GEPN Health Assessment Final Exam Review PDF

GEPN Health Assessment Final Exam Review  Exam Structure: 75 Questions In Total Neurological Abdominal Integumentary (Skin) 30Qs 30Qs 15Qs  Neurological How to d...

GEPN Health Assessment Final Exam Review  Exam Structure: 75 Questions In Total Neurological Abdominal Integumentary (Skin) 30Qs 30Qs 15Qs  Neurological How to determine patient alert and oriented status Screening neurological examination components: (orientation): Person → Mental status ○ Does the patient know their own name? Do they → Cranial nerves know the names of relatives or familiar healthcare → Sensory system personnel? → Motor system Place ○ Does the patient know where they are? Do they know the name of the clinic or hospital they are in? Do they know what city and state they are in? Time ○ Do they know the time of day, the day of the week? Month? Season? Year? Situation ○ Do they know what just happened/what is happening? Do they know why they are there?  Mental status exam components: Appearance and behavior ○ Posture and motor behavior Pay attention to your patient’s Assess for: normal so you can recognize Tense posture anything abnormal!! Restlessness Anxious fidgeting ○ Dress, grooming, personal hygiene Is the clothing clean? Appropriate for the weather? How is the grooming of the patient’s hair, nails, teeth, skin? ○ Facial expression Is the facial expression appropriate for the topics being discussed? Assess for expressions of: Anxiety, depression, apathy, anger, elation, facial immobility Speech and language ○ Characteristics of the patient’s speech: Quantity: is the patient talkative or silent? How is this compared to their baseline? Rate: Is the speech fast or slow? Loudness: is the speech loud or soft? Articulation: are the words clear and distinct? Fluency: What is the rate, flow, and melody of speech? Is the content of the speech appropriate? ○ Aphasia: Receptive→ impaired comprehension with fluent speech Expressive→ Preserved comprehension and slow, nonfluent speech  Mental Status Exam Continued Mood ○ Ask the patient to describe their mood, including their usual mood and if/how this has changed ○ Assess for: Sadness Contentment Joy Euphoria Elation Anger Rage Anxiety Detachment Indifference Thoughts and perceptions ○ Assess the logic, relevance, organization, and coherence of the patient’s thought processes Listen for speech patterns that may suggest disorders of thought processes Assess thought content Cognitive function ○ Orientation→ Alert and oriented status ○ Attention→ How well can the patient concentrate? ○ Remote memory→ inquire about birthdays, names of schools, etc. ○ Recent memory→ ask what day it is, the weather ○ New learning ability→ Give the patient four words that are not associated and ask them to repeat them back 3-5 minutes later  Glasgow Coma Scale and Levels of Consciousness A reliable score to assess level of consciousness, usually after a brain injury Three sections: → Eye opening → Best verbal response → Best motor response GCS Scoring: Severe→ GCS 3-8 Moderate→ GCS 9-12 Mild→ GCS 13-15 After a head injury, decreasing scores relate to higher mortality Levels of consciousness can be examined in the mental status exam, however, levels of consciousness are especially helpful in evaluating patients who have suffered a brain injury. Lethargic→ patients are drowsy, open their eyes to look at you, respond to questions, and then fall asleep Obtunded→patients open their eyes and look at you, but respond slowly and are somewhat confused Stuporous→ patients are unaware of their surroundings and are totally or almost immobile and unresponsive, even to painful stimuli Comatose→ patients are unconscious and do not respond to painful stimuli or voice and do not open their eyes Video: Neurological Assessment Review Hyporeflexia Cerebral Vascular Accidents (Strokes) Cranial Nerve No. 5 and Headaches Cranial Nerve No. 5 and Headaches Knowledge Check: Neuro During an assessment of the CNs, the nurse finds the following: Asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength During the assessment of deep tendon reflexes, the nurse finds that a patient's deep tendon reflexes are slightly more brisk than average bilaterally. What number should be used to indicate this deep tendon reflex response? A. 1+ B. 2+ C. 3+ D. 4+ When the nurse is testing the triceps reflex, what is the normal expected response? A. Extension of the forearm B. Flexion of the forearm C. Pronation of the hand D. Flexion of the hand A client was admitted after a vehicular accident. The provider finds him in a comatose state. Which Glasgow coma scale is indicative of coma? A. 15 B. 10 C. 6 D. 3 Which cranial nerves are responsible for the eye movement? a. CN VIII, XI b. CN VIII, X c. CN III, IV, VI d. CN I, II, V For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is: A. time of the patient's last meal B. time at which stroke symptoms first appeared C. patient's hypertension history and management D. family history of stroke and other cardiovascular diseases Video: Abdominal Assessment Review Abdominal Assessment Anatomy: What organs are found in each quadrant? Abdominal Assessment Steps Step 1: Step 2: Inspection Auscultation ○ Skin ○ We listen before we ○ Umbilicus palpate! ○ Contour ○ Palpating can alter the ○ Peristalsis characteristics of bowel ○ Pulsations sounds ○ Diastasis recti ○ Listening for normo, ○ Pregnancy hypo, or hyperactive Normal = 5-34 clicks/min Hypo = 34 Abdominal Assessment Steps Step 3: Step 4: Percussion Palpation Percuss in all 4 quadrants Light palpation: Percussion helps you to assess the amount ○ Aids detection of abdominal tenderness, and distribution of gas in the abdomen, muscular resistance, and some viscera, and masses that are solid or superficial organs and masses fluid-filled, and the size of the liver and Deep Palpation spleen. ○ Use both hands Normal = tympany ○ Push down approximately 5-8 cm ○ May have areas of dullness over ○ Correlate percussion findings to organs or feces in the colon palpation Percuss bladder, liver span, spleen Percuss in all 4 quadrants!  Bruits Bruits are a murmur-like sound in a vascular structure; tumultuous blood flow through an arterial structure We assess for bruits over the abdominal aorta, renal arteries, iliac arteries, and femoral arteries Auscultate before you palpate - we do not want to compress a vessel that is already partially compressed Examining the Liver, Spleen, Kidneys, and Aorta Liver Spleen Kidneys Aorta Main - Normal liver - Usually not - Usually not - Normal size Takeaways span is 6-12 cm palpable palpable 2.5-3cm - Firmness or - Splenomegaly - Are - DO NOT hardness, is 8 times more retroperitoneal palpate if bluntness, likely when - Causes of bruits are rounding of spleen is enlargement: heard on edges, and palpable hydronephrosis, auscultation surface - Dullness on cysts, tumors - Bruits are irregularity is percussion at - Palpated just indicative of suspicious of liver anterior axillary below and aortic disease line suggests parallel to 12th aneurysm - Can be non splenomegaly rib palpable Characteristics of Abdominal Pain Types Parietal Visceral Referred Description Steady, aching pain Gnawing, burning, Radiates or travels from cramping, aching site of origin More severe than visceral Difficult to localize Causes Inflammation from Hollow abdominal Often develops as initial parietal peritoneum organs such as pain worsens due to (AKA peritonitis) intestines/biliary contract distant sites being unusually forcefully or innervated by the same are distended/stretched spinal levels as inflamed area Characteristics and Aggravated by Severe cases can Can be palpated clinical findings coughing/movement cause: pallor, sweating, superficially or deeply n/v, restlessness Patients usually prefer to lie still  Abnormal Abdominal Assessment Findings Guarding Rigidity Rebound Tenderness - Voluntary muscle - Involuntary - Pain upon release Remember: contraction of the muscle of the examiner’s abdominal wall contraction of the hand Guarding, (during or before abdomen - “Which hurts rigidity, and palpation) - Can be caused by more, when I - Often peritoneal press down or let rebound accompanied by inflammation go?” tenderness = grimacing - Persists over - Can be a sign of - May diminish several appendicitis in the signs of when the patient examinations right lower peritonitis!! is distracted quadrant (McBurney’s Point) Specialty Exams for Abdomen Any of these signs can suggest appendicitis! Rovsing Sign Psoas Sign Obturator Sign - Used to assess for - Examiner places hand - Bend right knee and flex referred rebound just above patient’s right leg at the hip tenderness knee and asks them to - Internally rotate leg at the - Press evenly in LLQ and raise thigh against hip quickly release your pressure - Localized pain in the RLQ fingers - Can also be done with is a positive sign - Pain in the RLQ is a patient lying on left side positive sign with left leg passively extended Murphy’s Sign Used to assess for cholecystitis Assess when patient presents with RUQ pain and tenderness Assessment Technique: ○ Hook left thumb or fingers of right hand under the costal margin of the RUQ ○ Ask patient to take deep breath (this forces liver and spleen down to meet fingers) ○ Observe breathing and note tenderness ○ A sharp increase in A positive murphy’s sign TRIPLES the tenderness on inspiration = likelihood of acute cholecystitis positive Murphy’s sign Knowledge Check: Abdomen A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? A. Palpate lightly for tenderness and muscle tone. B. Auscultation for bowel sounds C. Palpate deeply for masses or aortic pulsation. D. Percuss for tones. When auscultating a patient's abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched murmurs over the right and left upper midline. What do these sounds indicate? A. Expected peristalsis B. Femoral artery stenosis C. Renal artery stenosis D. Hyperactive bowel sounds A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours? A. Absent bowel sounds B. Hyperactive bowel sounds C. Tympanic tones over the lower abdomen D. Dull tones over the suprapubic area The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient? A. Percussion of the costovertebral angle B. Deep palpation of the abdomen C. Testing for rebound tenderness D. Auscultation of all quadrants of the abdomen The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant? A. Liver and gallbladder B. Stomach and spleen C. Uterus, if enlarged, and right ovary D. Right ureter and ascending colon Murphy's sign is best described as: A. The pain felt when the hand of the examiner is rapidly removed from an inflamed appendix B. Pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder at the midclavicular line C. A sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle D. Not a valid examination technique The absence of bowel sounds is established after listening for: A. 1 full minute B. 3 full minutes C. 5 full minutes D. 7 full minutes Nerve pathways from the gallbladder share pathways that sense shoulder pain. This commonly leads to: A. Visceral Pain B. Parietal Pain. C. Guarding D. Referred pain. Integumentary Skin function: ○ Provides barrier ○ Regulation of body temperature ○ Synthesizes vitamin D ○ Sensory perception ○ Nonverbal communication ○ Provides Identity ○ Allows for wound repair ○ Excretion of metabolic wastes Ask about Important Past Health History: ○ Melanoma ○ Eczema/psoriasis ○ Diabetes/PAD ○ Allergies/food sensitivities ○ History of a severe sunburn ○ Corticosteroid use >2 weeks Skin Assessment Assessment Techniques: Inspection and Palpation 2 Types of Cyanosis: Note: ○ Moisture, color, temperature, texture, Central: mobility, turgor, edema, or lesions - O2 levels in arterial blood are low Texture - Indicative of decreased oxygenation in ○ Normal skin will feel smooth and firm patient with even surface Turgor: Peripheral: ○ Normal skin turgor will return - O2 levels are normal immediately into place - Could indicate decrease/slowed cutaneous ○ Testing on dorsal surface of hand in blood flow/tissues extract more oxygen elderly will result in a false positive than usual from the blood (delayed return of skin) Temperature: ○ Place back of hands against the skin, note generalized warmth or coolness ○ Note temperature of areas of increased pigmentation or erythema Pressure Injuries Most common pressure injury contributors: Contributing Factors: 1. Pressure Advanced age >65 2. Moisture Poor skin hygiene 3. Friction (occurs externally, ex. skin and Diabetes Mellitus outside surface) Diminished sensory perception 4. Shear (occurs internally, beneath skin in fat Use of corticosteroids or muscle tissue) Immunosuppression Excessive moisture exposure (incontinence) Altered nutrition/hydration deficits Most common pressure injury areas Spinal cord injury Healed pressure ulcer that has closed Staging of Pressure Injuries Stage 1 Skin is intact with non-blanchable erythema Stage 2 Partial thickness skin loss/exposed dermis May also present as intact or ruptured serum filled blister Adipose tissue not exposed Stage 3 Full thickness skin loss, adipose tissue exposed Granulation tissue (new connective tissue) often present Tunneling/undermining may occur Stage 4 Full thickness skin and tissue loss AND bone, muscle, tendon, ligament, or cartilage is exposed Tunneling or undermining often occur Slough or eschar may be present in some parts of wound bed Unstageable Obscured full thickness skin and tissue loss Slough or eschar cover base of the wound- cannot confirm extent of the wound Stage 1 Stage 2 Partial thickness: adipose tissue NOT present Stage 3 Full thickness: adipose tissue present Bone, muscle, cartilage, tendons or ligaments NOT present Stage 4 Full thickness tissue loss WITH exposed bone, muscle, tendons, or ligaments Unstageable Extent of damage cannot be confirmed due to slough or eschar Dead tissue must be removed with debridement before injury can be staged Slough: moist and stringy dried inflammatory fluid, can be yellow, brown, green, tan, or grey Eschar: necrotic tissue, can be leathery/thick, black/brown/tan Deep Tissue Injury Intact or non intact skin with areas of persistent, deep red/maroon/purple discoloration Could appear as blood filled blister Can possibly be restored without tissue loss Pain and temperature change can often precede color changes Looks different on darker pigmented skin Assessment of Pressure Injuries Assess for: ○ Size, drainage, pain, presence of sutures, drains, tubes, odor, color, location Measure: ○ Length x width x depth in centimeters ○ Length: measure head to toe (longitudinally) ○ Width: measure side-side (transverse) ○ Depth: Deepest point of injury Use Braden Scale to Assess Sore Risk Nursing Interventions- Pressure Injury Prevention Reposition patients in bed every 2 hours Reposition wheelchair users every 4 hours Assess skin daily Pay attention to bony prominences Use support surfaces as prescribed (cushions, low pressure mattresses, etc) Encourage early mobilization as tolerated Ensure adequate nutrition/hydration Utilize proper techniques to reposition 15-18= Low risk Prevent prolonged moisture 13-14= Moderate risk exposure 10-12= High Risk >9= Very High Risk Knowledge Check: Integumentary A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? A. A client who has a Braden Scale score of 9 B. A client who has a Braden Scale score of 23 C A client who has a Braden Scale score of 12 D. A client who has a Braden Scale score of 15 Full-thickness skin and tissue loss without visible muscle or bone located over a bony prominence is considered what stage of pressure injury? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 Full-thickness skin and tissue loss in which the extent of the tissue damage cannot be confirmed because the base is obscured by slough or eschar. A. Stage 3 B. Unstageable C. Stage 2 D. Stage 1 Which of the following are common sites for developing pressure ulcers? Select all that apply: A. Sacrum B. Sternum C. Ears D. Heels E. Elbows F. All of the above  Questions or want to discuss something specific? Please reach out… Ezra Otto at [email protected] Sean Morgan at [email protected] Allison Leavey at [email protected] Amanda Ilaira at [email protected] Ellie Wargo at [email protected] Marisa Mendez at [email protected]