Health Assessment Quiz

Assessment Learning Objectives

• Prepare the patient and environment for a health assessment, considering age-related variations in techniques.
• Identify factors affecting vital signs (temperature, pulse, respirations, blood pressure).
• Discuss the purposes of health assessments.
• Describe four assessment techniques used in physical assessments, including methods for measuring vital signs.
• Demonstrate knowledge of normal vital sign ranges across the lifespan.
• Demonstrate accurate vital sign assessment.
• Demonstrate steps in performing selected examination procedures, including expected findings and lifespan variations.
• Explain the physiology of body temperature, pulse, respirations, and blood pressure.

Holistic Assessment

• Physical
• Psychological
• Social
• Spiritual

Types of Assessments

• Initial (baseline) assessment
• Ongoing reassessment
• Problem-focused assessment
• Emergency assessment

Age Considerations

• Infants
• Toddlers
• School Age Children
• Adolescents
• Adults
• Older Adults

Cultural Considerations

• (No details provided)

History

• Review of acute and chronic medical problems
• Medications
• Family Health History
• Disease prevention and health maintenance
• Disease contact tracing

Functional Assessment

• Self-care abilities
• Risk for falls
• Cognition
• Nutrition and feeding
• Continence
• Mobility
• Sleep
• Skin care

Case Study - Morse Fall Scale

• History of falling (Yes = 25 points, No = 0 points)
• Ambulatory aid (Furniture = 30, Crutches/cane/walker = 15, None = 0)
• Gait/transferring (Impaired = 20, Weak = 10, Normal = 0)
• Secondary diagnosis (Yes = 15, No = 0)
• IV or Heparin lock (Yes = 20, No = 0)
• Mental status (Ask about bathroom use; score 15 if consistent with objective assessment, otherwise 0)

Hester Fall Scale

• 9-factor scale (scores range from 0-77; Hester et al., 2013).
• Each factor is scored 0-4 (except Age, 0-3).
• Factors include: Age, Last known fall, Mobility, Toileting, Mental status/LOC/awareness, Communication/sensory, Behavior, Medication, Volume/electrolyte status

Psychologic Assessment

• Open-ended or closed questions
• Suicide Prevention Screening

Spiritual Assessment

• (No details provided)

Social Support Network

• Community member
• Partner
• Neighbor
• Friend
• Family member
• Co-worker

Physical Assessment Methods

• Inspection
• Palpation
• Percussion
• Auscultation

Starting an Assessment

• Introduce yourself
• Implement infection control
• Explain the purpose of the assessment
• Obtain permission
• Ensure privacy

Vital Signs

• Temperature
• Pulse
• Blood Pressure
• Respirations
• Oxygen Saturation
• Pain

Environmental Inspection

• Room
• Equipment
• Lines

Assessing Patient General Appearance

• Observe skin color, respiratory effort, and distress.
• Evaluate mood and affect.
• Assess posture.
• Observe hygiene, grooming, and dress.
• Check for odor of breath and body.
• Measure height and weight.

Neuro Assessment (Glasgow Coma Scale)

• Eye opening (spontaneous, to loud voice, to pain, none)
• Verbal response (oriented, confused/disoriented, inappropriate words, incomprehensible sounds, none)
• Best motor response (obeys, localizes, withdraws, abnormal flexion posturing, extension posturing, none)
• Pupillary response

Sample Documentation: Normal Neurological Findings

• Alert, oriented to person, place, and time.
• Clear speech; follows commands.
• Normal neurological response to stimuli (auditory, visual, tactile).
• Pupils equal, round, and react to light (PERRLA) (sometimes abbreviated to PERRLA, accommodation).

Head Assessment

• Head
• Eyes
• Ears
• Nose & Mouth
• Throat
• Facial expressions

Sample Documentation: Normal Head Assessment

• Normocephalic (normal head size), face symmetrical, no redness or swelling. No drainage from eyes, ears, or nose. Moist mucous membranes. All teeth present and well-cared for.

Neck Assessment

• Trachea
• Carotid arteries
• Jugular vein distention
• Lymph nodes
• Thyroid gland

Sample Documentation: Normal Neck Assessment

• Trachea midline. Carotid pulses equal. No jugular vein distention (JVD). No swelling or painful lymph nodes.

Skin Assessment

• Color
• Temperature
• Moisture
• Turgor
• Edema
• Lesions
• Hair
• Nails

Sample Documentation: Normal Skin Assessment

• Skin is warm, pink, no lesions or edema. Skin turgor is non-tenting. Nails are clean and well-manicured.

Cardiac Assessment - Apical Pulse

• (Diagram of heart and related vessels)

Cardiac Assessment

• Heart sounds (Lub Dub) including location of S1 and S2.

Pulses

• Temporal
• Carotid
• Apical
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis

Sample Documentation: Normal CV Assessment

• S1 and S2 present, pulse rate within normal limits (WNL) and regular. Radial and pedal pulses are 3+. Absence of cyanosis, edema, and capillary refill <2 seconds.

Respiratory Assessment

• Shape and symmetry of chest
• Respiratory rate
• Respiratory effort
• Cough
• Breath sounds

Breath Sounds - Descriptions and Causes

• Wheezes
• Crackles (fine, coarse)
• Rhonchi
• Stridor

Sample Documentation: Normal Respiratory Assessment

• Respirations regular, unlabored, and symmetrical. Bilateral clear breath sounds, pink mucous membranes. No cough, no sputum production.

Gastrointestinal (GI)/Nutritional Assessment

• Inspection
• Auscultation
• Percussion
• Palpation
• Appetite
• Diet
• Weight

Sample Documentation: Normal GI Assessment

• No difficulty swallowing or chewing. Abdomen is soft, non-tender, and non-distended. Bowel sounds present in all four quadrants. No nausea, vomiting, or diarrhea. Last bowel movement [date].

Genitourinary (GU) Assessment

• Bladder palpation
• Fluid intake and output
• Assessment of genitalia

Sample Documentation: Normal GU Assessment

• Continent, able to empty bladder without difficulty. Urine clear, yellow to amber in color, no odor or sediment. No complaints of frequency, dysuria, or hematuria.

Sample Documentation: Normal Genital Assessment

• Genitalia normal, without redness, swelling, or discharge. Breasts are soft (firm) and non-tender.

Musculoskeletal Assessment

• Posture (general body symmetry, sway back, lumbar lordosis, thoracic kyphosis, forward head posture, good posture)
• Muscle strength
• Movement (gait)

Sample Documentation: Normal Musculoskeletal Assessment

• Full range of motion (ROM) in all extremities. Equal strength bilaterally. Absence of weakness. Steady balanced gait.

Safety Assessment

• Bed in low position
• Side rails up
• Call light within reach
• Personal belongings within reach
• Restraints

Test your knowledge on health assessment techniques and vital sign measurements. This quiz covers various assessment types, considers age-related variations, and discusses the holistic approach to patient evaluation. Prepare for a comprehensive understanding of physical, psychological, social, and spiritual assessments.