Health Assessment PDF

Interview & communication Subjective Data- what the client states/says also referred as symptoms ( feelings, perceptions, concerns) Objective data- healthcare provider observes and often perform as part of the physical exam in the assesment. Also referred as a signs ( observable and measurable data...

Interview & communication Subjective Data- what the client states/says also referred as symptoms ( feelings, perceptions, concerns) Objective data- healthcare provider observes and often perform as part of the physical exam in the assesment. Also referred as a signs ( observable and measurable data obtained from observation Health assessment has two parts: Health history ( the interview, mainly subjective) Physical exam ( physical exam, mainly objective) Sign- objective abnormality, detectable on physical or in laboratory reports Symptom-person feels or experience Characteristics of a symptom: Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Client’s perception Communication process: Sending: Verbal communication- the words you speak, vocalizations, tone of voice Non- verbal communication- expressions. Eye contact, posture,dress Receiving -the receiver puts their own interpretation on them Vital signs Normal respiratory rates: Neonate- 30-40 bpm 1 year-20-40 bpm 2 year-25-32 bpm 4 year- 23-30 bpm 8-10 year-20-26 bpm 12-14 year-18-22 bpm 16 year- 12-20 Adult- 10-20 bpm Weight: Underweight: BMI less than 18.5 Normal weight: BMIs 18.5 to 24.9 Overweight: BMIs 25 to 29.9 Obese BMI 30 and over Pain assessment Acute pain Sudden pain Often localized Often diminishes Persistent Chronic pain Often greater than 3 months Pain originates from peripheral and central sensitization of pain pathways Tolerance exist whereas vitals are not impacted Sources of pain: Noiceptive- caused by tissue injury; inflammation often involved described as aching or throbbing 1. Somatic- superficial from skin, deep form joints,tendons,muscles, or bone 2. Visceral- direct injury or stretching of large interior, result of tumour,ischemia, contraction Neuropathic- caused by lesion or disease, results from damage to nerve pathway, described as burning or shooting Classification of chronic pain triggers: Noiceptive Postoperative pain Arthritis Backpain  Cutaneous Neuropathic Cancer-related Diabetic neuropathy Phantom limb Respiratory system Cough: orange plem tuberculosis green plem is bacterial clear plem is virus (covid, influenza) Objective data ( anterior and posterior) 1. Inspection (looking) -position of the client -looks for symmetry -shape and configuration: Barrel chest - bulging chest that resembles a barrel, may indicate an underlying condition Pectus carinatum- (pigeon chest) - breastbone is pushed outward Pectus excavatum- (funnel chest)- breastbone is sunken into his chest kyphosis-(humpback)- forward rounding of the back Scoliosis- abnormal curvature of the spine 2. Palpation (touching) anterior and posterior -tenderness and sensation -chest expansion -asymmetrical changes 3. Percussion (tapping the surface of the body) posterior only -sounds: Resonance- healthy lung tissue Hyperresonance- emphysema(progressive chronic lung condition) Dullness- pneumonia, tumor Flat-bone  4. Auscultation (hearing) anterior and posterior breath sounds: Bronchial breath sounds Bronchovesicular breath sounds Vesicular breath sounds Adventitious sounds: Crackles- pneumonia, CHF,COPD Wheeze-asthma Pleural fiction rub- pneumonia Stridor-croup or obstruction Thorax variations in children 32 weeks surfactant is present Chest of newborn generally round and assumes adult proportion 2 years Chest wall is thin, more yielding & prominent Respiratory system does not function until birth first breath Thorax variations in Older adults Barrel chest appearance Chest wall may stiffen, and expansion is decreased Mucous membranes become drier Thorax variations during pregnancy Chest expansion increases, lung length decreases Deeper breathing Increased difficulty to breath lying on their back Subjective Prompts for Children low birth weight or assisted ventilation coughing or possible aspiration difficult feeding apneic episodes sibling crib death recurrent spitting up, recurrent pneumonia Subjective Prompts for the Elderly exposure and frequency of respiratory infections effects of weather and activity on respiratory status  difficulty swallowing immobilization or marked sedentary habits influenza and pneumonia vaccines Heart & Neck vessels Layers of heart wall: 1. Pericardium- outer layer of fibrous tissue 2. Myocardium-middle layer of thick muscle 3. Endocardium- inner layer of epithelial cells Systolic- heart contracts Diastolic- heart relaxes Heart sounds: First heart sound from mitral and tricuspid valve Second heart sound caused by the closure of the aortic and pulmonic valves Third heart sounds results from the impact of inflowing blood against a distended or incompliant ventricle mid diastole Fourth heart sounds is a low frequency gallop sound that results from a forceful atrial contraction during pre systole that eject blood into a ventricle which cannot expand further Murmurs- are abnormal sounds during your heartbeat cycle such as whooshing or swishing Characteristics of murmur sounds: -frequency (pitch, low, medium or high) -intensity (loudness) -Duration -Timing Common causes of a heart murmur: -increased velocity of blood -decreased viscosity of blood -valve defects -abnormal openings Murmur grades  ➔ Grade 1 Heard by an expert in optimum conditions ➔ Grade 2 Heard by a non-expert in optimum conditions ➔ Grade 3 Easily heard, no thrill ➔ Grade 4 Loud murmur, palpable thrill ➔ Grade 5 Very loud murmur, often heard over a wide area, palpable thrill ➔ Grade 6 Extremely loud, heard without a stethoscope Eyes and Ears Snellen eye chart- visual acuity. (use in primary care. Ophthalmologist) Normal result 14/14 Test visual field: Confrontation test- compares and measure of peripheral vision The Hirschberg test- corneal light reflex Cover test- The cover test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel Ears: Tinnitus- ringing in the ear Vertigo- room is spinning around them  Nose, Mouth and throat Infants Salivation occurs at 3 months Drooling for a few months after that is normal until the infant learns to swallow 20 temporary teeth (deciduous) These occur at 6-24 months All should be erupted by 2.5 yrs. Fall out 6-12 yrs. Musculoskeletal System: TMJ: Normal finding- smooth Abnormal finding- pop or click, grinding Sternoclavicular joint: Symmetrical always compare Swelling Cervical, thoracic and lumbar spine: Inspect posterior or lateral view Range of motion Shoulders: Symmetry Range of motion of shoulders Arm and elbow: Lateral= tennis elbow Medial= golfer Elbow Hips: Posture Stability ROM Knee: Temperature Size Shape Deformities Range of motion- is usually desrcibe in degrees of deviation from defined neutral or zero point for each joint ROM as: 1.Passive- examiner moves 2.Active passive- client moves Assess ROM of thoracic and lumbar spine Flexion (touch toes) Lateral bending Thoracic and lumber spine rotation Asses ROM of shoulders Abduction Adduction Outward rotation Inward rotation Flexion Hyperextnsion extension Asses ROM of arm and elbow Extension Flexion Asses ROM of hand and wrist Hand grip Wrist extension Flexion with resistance Asses ROM of hip Abduction Adduction  Extension Flexion external/ internal rotation Asses ROM of knee Flexion Extension External rotation Adduction Abduction Assess ROM of foot & ankle Eversion Inversion Plantarflexion dorsiflexion Neurovascular Assessment CSM Circulation -Pulses -Capillary Refill -Color & Temp Sensation -Pain -Tingling & Burning Movement -Wiggle 5 P’s -Pain / Point Tenderness -Pulse -Pallor -Paresthesia -Paralysi Health Assessment Worksheet Pain Assessment 1. Identify the following statements as either True or False: false: Cancer pain is more severe than noncancerous pain false:Children have a decreased perception of pain False: Using pain medication for a long period of time will cause addiction True: The most accurate indicator of pain, is a client’s self-report False: Older adults have decreased pain sensation False: Women have a lower threshold for pain compared to men 2. Match the likely pathology with the referred pain site Angina Umbilicus:jaw Gastroesophageal Reflux Disease:Chest Appendicitis Back:umbilicus Urinary Tract Infection:back Cholecystitis: Right scapula 3. A client presents with abdominal pain. What questions would you like to ask to assess the client’s symptoms? O: when did it start? P:what makes your pain worse/better? Q: what does the pain feel like? R:can you point where is the pain S: how would you rate your pain on a scale of 1-10 T:what treatment are you taking and how long does the pain last? U:what do you think is the causing the pain? V: is this acceptable level of pain for yourself? 4. Which type of pain scale would the nurse select for a 7-year-old child, a 20-year-old client, and a confused 78-year-old? 7-year-old child: Wong-Baker FACES Pain Rating Scale. This scale uses facial expressions to help children communicate their pain levels in a way they can understand. 20-year-old client: Numeric Pain Scale (0-10). This scale allows the client to rate their pain on a simple numerical scale, which is straightforward for adults to use. Confused 78-year-old: Verbal Descriptor Scale or the FLACC Scale (if they are unable to communicate verbally). The Verbal Descriptor Scale uses words like "no pain," "mild pain," "moderate pain," and "severe pain." The FLACC Scale assesses pain based on observations of facial expressions, leg movement, activity, crying, and consolability, which is useful for individuals who may not be able to self-report accurately. Respiratory System worksheet 1. How would you differentiate peripheral from central cyanosis? Peripheral Cyanosis: Location: Affects extremities (fingers, toes) and sometimes lips/nose. Appearance: Bluish discoloration, often with coldness. Causes: Decreased blood flow (e.g., peripheral vascular disease, hypothermia). Central Cyanosis: Location: Affects core and mucous membranes (lips, tongue). Appearance: Generalized bluish tint, particularly in pink areas. Causes: Systemic oxygenation issues (e.g., respiratory disorders, cardiac defects). Assessment Tips: Check oxygen saturation and skin temperature to aid differentiation. 2. A client has a decrease in oxygen from 100% to 85%, what assessment findings might a nurse find in their respiratory, integumentary, cardiovascular and neurological systems? Respiratory System: Increased respiratory rate (tachypnea) or effort (use of accessory muscles). Shortness of breath or dyspnea. Cyanosis (bluish tint, particularly around lips and fingertips). Abnormal lung sounds (e.g., wheezing, crackles). Integumentary System: Cyanosis (especially in mucous membranes and extremities). Pallor (pale skin). Coolness or clamminess of the skin. Cardiovascular System: Increased heart rate (tachycardia). Hypotension (low blood pressure) in severe cases. Weak or thready pulse. Possible arrhythmias. Neurological System: Confusion or altered mental status (e.g., lethargy, agitation). Headache. Dizziness or lightheadedness. Decreased level of consciousness in severe hypoxia. These findings indicate the body’s response to reduced oxygen levels and highlight the need for immediate assessment and intervention. 3. Upon posterior lung assessment, a client has clear lung fields, despite having a new diagnosis of right middle lobe pneumonia. How can this be possible? client with right middle lobe pneumonia may have clear lung fields during posterior assessment for several reasons: 1. Early Stage: The pneumonia may be in its initial phase, with minimal inflammation or consolidation. 2. Localized Infection: The pneumonia may not extend to areas assessed posteriorly. 3. Assessment Technique: The examination may not adequately capture the affected region. 4. Adequate Ventilation: Other lung regions may still be well-aerated. 5. Other Pathologies: Conditions like pleural effusion could obscure lung sounds. 4. Cyanois is a late sign of hypoxia. What other signs or symptoms should the nurse be aware of to detect early hypoxia? 1.shortness of breath 2.confusion 3.tachycardia Pallor 5. Which assessment findings illustrate a relationship between the respiratory system and other systems? In examining persons across the life span, it is important to consider: A ) the developmental stage when determining the sequence of the exam B ) privacy for all ages. C ) pacing the examination to meet the physical, mental, and emotional needs of the aging adult. D ) All of the above At the end of the examination, the clinician should: A) complete all the documentation before leaving the examination room. B) have findings confirmed by another provider. C) compare objective and subjective data for discrepancies. D) review the findings with the client. Which of the following is the most reliable indicator for persistent pain? A ) MRI results B ) Client self-report C ) Tissue enzyme levels D ) Blood drug levels Cardiovascular System Worksheet 1. During auscultation, which sound is louder at the apex (S1 vs S2), why? During auscultation, the second heart sound (S2) is typically louder at the apex compared to the first heart sound (S1). This is primarily due to the closure of the aortic and pulmonic valves, which occurs during S2. 2. Name 4 causes of a cardiac murmur. Increased blood flow Congenital heart defects Endocarditis 3. When auscultating for a carotid bruit, what instructions should you give the client? What does the presence of a cardiac bruit indicate? Presence of a caorid bruit indicates: Atherosclerosis Carotid stenosis Instructions for auscultating a carotid bruit Positioning Use of the stethoscope Breath control 4. Which assessment findings illustrate a relationship between the cardiovascular system and other systems? Respiratory system: -Shortness of breath -cyanosis Integumentary system -pallor -cyanosis 5. Write the anatomic location for the following cardiac auscultory areas: Aortic area - right second intercostal space Pulmonic area -left second intercostal space Erb’s point-left third intercostal space Tricuspid area-left fourth intercostal space Mitral area-left fifth intercostal Head, Neck and Face Worksheet Multiple Choice Questions  1. Select the statement that is true regarding cluster headaches. a) may be precipitated by alcohol and daytime napping b) usual occurrence is two per month, each lasting 1 to 3 days c) characterized as throbbing d) tend to be supraorbital, retro-orbital, or frontotemporal 2. Providing resistance while the patient shrugs the shoulders is a test of the status of cranial nerve: a) II b) V c) IX d) XI 3. It is normal to palpate a few lymph nodes in the neck of a healthy person. What are the characteristics of these nodes? a) mobile, soft, nontender b) large, clumped, tender c) matted, fixed, tender, hard d) matted, fixed, nontender 4. If the thyroid gland is enlarged bilaterally, which of the following maneuvers is appropriate? a) Check for deviation of the trachea. b) Listen for a bruit over the carotid arteries. c) Listen for a murmur over the aortic area. d) Listen for a bruit over the thyroid lobes. 5. What is meant when a client states that they are “nearsighted”? Having difficulty seeing distant objects clearly 6. What is meant when a client states that they are “farsighted? having difficulty seeing close objects clearly Musculoskeletal (MSK) System worksheet Matchup Terminology 1. Bursa: ○ Function: Cushions and absorbs shock; allows for smooth movement of joints.  2. Tendon: ○ Function: Connects muscle to bone; allows for movement. 3. Ligament: ○ Function: Connects bone to bone; provides stability to joints. 4. Cartilage: ○ Function: Provides support and cushioning between bones. 5. Bone: ○ Function: Provides structure and support, produces red blood cells, and stores calcium. 6. Joint: ○ Function: The articulation of two adjacent bones or cartilage; allows for movement. Movements 1. Extension: ○ Definition: Straightening a joint angle (increases the angle). 2. Flexion: ○ Definition: Shortening a joint angle (decreases the angle). 3. Internal Rotation: ○ Definition: Turning inward toward the midline. Movements: 4. External Rotation: ○ Definition: Turning away from the midline. 5. Abduction: ○ Definition: Movement away from the midline. 6. Adduction: ○ Definition: Movement toward the midline. Movements: 7. Pronation: ○ Definition: Turning the palms down. 8. Supination: ○ Definition: Turning the palms up. 9. Inversion: ○ Definition: Turning soles of the feet inward. 10. Eversion: ○ Definition: Turning soles of the feet outward. 11. Protraction: ○ Definition: Pushing out or forward. 12. Retraction: ○ Definition: Pulling back or inward. 13. Circumduction: ○ Definition: Circular movement of a limb.  Short Answer Questions 1. You are assessing a client for possible scoliosis, what is the best position for the client to be in? Standing position 2. What are the four normal curves of the spine? Cervical lordosis (neck region) Thoracic kyphosis (upper back) Lumbar lordosis (lower back) Sacral kyphosis (base of the spine) 3. Name 4 ways to assess cerebellar function. Balance Tests: Such as the Romberg test (standing with feet together, eyes closed). Coordination Tests: Such as the finger-to-nose test or heel-to-shin test. Gait Assessment: Observing the client's walking pattern for stability and coordination. Rapid Alternating Movements: Such as having the client rapidly tap their fingers or palms. 4. Which factors increase the risk of back injury, or back problems in a client? Poor posture Obesity Sedentary lifestyle or lack of exercise Heavy lifting or repetitive strain Previous back injuries Aging 5. Which clients would require a complete MSK assessment? ○ Clients with pain or discomfort in joints or muscles ○ Individuals with a history of musculoskeletal disorders or injuries ○ Patients with limited range of motion or mobility issues ○ Those experiencing symptoms like swelling, weakness, or deformity in limbs or spine. Crepitation is an audible sound that is produced by: A) roughened articular surfaces moving over each other. B) tendons or ligaments that slip over bones during motion. C) joints that are stretched when placed in hyperflexion or hyperextension. D) an inflamed bursa. Heberden's and Bouchard's nodes are hard and nontender and are associated with: A) osteoarthritis B) rheumatoid arthritis C) Dupuytren's contracture D) metacarpophalangeal bursitis The divisions of the spinal vertebrae include which of the following? A) Cervical, thoracic, and scaphoid B) Scapular, clavicular, and lumbar C) Thoracic, lumbar, and coccygeal D) Cervical, lumbar, and iliac Crossword Puzzle - SOGIE Glossary of Terms 1. Feeling romantic, emotional, and sexual attraction to a person(s) of the opposite gender with which one identifies; sometimes referred to as being straight. Heterosexual 2. Discrimination and unfair treatment based on sex or gender in which advantage is usually afforded to men and not women. sexism 3. A term used to describe a man who is attracted to other men. Gay 4. Feeling romantic, emotional, and/or sexual attraction to people of the same gender with which one identifies. This term is considered stigmatizing by many due to its history of being categorized as a mental illness. Discouraged from use unless an individual uses it to self-identify. Homosexual 5. An umbrella term for gender identities that are outside of the gender binary, meaning not exclusively either boy/girl, or man/woman. Non-binary 6. An umbrella term constructed to describe variations of sex characteristics. intersex 7. A term used to describe a woman who is attracted to other women. Lesbian 8. represents all individuals who fall outside of the gender and sexual orientation “norms.” LGBTQ+ 9. An umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. Transgender 10. A person whose gender identity and assigned sex at birth align. Cisgender 11. Someone who dresses and performs as another gender for entertainment purposes. Drag performer 12. A person who is attracted to people of their own gender as well as other genders. Bisexual 13. A person who does not have sexual desire or asexual 14. A person who is attracted to people regardless of sex, gender identity, or gender expression. pansexual 15. A gender expression that has both masculine and feminine elements.androgynous Interview and Communication Worksheet Multiple Choice Questions 1. When reading a medical record, you see the following notation: Patient states, “I have had a cold for about a week, and now I am having difficulty breathing.” This is an example of: a.past history b.a review of systems c.a functional assessment d.a reason for seeking care 2. The statement “Reason for seeking care” has replaced the “chief complaint.” This change is significant because: a.“chief complaint” is really a diagnostic statement b.the newer term allows another individual to supply the necessary information c.the newer term incorporates wellness needs d.“Reason for seeking care” can incorporate the history of present illness 3. Select the best description of “review of systems” as part of the health history. a.the evaluation of the past and present health state of each body system b.a documentation of the problem as described by the patient c.the recording of the objective findings of the practitioner d.a statement that describes the overall health state of the patient 4. Which of the following is considered to be subjective? a.temperature of 101.2° F b.pulse rate of 96 c.measured weight loss of 20 pounds since the previous measurement d.pain lasting 2 hours Crossword