Podcast
Questions and Answers
What type of information is considered subjective in health assessment?
What type of information is considered subjective in health assessment?
Which technique is used to assess temperature and texture during a health assessment?
Which technique is used to assess temperature and texture during a health assessment?
What is the ideal distance between a health professional and a patient during the interview?
What is the ideal distance between a health professional and a patient during the interview?
During the general survey, which aspect involves evaluating a patient’s height and posture?
During the general survey, which aspect involves evaluating a patient’s height and posture?
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Which aspect of the general survey would help determine if a patient is malnourished?
Which aspect of the general survey would help determine if a patient is malnourished?
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What does the term 'gait' refer to in the context of mobility assessment?
What does the term 'gait' refer to in the context of mobility assessment?
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Which of the following is an example of an objective finding in health assessment?
Which of the following is an example of an objective finding in health assessment?
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What is the primary purpose of using open-ended questions during the interview phase of health assessment?
What is the primary purpose of using open-ended questions during the interview phase of health assessment?
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What score on the GAD-2 indicates the presence of anxiety?
What score on the GAD-2 indicates the presence of anxiety?
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What does a PHQ-2 score of 2 or more indicate?
What does a PHQ-2 score of 2 or more indicate?
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Which of the following is a component of the Mini-Mental State Exam (MMSE)?
Which of the following is a component of the Mini-Mental State Exam (MMSE)?
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What type of documentation is essential when recording histories of domestic violence?
What type of documentation is essential when recording histories of domestic violence?
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What should be included in documentation for suspected elder abuse?
What should be included in documentation for suspected elder abuse?
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Which profession is considered a mandatory reporter?
Which profession is considered a mandatory reporter?
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What is the focus of a risk nursing diagnosis?
What is the focus of a risk nursing diagnosis?
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Which of the following is NOT a symptom to look for in suspected elder abuse?
Which of the following is NOT a symptom to look for in suspected elder abuse?
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What does the BEFAST assessment tool help identify?
What does the BEFAST assessment tool help identify?
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When documenting child abuse, what must be taken into consideration?
When documenting child abuse, what must be taken into consideration?
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What is the correct order of the nursing process?
What is the correct order of the nursing process?
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Which component of a SOAP note captures measurable data from a physical exam?
Which component of a SOAP note captures measurable data from a physical exam?
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What is indicated by a positive Murphy's Sign?
What is indicated by a positive Murphy's Sign?
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What does the 'C' in ABCDE lesion assessment primarily refer to?
What does the 'C' in ABCDE lesion assessment primarily refer to?
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In the assessment of thyroid and trachea, an abnormal finding may present as what?
In the assessment of thyroid and trachea, an abnormal finding may present as what?
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What is the most appropriate initial step in assessing bowel sounds?
What is the most appropriate initial step in assessing bowel sounds?
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Which muscle strength grading indicates normal power?
Which muscle strength grading indicates normal power?
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Which characteristic defines a wheal lesion?
Which characteristic defines a wheal lesion?
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What does melena indicate?
What does melena indicate?
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What assessment technique is used to test for deep vein thrombosis?
What assessment technique is used to test for deep vein thrombosis?
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What neurological condition is indicated by the Babinski reflex in adults?
What neurological condition is indicated by the Babinski reflex in adults?
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What condition is characterized by clouding of the lens and is a common cause of vision impairment?
What condition is characterized by clouding of the lens and is a common cause of vision impairment?
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Which lung sound is characterized as a high-pitched musical squeaking sound?
Which lung sound is characterized as a high-pitched musical squeaking sound?
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What indicates abnormal deep tendon reflexes according to the grading scale?
What indicates abnormal deep tendon reflexes according to the grading scale?
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What is the normal finding for pupil response assessed by the PERRLA test?
What is the normal finding for pupil response assessed by the PERRLA test?
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Which condition is characterized by excessive outward curvature of the spine?
Which condition is characterized by excessive outward curvature of the spine?
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What physical sign is associated with jugular vein distention?
What physical sign is associated with jugular vein distention?
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What is the purpose of the Phalen Test?
What is the purpose of the Phalen Test?
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What does an abnormal assessment of the trachea indicate?
What does an abnormal assessment of the trachea indicate?
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What does a positive Blumberg’s Sign indicate?
What does a positive Blumberg’s Sign indicate?
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What does the Romberg Test assess?
What does the Romberg Test assess?
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Which type of lesion is greater than 1 cm in size and is fluid-filled?
Which type of lesion is greater than 1 cm in size and is fluid-filled?
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What condition may lead to sharp chest pain during breathing due to inflammation?
What condition may lead to sharp chest pain during breathing due to inflammation?
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What characterizes a clonus response during a neurological exam?
What characterizes a clonus response during a neurological exam?
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Which technique is used to assess costovertebral angle tenderness?
Which technique is used to assess costovertebral angle tenderness?
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What does a grading scale of 0 represent in muscle strength testing?
What does a grading scale of 0 represent in muscle strength testing?
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Study Notes
Introduction/Interview
- The first interaction you have with the patient is the start of collecting subjective data
- During the interview, privacy is essential, and the distance between you and the patient should be 4-5 feet
- Open-ended and closed questions are used; open-ended questions are especially helpful for gathering unbiased information
Health Assessment
- This collection of comprehensive data is done to assess a person’s health state
- Subjective data is information that a person tells you about their health
- Objective data is information that you can observe or measure
Assessment Techniques
- Inspection is the visual observation of size, color, shape, position, and symmetry
- Palpation is used to assess temperature, turgor, texture, moisture, vibration, and shape
- Percussion is used to assess the location, size, and density of tissues and organs
General Survey
- This first impression of the patient happens before you begin the history or physical assessment
-
Physical Appearance:
- Age: Does the patient look their stated age?
- Sex: Are their sexual development features appropriate for their age and gender?
- Level of Consciousness: Are they alert and responsive?
- Skin Color: Does their skin have an even tone, and are there any abnormalities?
- Facial Features: Are their facial features symmetrical?
-
Body Structure:
- Stature: Is their height and posture normal?
- Nutritional Status: Are they obese or malnourished?
- Symmetry: Are their limbs symmetrical?
- Posture: Can they stand and sit comfortably?
- Body Build: Are they proportionate?
-
Mobility:
- Gait: Are their feet shoulder width apart?
- Foot Placement: Is their foot placement accurate, and do they walk smoothly?
- Range of Motion: Do they have full range of motion?
-
Behavior:
- Facial Expressions: Do they maintain eye contact and have appropriate expressions?
- Mood and Affect: Are they comfortable?
- Speech: Are they fluent, and do they communicate clearly?
- Dress: Is their clothing appropriate?
- Hygiene: Are they clean and practicing good hygiene?
Nursing Process
- The nursing process consists of 5 steps:
- Assessment: Gathering subjective and objective data
- Diagnosis: Identifying patient health problems
- Planning: Developing a plan to achieve desired health outcomes
- Implementation: Executing the plan
- Evaluation: Assessing the patient’s response and revising the plan
SOAP Note
- SOAP notes are used for documentation:
- Subjective: What the patient reports
- Objective: Measurable data from the physical exam
- Assessment: Diagnosis or clinical judgment based on the findings
- Plan: Immediate actions, diagnostic tests, or follow up
Pain Assessment
-
OLDCARTS is a helpful tool for assessing pain:
- Onset
- Location
- Duration
- Characteristics
- Aggravating Factors
- Relieving Factors
- Time
- Severity
- Wong-Baker FACES Pain Rating Scale and Faces Pain Scale- Revised are used to assess pain severity on a scale of 0-10
- FLACC (Facial Expression, Leg Movement, Activity Level, Cry, Consolability) and CRIES (Crying, Oxygenation Requirements, Vital Signs, Facial Expression, Sleeplessness) are used to measure pain in neonates and infants
Lesion Assessment
- The ABCDE method is helpful for assessing lesions:
- Asymmetry: One half of the lesion does not match the other half
- Border: Edges are ragged or blurred
- Color: Multiple colors are present
- Diameter: Greater than 6 mm
- Evolving: Any change in size, shape, color, or elevation
-
Status:
- Primary: Develops on unaltered skin
- Secondary: Changes in lesions due to scratching or infection
Types of Lesions
- Nodule: Firm or soft lesion larger than 1 cm
- Bulla: Vesicle larger than 1 cm in diameter
- Papule: Raised, solid lesion less than 1 cm in diameter
- Wheal: Superficial, raised, transient lesion with irregular borders
- Pustule: Pus-filled, elevated lesion that is usually less than 1 cm
- Vesicle: Fluid-filled, elevated lesion less than 1 cm, fluid is usually clear
Facial Droop
- Signs: Uneven smile, drooping eyelid, difficulty closing eye, speech difficulties, drooling, facial weakness
- Causes: Stroke, Bell’s Palsy, tumor, Lyme disease, shingles, trauma
Sinus Assessment
- To assess frontal sinuses, palpate under the eyebrows
- To assess maxillary sinuses, palpate below the cheekbones
- Tenderness or pressure indicates chronic allergies or sinusitis
Thyroid and Trachea Assessment
-
Thyroid:
- Inspect the anterior neck while the patient swallows
- Palpate the thyroid gland from a posterior approach
- Normally the thyroid feels spongy, nonmodular, and non-tender
- An enlarged thyroid may cause a bruit (whooshing sound)
-
Trachea:
- Palpate the trachea in the midline
### Corneal Light Reflex Test
- This test assesses extraocular function
- Shine a light into the middle of the patient’s eyes and note if the light reflects in the same place in both eyes
Snellen Eye Chart Test
- This test assesses distance vision
- Have the patient stand 20 feet away from the chart and read the letters
- Normal vision is 20/20
- The larger the denominator (over 20), the worse the vision
Confrontation Test
- This test assesses the patient’s peripheral vision
PERRLA Test
- This test assesses pupil function and cranial nerve III
- Shine a light into the patient’s eyes and note if the pupils constrict equally
- Pupils are Equal, Round, and Reactive to Light and Accommodation
Cataracts
- Clouding of the lens, a common age-related condition
- Causes blurred vision
Ocular Deviation
-
Strabismus (crossed eyes):
- Esotropia: Inward
- Exotropia: Outward
- Hypertropia: Upward
- Hypotropia: Downward
- Nystagmus: Repetitive, uncontrolled eye movements
### Otoscopic Exam
- Use an otoscope to examine the external auditory canal and tympanic membrane
- For patients over age 3, pull the pinna up and back before inserting
- Normal: Clear of debris, tympanic membrane appears pearly gray, cone of light visible
- Abnormal: Redness/swelling - otitis externa; yellow or amber fluid - otitis media; perforation; bulging/retraction - pressure changes
Adventitious Lung Sounds
- High-pitched wheeze: Musical squeaking sounds, often polyphonic
- Low-pitched wheeze: Monophonic, musical snoring/moaning
- Stridor: High-pitched, monophonic crowing sound
- Fine crackles: Discontinuous, high-pitched, short crackling popping sounds
- Coarse crackles: Loud, low-pitched bubbling and gurgling sounds
- Atelectatic crackles: Sound like fine crackles but do not last and are not pathologic
Auscultation Breath Sounds
- Bronchial: High pitch and loud amplitude, heard over trachea and larynx
- Bronchovesicular: Moderate pitch and amplitude, heard over major bronchi
- Vesicular: Low pitch and amplitude, heard over peripheral lung fields
Tactile Fremitus
- Normally, the lungs transmit a palpable vibratory sensation to the chest wall.
- 99 test: Place your hands on either side of the chest and have the patient say "99."
- Increased fremitus: Presence of lung consolidation (pneumonia)
- Decreased fremitus: Presence of pleural effusion, emphysema, or pneumothorax
Anteroposterior Diameter
- The Anteroposterior diameter should be less than the transverse diameter - 1:2 ratio
- An AP = transverse diameter indicates a barrel chest, which is abnormal
Pleurisy
- Inflammation of the pleura, causing sharp chest pain when breathing or a constant dull ache
- Caused by pneumonia, TB, viral infections, chest trauma, cancer, blood clots
Cardiac Sites
- Aortic Valve: Right side of the heart at the 2nd ICS (S2 loudest)
- Pulmonic Valve: Left side of the heart at the 2nd ICS (S2 loudest)
- Tricuspid Valve: Left side of the sternum at the 4th-5th ICS (S1 loudest)
- Mitral Valve: Over MCL at the 5th-6th ICS (S1 loudest)
Heart Sounds
- S1: "LUB," closure of the tricuspid and mitral valves, beginning of systole
- S2: “DUB,” closure of the aortic and pulmonic valves, the end of systole
- S3: Ventricular gallop, occurs immediately after S2
- S4: Atrial gallop, occurs just before S1
Thrills
- Palpable vibration felt on the skin overlying the heart or blood vessel, caused by turbulent blood flow
- Assessed by feeling the chest with fingers or palms
Bruits
- Abnormal, whooshing sound heard during auscultation of an artery, caused by turbulent blood flow
- Assessed by auscultation with the bell of the stethoscope
PMI
- Point of Maximal Impulse (apical pulse)
- Located at the 5th ICS and MCL
- Note if a thrill is present (abnormal)
Pulses
- Palpate radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses
- 3-point scale:
- 3+ full, bounding
- 2+ normal
- 1+ weak
- 0 absent
Jugular Vein Distention
- To assess, have the patient lie in Fowler’s position (45 degrees) and turn their head to the side
- Normal finding - no distention
- Presence of JVD indicates hypovolemia
- Signs and symptoms: Bulging jugular veins, dyspnea, peripheral edema
Deep Vein Thrombosis
- Unilateral leg swelling, tenderness to severe pain, possible warmth and redness, and possible superficial venous dilation
- Assessed using Wells Score: 1 to 2 - moderate probability; 3 or more - high probability
- Calf swelling of 2 cm or more
Venous Stasis
- Slowing or pooling of blood flow in the veins, most commonly in legs
- Causes: Venous insufficiency, prolonged immobility, DVT, obesity, pregnancy
Peripheral Artery Disease
- Narrowed arteries reduce blood flow to the limbs, typically the legs
- Occurs due to atherosclerosis
- Symptoms: Pain or leg cramping, weak or absent pulses, coldness in the lower legs, pale or blue skin discoloration, slow healing sores
Lymph Node Assessment
- When palpating lymph nodes, they should feel movable, soft, separate and distinct, and non-tender
- Use a circular motion with finger pads to palpate
- Begin with preauricular lymph nodes, then posterior auricular, occipital, submental, submandibular, superficial cervical, deep cervical, and supraclavicular
Lymphadenopathy
- Enlargement of lymph nodes, may be present in infection, cancer, HIV, lymphomas
Abdomen Quadrants
- Right Upper Quadrant: Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon
- Right Lower Quadrant: Cecum, appendix, right ovary and tube, right ureter, right spermatic cord
- Left Upper Quadrant: Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal, splenic flexure of colon, part of transverse and ascending colon
- Left Lower Quadrant: Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord
### Percussion Sounds
- Tympany: Should predominate
- Dullness: Occurs over fluid and underlying organs
Vascular Sounds
- These are called bruits
- Normal finding - nothing heard
- Abnormal finding - whooshing sound that is reflective of turbulent blood flow
Bowel Sounds
- Normal: High pitched, gurgling, cascading, 5 to 30 times per minute
- Hyperactive: Loud, high pitched, rushing, tinkling sounds
- Hypoactive: Low or absent, usually follow abdominal surgery or may be due to inflammation
Order of Assessment
- 1. Inspection: Look for any obvious abnormalities.
- 2. Auscultation: Listen for bowel sounds, vascular sounds, and heart sounds.
- 3. Percussion: Tap on the abdomen to assess the density of internal organs.
- 4. Palpation: Feel the abdomen for tenderness, masses, and organ size.
Auscultation Technique
- Use diaphragm of stethoscope to hear high-pitched bowel sounds
- Start listening in the right lower quadrant (RLQ) at the ileocecal valve, as bowel sounds are normally present there
- Auscultation happens before palpation and percussion to avoid altering bowel sounds
Peritoneal Inflammation
- Blumberg’s sign – Positive sign in the rebound tenderness test, suggesting peritoneal inflammation
- May indicate appendicitis
Gallbladder Inflammation
- Murphy’s sign – Positive sign in the inspiratory arrest test, suggesting cholecystitis
Stool Abnormalities
- Melena – Black or tarry stools, indicating upper gastrointestinal bleeding
- Steatorrhea – Pale and oily stools, indicating excessive fat in stool due to malabsorption
Kidney Inflammation
- Costovertebral angle (CVA) tenderness – assessed by striking the hand over the 12th rib at the CVA; sharp pain indicates inflammation
Breast Lumps
- Breast tissue texture changes with hormone fluctuations during the menstrual cycle
- Abnormal signs to watch for:
- Area, size, soft or firm
- Tenderness, fixation
- Skin color changes
- Discharge
Range of Motion (ROM)
- Passive ROM – movement with provider's assistance, may reveal pain, tenderness, or crepitation
- Active ROM – movement by the patient, stabilize the body area proximal to the joint being moved
- ROM Movements:
- Flexion – bending
- Extension – straightening
- Circumduction – moving in a circle
- Eversion – turning sole outward
- Inversion – turning sole inward
- Abduction – moving away from midline
- Adduction – moving towards midline
- Protraction – moving forward
- Pronation – turning palm down
- Supination – turning palm up
- Retraction – moving backward
Muscle Strength Assessment
- Repeat active ROM movements and assess resistance against opposing force
- Strength should be equal bilaterally
- Muscle Strength Grading Scale:
- 5 – Normal power
- 4 – Active movement against gravity with resistance
- 3 – Active movement against gravity without resistance
- 2 – Active movement with gravity eliminated
- 1 – Trace or flicker of movement
- 0 – No movement
Deep Tendon Reflexes (DTRs)
- Involuntary muscle contractions when a tendon is stretched
- Common reflexes: biceps, brachioradialis, triceps, patellar, achilles
- Grading Scale:
- 4 – Very brisk, hyperactive with clonus, indicative of disease
- 3 – Brisker than average, may indicate disease
- 2 – Average, normal
- 1 – Diminished, low normal, or occurs with reinforcement
- 0 – No response
- Hyperreflexia – Seen in upper motor neuron lesions (e.g., stroke)
- Hyporeflexia – Seen in lower motor neuron lesions (e.g., spinal cord injury)
Clonus
- Hyperreflexia causing rapid rhythmic muscle contractions
- Clonus Test – Briskly dorsiflexing the foot while holding the stretch
- Normal – No further movement
- Clonus Present – Rhythmic contractions of the calf and foot movement
Babinski Reflex
- Abnormal reflex response
- Assessment – Stroke the bottom of the foot with an upside down J motion
- Normal response:
- Children under 2 – Fanning toes
- Adults – Toes curling and foot curving inward
- Positive Babinski Sign: Fanning toes in adults, possibly indicating upper motor neuron disease.
Abnormal Spine Conditions
- Scoliosis – Abnormal S-shaped curvature of the spine.
- Lordosis - Excessive inward curvature of the lumbar spine (swayback).
- Kyphosis - Excessive outward curvature of the thoracic spine (hunchback).
Carpal Tunnel Tests
- Phalen Test – Place the backs of hands together and press; pain or tingling suggest carpal tunnel.
- Tinel’s Sign – Percuss the median nerve; pain or tingling suggests carpal tunnel.
Neuro Assessment
- Mental status
- Cranial nerves
- Motor system
- Sensory system
- Reflexes
Glasgow Coma Scale (GCS)
- Assesses level of consciousness (eye movement, motor function, speech)
- Best score – 15
- Score 7 or less – Coma state
Cerebellar Coordination Function Tests
- Rapid Alternating Movements (RAM) Test – Pat knees quickly with palms, then back of hands.
- Finger to Finger Test – Touch the nose then the examiner's finger repeatedly; deviation to one side is called past pointing.
- Finger to Nose Test – Touch the nose with alternating fingers.
- Heel to Shin Test – Lie supine and slide one heel down the other leg's shin.
Cerebellar Balance Function Tests
- Gait Test – Observe walking 10-20 feet, then return.
- Romberg Test – Stand with feet together, eyes closed for 20 seconds; swaying or falling is positive.
Paresthesia
- Abnormal skin sensations (tingling, burning, pricking, numbness, itching).
- Most common in arms and legs.
Syncope
- Fainting or passing out – Sudden drop in blood flow to the brain.
Muscle Abnormalities
- Tics – Involuntary physical or psychological twitch.
- Myoclonus – Sudden jerk (e.g., hiccups).
- Tremor – Contraction of opposing muscle groups.
- Fasciculations – Rapid, continuous twitching.
Abnormal Postures
- Decorticate Rigidity – Upper extremities flexed; lower extremities extended; suggests hemispheric lesion.
- Decerebrate Rigidity – Upper extremities extended; lower extremities extended; suggests brainstem lesion.
- Opisthotonos – Prolonged arching of the back; suggests meningeal irritation.
- Flaccid Quadriplegia – Paralysis or weakness in arms and legs, with reduced muscle tone.
Cranial Nerve Tests
- Olfactory – Smell test (familiar aromatic substance).
- Optic – Visual acuity testing (confrontation test and Snellen chart); ocular fundus examination.
- Oculomotor, Trochlear, Abducens – Pupil accommodation, equality, light reaction, extraocular movements.
- Trigeminal – Motor (palpating muscles during clenching); sensory (touching face with cotton wisp).
- Facial – Motor (smiling, frowning, closing eyes, raising eyebrows, showing teeth).
- Acoustic – Hearing test (conversation, whispered voice).
- Glossopharyngeal and Vagus – Pharyngeal movement, gag reflex, speech.
- Spinal Accessory – Checking size and strength of sternomastoid and trapezius muscles.
- Hypoglossal – Inspecting tongue and speech.
Mental Status Exam
- Systematic check of emotional and cognitive functioning
- ABCT: Appearance, Behavior, Cognition/Thought Process, Thought Content
- Performed when screening suggests anxiety, depression, memory loss, etc.
Intimate Partner Violence (IPV) Screening
- HITS (Hurt, Insult, Threaten, Scream) – Assess frequency of partner's abusive behavior.
- Ask about past incidents and document verbatim poignant statements.
Anxiety Screening
- GAD-2 and GAD-7 – Measure anxiety severity; scores above 3 suggest anxiety.
Depression Screening
- PHQ-2 – Ask two questions about depressed mood and anhedonia; score of 2 or more warrants PHQ-9.
- PHQ-9 – Measures depression severity.
Suicide Screening
- Ask Suicide-Screening Questions (ASQ) – Four screening questions; positive screen if any "yes" answers.
Mini-Mental State Exam (MMSE)
- Assesses cognitive functions (memory, orientation, naming, copying, writing, following commands).
- Useful for initial and serial measurement.
Documentation of DV/IPV Abuse
- Include detailed progress notes, injury maps, photographic documentation, and verbatim history.
- Document threats of harm made by the perpetrator.
Documentation of Child Abuse/Neglect
- Use the child's words to describe the injury.
- Obtain reports from caregivers if the child is nonverbal.
- Follow institutional protocols for obtaining history.
Documentation of Elder Abuse
- Take photographic evidence and ask about past trauma.
- Be alert for: STIs, pelvic pain, sexual dysfunction complaints, chronic IBS, back pain, depression, PTSD symptoms, sleep problems, panic attacks, nervousness.
- Document history verbatim.
Mandatory Reporter
- Legally required to report suspicions of abuse or neglect (e.g., child abuse, DV, IPV, elder abuse).
- Examples include: teachers, doctors, nurses, social workers, therapists.
NANDA Nursing Diagnoses
- Actual Nursing Diagnoses – Reflect a current problem present at the time of assessment.
- Risk Nursing Diagnoses – Indicate a potential future problem based on risk factors.
- Health Promotion Diagnoses – Focus on readiness to enhance health behaviors.
BEFAST Assessment Tool
- Used to identify early signs of stroke:
- Balance – Sudden loss of balance or coordination?
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Description
This quiz covers various techniques and principles related to health assessment, including subjective and objective findings, interviewing strategies, and general survey parameters. Test your knowledge on the essential aspects of evaluating patient health and the skills necessary for effective communication in a healthcare setting.
