Health Assessment Exam 1 Reviewer PDF Fall 2024

EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 A1 OBJECTIVE DATA HEALTH PROMOTION AND ASSESSMENT BASICS Objective = Observed...

EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 A1 OBJECTIVE DATA HEALTH PROMOTION AND ASSESSMENT BASICS Objective = Observed Physical assessment findings Example TOPIC OVERVIEW A. COMPONENTS OF PATIENT A2 SUBJECTIVE DATA ASSESSMENT a. Objective Patient’s point of view b. Subjective Chief complaints B. THREE LEVELS OF PREVENTION s/s that cannot necessarily be C. RECOMMENDED TESTS observed/assumed a. Physical exam ○ Should be noted by the nurse b. Dental exam c. Blood pressure screening d. Serum cholesterol Examples e. Blood glucose Patient’s skin is dry and flaky = O f. Vision exam Patient complains of itchy skin = S D. TYPES OF ASSESSMENT a. Basic b. System-based B THREE LEVELS OF PREVENTIONS c. Focused d. Comprehensive E. PREVENTATIVE INTERVENTIONS LEVELS OF PREVENTION a. Breast cancer screening b. Prostate PRIMARY - Health Immunization c. Lung promotion Child car seat d. Skin - Disease Nutrition prevention Exercise F. ASSESSMENT TECHNIQUES - Decrease the a. Palpation risk of exposure b. Inspection for the disease c. Percussion d. Auscultation SECONDARY - Identifying Screenings illness BP checks - Provide Blood sugar A COMPONENTS OF PATIENT treatment level checks ASSESSMENT - Help prevent Cholesterol worsening level checks health status PATIENT HEALTH HISTORY TERTIARY - Prevents Taking aspirin Contributes 70% to the patient’s long-term after a diagnosis consequences myocardial of a chronic infarction Physical test = 15%-20% illness or Diagnostic tests = 10%-15% disability PAGE 1 KHATE LLANILLO - 2024 - UWM NURSING ‘26  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 Note C5 BLOOD GLUCOSE While dependent on comorbidities, it is preferred to start with the primary level of prevention for every patient. Level of sugar in blood Frequency ○ 45+ y/o = every 3 years C RECOMMENDED TESTS C6 VISION EXAM C1 PHYSICAL EXAM Eye health Frequency Checks for overall health, addresses ○ Under 40 y/o = every 3-5 years concerns, updates vaccination, and help ○ 40-65 y/o = every 2 years maintain good health ○ 65+ y/o = annually Frequency ○ Every 1-3 years = Female D TYPES OF ASSESSMENT ○ Every 5 years = Male C2 DENTAL EXAM NURSING ASSESSMENT Nurses collect data on a patient’s Frequency physical, psychological, emotional, social, ○ Every 6 months and environmental status. Essential for accurate and holistic understanding of a patient's health C3 BLOOD PRESSURE SCREENING condition, needs, and potential risks. Noninvasive D1 BASIC ASSESSMENT Reduce the risk of heart disease and stroke Frequency Nursing assessment of multiple body ○ Every 2 years systems but not as in-depth per each ○ Annually if BP is elevated system. Example ○ Patient discharged home at the C4 SERUM CHOLESTEROL end of your shift who was admitted for pneumonia and had Serum cholesterol = total amount of a fall during their hospital stay. lipids in the blood Can indicate risk of heart disease Note Frequency Should give indications of whether a ○ 20+ y/o = every 5 years focused assessment is needed in a particular system, PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 2  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 D2 COMPREHENSIVE ASSESSMENT Note Assess the entire system that is impacted. Detailed physical examination of the entire body. Example E PREVENTATIVE INTERVENTIONS ○ Newly admitted patient who has a ruled out stroke. HEALTH SCREENING Note Detect diseases and chronic conditions Include detailed health history, early and improve health outcomes. interview questions related to the patient’s health and potentially imaging tests/labs E1 BREAST CANCER SCREENING Mammograms D3 FOCUSED ASSESSMENT ○ Every 2 years from 50-74 y/o ○ Personal preference between Focuses on the chief complaint or area 40-49 y/o affected by condition change, Clinical breast exams (CBE) and symptoms, disease process, etc. self-exams are not evidence based Can occur after basic assessment when ○ Increased cost an abnormal finding exists. ○ Anxiety Example ○ Patient who comes into the ER E2 PROSTATE CANCER SCREENING with a suspected fracture on the right arm. For men with average risk aged 45-75 y/o Note Annual exam for men Assess just the area that is impacted. PSA test (every 1-2 years or 2-4 years, depending on level) Discuss risk factors with the provider D4 SYSTEM-BASED ASSESSMENT E3 LUNG CANCER SCREENING Focuses on the chief complaint or area affected by condition change, Yearly low-dose CT scan (LDCT) symptoms, disease process, etc. ○ Show potentially cancerous Can occur after basic assessment when tumors when they’re still small an abnormal finding exists. ○ Latkes pictures of the insides of ○ Patient who enters clinic with the lungs complaints of constipation and bloating. E4 SKIN CANCER SCREENING Visual exam of the skin Certain unusual marks may be signs of skin cancer PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 3  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 F ASSESSMENT TECHNIQUES F1 PALPATION Method of feeling with fingers or hands during a physical examination. Example ○ Palpating the head and scalp to check shape, size, and symmetry to check for abnormalities from trauma F2 INSPECTION Purposeful and systematic observation of the client Requires the use of vision, hearing, touch, and smell Example ○ Observing gait F3 PERCUSSION Tapping your fingers or hands quickly and sharply against parts of the body Help locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas Example ○ Percuss over the abdomen to reveal gas-filled areas F4 AUSCULTATION Listening to internal sounds of the body Example ○ Auscultating for lung sounds PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 4  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 MUSCULOSKELETAL A JOINT AND MUSCLE FINDINGS JOINTS TOPIC OVERVIEW A. JOINT AND MUSCLE FINDINGS Joints = provide movement and flexibility a. Assessment Inspect then palpate b. Expected finding c. Unexpected finding A1 ASSESSMENT B. GAIT ASSESSMENT a. Components b. Types ASSESSING JOINTS C. RANGE OF MOTION a. Types of ROM Assess for inflammation b. ROM terminologies ○ Warmth, edema, redness D. SPINE CURVATURE Crepitus E. CRANIAL NERVE IX ○ Grating sound/sensation F. EXAM SEQUENCE produced by friction between a. Inspection bone and cartilage or the b. Palpation fractured parts of a bone. c. ROM Tenderness d. Strength ○ Note patient’s facial expression when assessing Deformities CHANGES ASSOCIATED WITH AGING limitations/stiffness Instability 35 y/o = bone formation and destruction become unequal TMJ ○ reabsorption/destruction increases and formation Open and close jaw decreases = decreased bone mass ROM and increased risk for injury ○ Flexion Osteopenia ○ Extension ○ Decreased bone density SHOULDERS Increased bone prominence Kyphotic posture ROM = for rotation ability Less elastic and compressible synovial elevate/depress joint cartilage Circumduction Muscle tissue atrophies adduction/abduction Decreased ROM flexion/extension Slowed movement ○ Lifting arms straight forward and back ELBOWS ROM ○ flex/extend ○ pronate/supinate PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 5  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ dorsiflexion/plantar flexion Note ○ invert/evert Apply resistance to the forearm to Strength assessed by resistance assess elbow strength. MUSCLE ASSESSMENT WRISTS Palpate muscles Assess strength ROM ○ Push and pull ○ flex/extend ○ internal/external rotation MUSCLE TESTING ○ pronate/supinate Strength Test strength of prime muscles groups ○ Apply resistance to the top and for each joint bottom of the hand ○ Repeat actions for AROM Ask patient to flex and hold as you apply HANDS (FINGERS) opposing force Have patient squeeze your fingers for hand strength A1 EXPECTED FINDINGS SPINE MUSCLES Inspect spine while patient is standing Firm Palpate the spine when bent down and Symmetry standing ○ Dominant side, slightly larger 30 bowel sounds figure ○ Absent ○ Splenomegaly No bowel sounds heard Enlarged spleen Listen for at least 5 mins ○ Hepatomegaly May be loud, gurgling, or quiet Enlarged liver Bruits ○ No pain/tenderness with ○ Whooshing sounds located over palpation on all quadrants an artery Rebound tenderness ○ Aorta (if positive bruit = AAA) ○ To be performed by an APRN ○ Renal arteries ○ Deeper palpation and then ○ Iliac arteries released ○ Femoral arteries ○ Pain occurs with the stopping of palpation/pressure Areas of palpation ○ Liver ○ Spleen ○ All four quadrants PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 11  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 Motor B CRANIAL NERVES ○ Conscious patient: depress tongue and note pharyngeal movement (“ahh”) = uvula and B1 CRANIAL NERVE V : TRIGEMINAL soft palate should rise midline, and tonsillar pillars should move Controls ability to chew medially ○ Not intact Clear, loud voice Potential choking or ○ Unconscious patient: touch aspiration posterior pharyngeal wall with Motor tongue blade = note gag reflex ○ Assess muscles of mastication Smooth voice (not Palpate temporal and strained) masseter muscles as ○ Not intact patient opens and Uvula deviates to the side clenches jaw No gag reflex Should feel equally strong Hoarse on both sides Brassy Try to separate jaws by Nasal twang or husky voice pulling down on chin Dysphagia (patient should resist) Fluids regurgitate through ○ Not intact nose Weakness of masseter or Sensory temporalis muscles ○ CN IX mediate taste on posterior Sensory one third of tongue ○ Patient eyes closed, test light ○ Technically difficult to test touch sensation (forehead, cheeks, and chin) B3 CRANIAL NERVE XII : HYPOGLOSSAL ○ Test all three divisions of CN V (ophthalmic, maxillary, and mandibular) Ability to swallow ○ Test sensory portion of corneal Not intact blink reflex along with CN VII ○ Potential for choking or aspiration (facial) = motor component Motor ○ Not intact ○ Inspect tongue Absent sensation of touch No wasting ot tremors or pain should be present Paresthesias Should be midline No blink noted ○ Repeat “light, tight, dynamite” Note lingual speech (sound of letters l, t, d, n) is B2 CRANIAL NERVE IX & X : clear and distinct GLOSSOPHARYNGEAL AND VAGUS ○ Not intact Tongue deviates to side Ability to swallow and presence of gag Slowed rate of tongue reflex movement ○ Not intact Sounds of l, t, d, n are not Potential choking or clear and distinct aspiration PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 12  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 C ASSESSMENT FINDINGS C3 HERNIA Protruded abdomen C1 APPENDICITIS Valsalva maneuver to assess at groin, umbilical, or surgical sites Extreme pain in the RLQ Rebound tenderness present C4 DIARRHEA C2 CONSTIPATION History and interview questions ○ Date of last BM History and interview questions ○ Consistency of BM ○ Date of last BM ○ Urgency to have BM, cramping, ○ Consistency of BM abdominal pain ○ Straining to have BM, bloating, ○ > 3 BM in a day potentially N/V Auscultation ○ Less than 3 BM in a week ○ Hyperactive bowel sounds ○ Recent lack of fluids or Complications dehydration ○ Dehydration and fluid imbalance Inspection Intake and output (I&O) ○ Distended abdomen Skin turgor Palpation Moisture level and color of ○ Hard, palpable stool mucous membranes Auscultation Irregularity of heart ○ May have hypoactive bowel rhythm/rate sounds Dark colored urine Complain or cramping Less frequent urination or decreased amount Thirst BRISTOL STOOL CHART PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 13  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 GENITOURINARY A2 HEALTH HISTORY Any difficulty in urinating? TOPIC OVERVIEW ○ Hesitancy or straining A. ASSESSMENT OF GU ○ Weakened force of stream, a. Noticing dribbling, or incomplete b. Health history emptying B. URINARY INCONTINENCE AND ○ BPH, potential increased risk for CONTINENCE UTI C. ASSESSING FLUID STATUS Leak water or urine when you don’t want D. PHYSICAL ASSESSMENT to? E. ABNORMAL URINARY PATTERNS ○ Use of pads or tissue to catch a. Oliguria urine in your underwear? b. Anuria Pain when urinating or in your flank c. Nocturia region? d. Polyuria Do you need to get up at night to F. ASSESSMENTS urinate? a. Urine ○ What medications are you b. Foley catheter taking? c. AV fistula ○ What fluids do you drink in the G. GU DISEASES evening? a. Renal calculi b. Acute urinary retention B URINARY INCONTINENCE AND c. Urethral stricture CONTINENCE d. Renal failure H. FINDINGS e. Dehydration URINARY INCONTINENCE f. Urinary retention g. Receiving IV fluids Involuntary loss of urine Types ○ urge/overactive bladder A ASSESSMENT OF GU Want to urinate, though bladder is not full ○ Stress Abdominal pressure leads A1 NOTICING to pressure on bladder Jump, laugh, sneeze, etc. Demographic information ○ Functional Socioeconomic status Urinary tract is functioning Nutrition history but other disease process Medication history does not allow you to be Family and genetic risk continent (dementia, Current health problems medications, mental illness) PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 14  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 URINARY CONTINENCE Percuss bladder ○ Distended = dull Educate parents of pediatric patients Percuss costovertebral angle for Changing diaper frequently tenderness Wiping technique (front to back) ○ Non-tender side first (if Proper timeline of toilet training applicable) ○ Many begin training at age of 2 ○ Murphy’s punch sign ○ Expected continence: 3-4 y/o Flat hand on back ○ Boys may take longer ○ Expected: No pain No tenderness C ASSESSING FLUID STATUS ○ Assess for: Kidney stones Weight Pyelonephritis Blood pressure Polycystic kidney Intake and output (I&O) UTI ○ What goes in must match what Urinary obstruction comes out ○ If kidney issues or retention occur: E ABNORMAL URINARY PATTERNS I>O D PHYSICAL ASSESSMENT E1 OLIGURIA Kidneys Decreased urine output ○ Inspection, auscultation, Less than 400 mL in a day palpation Inspect abdomen and flank E2 ANURIA ○ Sitting and supine ○ Expected: Symmetry No urine output No swelling Less than 1100 mL in a day No discoloration especially in the CVA (costovertebral angle) E3 NOCTURIA CVA location (12th rib and vertebral column) Excess urination at night Assess renal artery for bruit Disturbed sleep pattern ○ Use bell side E4 POLYURIA Note If tumor or aneurysm is suspected = do not palpate Increased urine output Place patient supine Could be associated with increased Palpate abdomen in all 4 quadrants frequency as well ○ Note any tenderness or pain, distention PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 15  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 Thrill F ASSESSMENTS ○ Hold gloved hand over AV fistula ○ Expected: Vibration (similar to F1 URINE phone) Bruit Observe urine color, odor, and clarity ○ Whooshing sound (use bell side) Clarity ○ Clear G GU DISEASES ○ Cloudy ○ Sediment ○ Pus G1 RENAL CALCULI ○ Blood Kidney stones URINE COLOR Painful May pass on their own or need invasive intervention Strain urine G2 ACUTE URINARY RETENTION Inability to empty bladder completely Abdominal pain Distended abdomen G3 URETHRAL STRICTURE F2 FOLEY CATHETER Narrowing in the urethra Issues with flow Assess color in bag ○ Spraying or need to force stream Assess clarity/consistency out ○ Clear Incomplete emptying of bladder ○ Cloudy ○ Sediment ○ Blood G4 RENAL FAILURE ○ Pus ○ Mucus Edema SOB F3 AV FISTULA Anuria Abnormal skin tone ○ Jaundice or gray For hemodialysis, connecting an artery Itching and a vein Fatigue PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 16  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 OTHER GU DISEASES URINARY TRACT - Febrile INFECTION - Confusion in older adults Burning or pain when urinating - Frequency of urination - Find the cause: urinary retention, wiping technique, etc. HYPOSPADIAS - Urethra is located lower than usual - Stream = downward - If found at birth, consider avoiding circumcision - After surgery watch for two streams from fistula forming H FINDINGS H1 DEHYDRATION Start of dehydration ○ Dark yellow urine Extreme dehydration ○ Amber to brown urine Mucous membranes would be dull, not shiny/moist Hardened stool Constipation H2 URINARY RETENTION Distended abdomen Abdominal pain Reduced or complete lack of micturition or urination H3 RECEIVING IV FLUIDS Too much or bolus = turn urine to clear PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 17  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 Corneal light reflex EYES, EARS, NOSE, MOUTH, AND ○ Expected finding THROAT Reflected dot of light should be in the same position on each eye TOPIC OVERVIEW Peripheral vision ○ Assess using hand or object from A. EYES behind a. Assessment Cover/uncover b. Cranial nerves ○ Tests ocular deviation c. Unexpected findings ○ Expected finding: B. EARS Equal strength of eyes a. Assessment b. Cranial nerves c. Tuning fork tests Strabismus d. Types of hearing loss Hirschberg test C. NOSE ○ Assess whether a person has a. Assessment ocular misalignment b. Cranial nerves D. MOUTH AND THROAT CHARTS FOR EYE ASSESSMENT a. Assessment b. Cranial nerves Snellen ○ Test if patient can see far ○ Failed snellen = patient has A EYES myopia (nearsightedness) Patient have larger pupils Rosenbaum A1 ASSESSMENT ○ Test if patient can see near ○ Failed rosenbaum = patient has hyperopia (farsightedness) Order of assessment Patient have smaller pupils ○ Inspection Ishihara ○ Palpation ○ Assess color perception Inspection ○ Symmetry ○ Placement in orbits Note ○ Eyelids OU = Both eyes Should close completely OD = Right eye Ptosis should not be OS = Left eye present No redness, swelling, or INSPECTION OF THE EYE lesions ○ Sclera Pupils and pupillary response White PERRLA (CN II and III) ○ Conjunctiva ○ Pupils equal Pink, no discharge Normal size 3-5 mm ○ Cornea Anisocoria = difference in Clear/transparent, smooth, pupil size between eyes and shiny ○ Round PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 18  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Reactive to light ○ Motor Expected: constriction Mobility and facial occurs briskly within 1 symmetry as patient second responds to requests to Unexpected: sluggish smile, frown, close eyes (longer than 1 second), tightly , lift eyebrows, show nonreactive or fixed (no teeth response) Have patient puff cheeks, ○ Accommodation then press puffed cheeks Expected: constrict when in (air must escape equally looking at finger, dilate from both sides) when viewing distantly ○ Sensory Test only when facial nerve injury is suspected A2 CRANIAL NERVES When indicated, test sense of taste CRANIAL NERVE II : OPTIC Note Connects optic disc to brain Normally, patient will blink bilaterally Sight nerve Corneal reflex may be decreased or Motor absent in those who have worn ○ Visual acuity contact lenses Snellen chart Rosenbaum chart ○ Visual fields A3 UNEXPECTED FINDINGS Peripheral vision ○ PERRLA Exophthalmos TESTED BY 6 CARDINAL FIELDS OF GAZE ○ Protrusion of eye Enophthalmos Assess extraocular movements by ○ Sunken eyes cardinal positions of gaze Sclera Expected finding: ○ Yellow = jaundice (may be normal ○ Both eyes should move smoothly, if mild in persons of dark-skin) parallel together CN II (optic) not intact ○ Defect or absent central vision CRANIAL NERVES V AND VII : TRIGEMINAL ○ Defect in peripheral vision AND FACIAL ○ Hemianopsia Blindness in part of the Corneal blink reflex field of vision) ○ Patient look forward > bring wisp ○ Absent light reflex of cotton in from side and lightly ○ Papilledema touch cornea (not conjunctiva) Swollen optic nerve ○ Tests sensory afferent in cranial ○ Optic atrophy nerve V and motor efferent in CN ○ Retinal lesions VII (muscles that close eye) CN III (oculomotor) not intact CN VII (facial) ○ Dilated pupil, ptosis, eye turns out ○ Innervates lacrimal glands and slightly down muscles ○ Failure to move eye up, in, down PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 19  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Absent light reflex Palpation of the pinna, tragus, and ○ Nystagmus mastoid process Involuntary twitching of ○ Note any of the following the eye abnormalities CN IV (trochlear) not intact Furuncles (boil) ○ Failure to turn eye down or out Large amounts of ○ Nystagmus cerumen (wax) CN V (trigeminal) not intact Scaliness ○ Potential for choking or aspiration Redness CN VI (abducens) not intact Swelling ○ Failure to move laterally, diplopia Drainage (amount, color, (double vision) on lateral gaze consistency) ○ Nystagmus B2 CRANIAL NERVES CN VII (facial) not intact ○ Motor Facial drooping, ptosis, CRANIAL NERVE VIII : VESTIBULOCOCHLEAR asymmetrical movement when making expressions Hearing and balance ○ Sensory Can test hearing acuity by patient’s Inability to taste ability to hear normal conversation and whisper test B EARS Not intact: ○ Decrease loss of hearing HEALTH HISTORY B3 TUNING FORK TESTS Pain Discharge RINNE TEST Vertigo Tinnitus Compares air vs bone conduction of Difficulty of hearing sounds or words sound Ear trauma or surgery Air conduction = 2-3x longer Excess wax (how do you remove it) Strike tuning fork > place on mastoid Exposure to loud noise process until sound stops > then hold in Air travel front of pinna until sound stops Swimming Use of hearing aids WEBER TEST ORDER OF ASSESSMENT Strike the tuning fork and place it on top of the head Inspection Patient should hear ringing equally palpation B1 ASSESSMENT Inspection of external ear ○ Note swelling, nodules, or lesions PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 20  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Assess which nare to use for NG B4 TYPES OF HEARING LOSS insertion Palpation of external nose CONDUCTIVE ○ Expected: no pain and tenderness Inspection of nasal cavity Interruption in conduction of sound ○ Septum should be midline waves d/t obstruction ○ Note any abnormalities (deviated ○ Ear wax plug septum) ○ Foreign body ○ Bulging tympanic membrane SINUSES ○ Infection ○ tumors Palpation and percussion of the sinuses Include SENSORINEURO ○ Frontal ○ Maxillary Damage to inner ear or auditory cranial ○ Ethmoid nerve ○ Sphenoid Prolonged exposure to loud noise = No pain or tenderness should occur damages hair cells of cochlea C2 CRANIAL NERVES PRESBYCUSIS Type of sensorineural hearing loss CRANIAL NERVE I : OLFACTORY ○ Degeneration of cochlear nerve cells Test sense of smell in those who report: ○ Loss of elasticity of the basilar ○ Loss of smell membrane ○ Head trauma ○ Decreased blood supply to inner ○ Abnormal mental status ear ○ Suspected presence of intracranial lesion Intact: C NOSE ○ Patient can identify an odor on each side of nose ORDER OF ASSESSMENT ○ Normally decreased with aging Not intact: Inspection ○ Anosmia Palpation Loss of smell Percussion ○ Any symmetry in sense of smell is important C1 ASSESSMENT D MOUTH AND THROAT Inspection of the nose and patency testing ORDER OF ASSESSMENT ○ Instruct patient to occlude one nare at a time Inspection ○ Breathe in and out through the nose PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 21  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 D1 ASSESSMENT D2 CRANIAL NERVES MOUTH AND THROAT CRANIAL NERVES IX & X : GLOSSOPHARYNGEAL & VAGUS Inspect and palpate lips ○ Note color and symmetry Ability to swallow and presence of a gag ○ Note any dryness or cracking reflex Inspection of the teeth Not intact: ○ Note any missing or loose teeth, ○ Potential for choking or aspiration strong odors (fruity, alcohol, foul, etc.) CRANIAL NERVE XII : HYPOGLOSSAL ○ Assess for hygiene Inspection and palpation of the buccal Ability to swallow mucosa, gums, and tongue Not intact: ○ Use gauze to lift tongue up/down, ○ Potential for choking or aspiration side to side Motor ○ Monitor for lesions, white spots ○ Inspect tongue; no wasting or (fungal infection), inflammation, tremors should be present etc. ○ Tongue should be midline Inspection of the throat ○ Note that lingual speech (sounds ○ Monitor for lesions, white spots of letters l, t, d, n) is clear and (fungal infection), red spots (strep distinct throat), tonsil stones, ○ Not intact: Tongue deviates to inflammation, etc. side, slowed rate of tongue movement, sounds of l, t, d, and n are not clear and distinct TONSIL SIZE AND GRADE PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 22  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Groin in region of L1 NEUROLOGICAL AND MENTAL ○ Knee at L4 STATUS Used to control post-op pain Patients given spinal blocks or epidurals for pain management are assessed TOPIC OVERVIEW post-operatively to determine where the dermatome level will recede A. ASSESSMENT a. Mental status ORDER OF EXAM b. Level of consciousness c. Painful stimuli Inspection d. Orientation Strength of muscles/coordination of e. Cognitive and intellectual activity processes f. Speech/language g. Motor function A1 MENTAL STATUS h. Sensory function B. LEVELS OF RIGIDITY Appearance a. Decorticate rigidity ○ Hygiene and appropriateness b. Decerebrate rigidity Mood C. TESTS ○ Expected a. Glasgow coma scale Eye contact b. Mini mental state examination Emotion correlate to (MMSE) situation D. REFLEXES ○ Unexpected a. Deep tendon reflexes Flat affect b. Superficial Aggressive c. Visceral Anxious d. Pathologic Impulsive A ASSESSMENT A2 LEVEL OF CONSCIOUSNESS DERMATOMES Alert ○ Engaged and responsive Circumscribed skin area supplied mainly ○ Opens eyes and answers from one spinal cord segment through questions particular nerve Lethargic Dermatomes overlap ○ Drowsy and doesn’t hold If one nerve is severed, most sensations attention long without falling are transmitted by one above and one back asleep below ○ Easy to awake Landmarks Obtunded ○ Thumb ○ Confused and slow to respond ○ Middle finger ○ Needs additional stimuli like ○ Fifth finger are C6, C7, and C8 touch (mild shaking/0 to get ○ Axilla at T1 attention/response ○ Nipple at T4 ○ Umbilicus at T10 PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 23  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 Stupor Situation ○ Responds only after painful or ○ Why are you here? vigorous stimuli Comatose A5 COGNITIVE AND INTELLECTUAL ○ No response to painful stimuli PROCESSES ○ Levels of rigidity Assess memory A3 PAINFUL STIMULI ○ Long-term, recall, and immediate Level of knowledge about current Peripheral situation ○ Use of pressure on upper nail bed Serial calculations (count up by 7’s) Supraorbital Abstract thinking ○ Place thumb under orbital rim in ○ “A bird in the hand is worth two in middle of eyebrow and push the bush” upward Insight ○ Do not use with patients who Judgment have orbital or face fractures ○ Ask patient to provide solution to Trapezius a common problem ○ Squeeze or pinch Thought process Mandibular ○ Coherent and methodical in ○ Apply pressure/pinch lower jaw transitions Sternal ○ Unexpected: ○ Rub fust/knuckles against Inappropriate words sternum Made-up words Changing topics Thought content A4 ORIENTATION ○ Assess for delusions or hallucinations Level of orientation can be affected by: ○ Time of day A6 SPEECH/LANGUAGE ○ Need for sleep ○ Glucose or oxygen levels ○ medication/drug therapy Expected ○ Infection ○ Meaningful responses ○ Appropriate words Unexpected Note ○ Slow Be able to prioritize if these orientation ○ Delayed has changed ○ Garbled ○ Slurred Self/person ○ Incomprehensible ○ Can you tell me your name? ○ Who else is in the room? Place A7 MOTOR FUNCTION ○ Where are you? Time Rapid altering movement ○ What is today’s date? ○ Finger to finger ○ Include month, day, and year ○ Finger to nose PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 24  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Heel to shin Lower extremities ○ Thumb to fingers ○ Stiffly extended, plantar flexion, ○ Rotating palm and hand slap on hyperextended back = lesion in thigh brain stem at midbrain or upper Gait pons Romberg Heel-to-toe walking C TESTS Muscle strength A8 SENSORY FUNCTION C1 GLASGOW COMA SCALE Distinguish between sharp and dull Eye opening response Wiggle appendages (fingers/toes) up and ○ Spontaneous - open with blinking down at baseline Light touch 4 points Two-point discrimination ○ To sound Stereognosis 3 points Graphesthesia ○ To pain 2 points B LEVELS OF RIGIDITY ○ No response 1 point Verbal response (t for intubated) ○ Oriented B1 DECORTICATE RIGIDITY 5 points ○ Confused conversation, but able Associated with lesions that interrupt the to answer questions corticospinal pathway 4 points Upper extremities ○ Inappropriate words ○ Flexion of arm, wrist, and fingers 3 points ○ Adduction of arm: tight against ○ Incomprehensible speech thorax 2 points Lower extremities ○ No response ○ Extension, internal rotation, 1 point plantar flexion = hemispheric Mood response lesion of cerebral cortex ○ Obeys commands for movement 6 points ○ Purposeful movements to painful B2 DECEREBRATE RIGIDITY stimuli/localizes 5 points Associated with dysfunction in the ○ Withdraws in response to brainstem pain/normal flexion Low survival rate 4 points Upper extremities ○ Flexion in response to pain ○ Stiffly extended, adducted, (decorticate posturing)/abnormal internal rotation, palms pronated, flexion teeth clenched 3 points PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 25  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Extension response in response to ○ Brachioradialis pain (decerebrate posturing) Expected: pronation of the 2 points forearm and flexion of the ○ No response elbow 1 point ○ Triceps Expected: extension of elbow C2 MINI MENTAL STATE EXAMINATION ○ Patellar Expected: extension of the Orientation to time and place lower leg Attention and calculation ○ Achilles Recognition and recall of objects Expected: plantar flexion Long-term memory Grading Language ○ Very brisk, hyperactive with ○ Naming objects clonus, indicative of disease ○ Following commands 4 points ○ Writing ○ Briskier than average, may Reading indicate disease 3 points ○ Average, normal D REFLEXES 2 points ○ Diminished, low normal, or occurs Basic defense mechanisms of nervous with reinforcement system 1 point Involuntary ○ No response ○ Below level of conscious control 0 point permitting quick reaction to potentially painful or damaging D2 SUPERFICIAL situations Plantar reflex D1 DEEP TENDON REFLEXES ○ Draw light stroke up lateral side of sole of foot and inward across ball Measurement of stretch reflexes reveals of foot = “upside down J” intactness of reflex arc at specific spinal ○ Expected levels and normal override on reflex of Plantar flexion of toes and higher cortical levels inversion and flexion of Limb should be relaxed and muscle forefoot partially stretched ○ Unexpected Stimulate reflex by directing short, Positive Babinski’s sign snappy blow of reflex hammer onto (older than 2 years of age) muscle’s insertion tendon Dorsiflexion of the big toe, Compare right and left sides fanning all other toes ○ Responses should be equal Sign/presence of CNS Locations disease ○ Biceps Drug/alcohol intoxication Expected: flexion of elbow After seizure Multiple sclerosis Severe liver damage PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 26  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ABNORMALITIES IN MUSCLE TONE AND MOVEMENT Flaccidity Spasticity ○ Consistent Rigidity Cogwheel (rigidity) ○ Start and stop movements Paralysis Fasciculations ○ Twitch Tic Myoclonus ○ Quick muscle jerk Seizure disorder Tremor ○ Rest tremor, intention tremor ○ Tremor worsens as intended movement is almost reached Chorea ○ Involuntary, unpredicted movement Athetosis ○ Slow, writing movements D3 VISCERAL Pupillary response to light D4 PATHOLOGIC Abnormal > Babinski’s reflex or extensor plantar reflex PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 27  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 PERIPHERAL VASCULAR AND A2 PALPATION LOWER LYMPHATICS Pulse points Upper lymph nodes TOPIC OVERVIEW A. ASSESSMENT A3 AUSCULTATION a. Inspection b. Palpation Carotid c. Auscultation ○ Ask patient to hold their breath d. Standing assessment ○ One at a time B. PERIPHERAL PULSES ○ Use bell side C. CAROTID ARTERIES D. EDEMA a. Assessment technique A4 STANDING ASSESSMENT b. Grading c. Assessment of hands E. LOWER LYMPHATICS Ask patient to stand to assess venous a. Assessment system F. TESTS May be done at the beginning or end of a. Allen’s test the assessment for fluidity b. Modified allen’s test c. Homan’s sign Note! G. DEEP VEIN THROMBOSIS Note any visible, dilated, and tortuous H. ARTERIOVENOUS FISTULA veins If present, varicose veins cause pain, swelling, fatigue, and cramping A ASSESSMENT B PERIPHERAL PULSES A1 INSPECTION Carotid Laying and standing positions Brachial Expected: Radial ○ Skin is pink and warm Femoral Unexpected: Popliteal ○ Edema Dorsalis pedis ○ Pallor Posterior tibial ○ Cool to the touch ○ Moist skin ASSESSMENT OF PERIPHERAL PULSES ○ Cyanosis ○ Rubor (dusky redness r/t arterial Rate or venous insufficiency) ○ beats/minute Rhythm ○ Irregular or regular Strength ○ Absent, unable to palpate = 0 PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 28  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 ○ Diminished, weaker than Disappears after 10-15 seconds expected = +1 ○ 4 mm ○ Brisk, expected = +2 ○ +2 ○ Increased, strong = +3 Disappears after 1 minute ○ Full volume, bounding = +4 ○ 6 mm Equality ○ +3 ○ Symmetrical bilaterally Disappears after 2-5 minutes ○ 8 mm or greater ○ +4 C CAROTID ARTERIES E LOWER LYMPHATICS PERIPHERAL VASCULAR ASSESSMENT Inspection E1 ASSESSMENT Palpation ○ One side at a time Auscultation Gentle circular motion of fingertips, ○ Assess for bruits palpate lymph nodes Whooshing sounds ○ Epitrochlear ○ Axillary D EDEMA ○ Inguinal Palpate the groups of lymph nodes in routine order WHAT IS EDEMA? Many nodes are closely packed, so you must be systematic and thorough in your Accumulation of fluid examination Caused by: Do not vary sequence or you may miss ○ Direct trauma small nodes ○ Impaired venous return Skin may appear shiny, tight LYMPHEDEMA Non-pitting and pitting Unilateral swelling associated with an obstruction in lymph nodes E1 ASSESSMENT TECHNIQUE ASSESSMENT OF HANDS Evaluate pitting by pressing on the skin for at least 5 seconds over a bony Inspection prominence ○ Note color Behind medial malleolus ○ Clubbing of nails Dorsum of foot Observation of capillary refill in both Over the shin hands ○ Should be less than 2 seconds E2 GRADING Indent disappears rapidly ○ 2 mm ○ +1 PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 29  EXAM 1 REVIEWER N398 HEALTH ASSESSMENT AND PROMOTION IN NURSING PRACTICE - FALL 2024 F TESTS H ARTERIOVENOUS FISTULA Abnormal connection between an artery F1 ALLEN’S TEST and vein Commonly caused by piercing injuries, Measures how well blood flows in your genetics, or procedures hand through two arteries Assess for: First-line standard test used to assess the ○ Thrill arterial blood supply of the hand ○ Bruit ○ Absence when patient is on dialysis is alarming F2 MODIFIED ALLEN’S TEST Evaluate collateral circulation prior to cannulating radial artery ○ Firmly occlude both ulnar and radial arteries of one hand while patient makes a fist several times (5x); this causes hand to blanch ○ Ask patient to open hand without hyperextending it; then release pressure on the ulnar artery while maintaining pressure on radial artery ○ Adequate circulation is suggested by a return to hand’s normal color in approximately 2 to 5 seconds F3 HOMAN’S SIGN Dorsiflexion sign test Tests for deep vein thrombosis Positive Homan’s sign could mean DVT G DEEP VEIN THROMBOSIS Occlusion of a deep vein by a blood clot Inspection/Assessment ○ Erythema ○ Warm or hot to the touch ○ Edema/swollen Do not palpate if suspected DVT ○ Positive Homan’s sign PAGE KHATE LLANILLO - 2024 - UWM NURSING ‘26 30