyperactive
Created by: tuhcoolyuh