Health Assessment Exam 2.pdf

Tissue Health Health history - Present health status - History of present illness (HPI) - Pruritus - Lesions - Change in skin color - Change in nails - Change in hair - Past health history -...

Tissue Health Health history - Present health status - History of present illness (HPI) - Pruritus - Lesions - Change in skin color - Change in nails - Change in hair - Past health history - Family history Skin observation Expected outcomes Variances Smooth Intentional = tattoos, coining, cupping Without lesions patterns Discoloration Scars Localized variations = pigmented nevi Striae (moles), freckles, patches, birthmarks, striae Skin palpation expected outcomes - Texture = smooth, soft, intact, even surface, with calluses on hands, feet, elbows, knees - Temp and moisture = warm but may get cooler at extremities and dry - Mobility and turgor = mobile with elastic turgor bilaterally - Thickness = palms and soles thickets, eyelids thinnest, variation is callus Other primary skin lesions - Sebaceous cyst - Bulla - Skin cancer - Pustule Secondary skin lesions - Crust - Scale - Fissure - Erosion - Ulcer - Excoriation - Scar - Keloid Vascular skin lesions - Petechiae - Purpura - Ecchymosis - Angioma - Capillary Hemangioma - Telangiectasia - Venous Star Hair examination Scalp and hair Expected outcomes Variances Scalp and surface characteristics smooth Balding patterns and hair loss without flaking Male pattern baldness or alopecia Scaling Redness Inhabitants or lesions Hair shiny and soft Quantity and evenly distributed Facial and body hair Facial and body hair evenly distributed Hair unevenly distributed Areas of alopecia Nail examination - Expected outcomes - Edges = smooth and round  - Contour = flat and slightly rounded - Color = pink in light-skinned patients, yellow or brown in dark-skinned patients - Thickness = smooth, uniform - Variances - Clubbing - Grooves - Ridges - Pitting - Cyanosis Wound and drainage assessment - Where is the wound located? - How long have you had the wound? - Do you have any associated symptoms such as pain or drainage? Rate the pain and describe type and amount of drainage Types of drainage - Serous = normal drainage and consists mostly of serum (clear) - Purulent = thicker than serous, contains pus with leukocytes and bacteria - Sanguineous = large amounts of red blood cells - Serosanguinous = mixture of blood and serous fluid Skin cancer screening (ABCDEF!) - Asymmetry - Border irregularity - Color variation - Diameter greater than 6mm - Elevation or enlargement - Feeling Diversity, Spirituality, and Inclusion Diversity = Fostering an environment of awareness, inclusion, and compassion for everyone in our community and our guests, regardless of age, culture, faith, ethnicity, immigrant status, race, gender, sexual orientation, language, physical appearance, physical ability, or social class. Spirituality = Speaks to what gives ultimate meaning and purpose to one’s life. It is that part of people that seeks healing and reconciliation with self and others.  Assessment Abdominal assessment 1) Inspection 2) Auscultation 3) Palpation 4) Percussions Inspection Expected outcomes Variances Smooth Peristalsis visible Pink undertones Multiple lesions Centrally located umbilicus Ecchymosis Slight pulsation in epigastric space Striae No striae/scars Protruding abdomen Faint symmetrical vascular network Flat to slightly rounded Auscultation of bowel sounds Gurgling/clicking every 5-15 seconds in all Absence of bowel sounds after 2-3 minutes four quadrants (normoactive) Hypoactive or hyperactive bowel sounds Auscultation of vascular sounds No bruits Presence of bruits Palpation No tenderness Facial grimacing (pain) Abdominal muscles relaxed and symmetrical Asymmetry of abdominal muscles No masses/bulges Masses/bulges Percussions No costovertebral angle (CVA) tenderness CVA tenderness unilaterally or bilaterally Nutrition interview - Problem-based history - Weight loss or gain? - Difficulty in chewing or swallowing? - Loss of appetite or nausea? - Healthy history - Past/present health status? - Family history? - Personal/psychosocial history? - Meds? - Weight - Concerns? - Measures to correct? - Effectiveness? Oral feeding assessment - Identify patient - Perform hand hygiene - Check orders for nutrition type - Read notes  - Assess mental status Oral feeding assisting - Safety - Provide dignity - Correct foods - Chin down - Go slow - Small bites Braden scale assessment = identify risks of developing pressure sores Braden scale Sensory perception 1) Completely limited 2) Very limited 3) Slightly limited 4) No impairment Moisture 1) Constantly moist 2) Very moist 3) Occasionally moist 4) Rarely moist Activity 1) Bedfast 2) Chairfast 3) Walks occasionally 4) Walks frequently Mobility 1) Completely immobile 2) Very limited 3) Slightly limited 4) No limitation Friction and shear 1) Very poor 2) Probability inadequate 3) Adequate 4) Excellent Nutritional status 1) Problem 2) Potential problem 3) No apparent problem  Nutrition Dysphagia - Difficulty swallowing - Patients may need assistance with eating - Position client in upright position - Soft foods and thickened liquids are easier to swallow Modified consistency diets - Clear liquids - Thickened liquids - Pureed and mechanically altered diet Special diets Clear liquid Broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, popsicles Full liquid Clear liquids with addition of smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, all fruit juices Pureed Full liquids with addition of scrambled eggs and pureed meats, vegetables, fruits, mashed potatoes and gravy Mechanical soft Pureed diet with addition of ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter Regular No restrictions Soft/low residue Low-fiber, easily digested foods, including pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, desserts without nuts or coconut High fiber Addition of fresh uncooked fruits, steamed vegetables, bran, cornmeal, dried fruits Modified fluid consistency diets Nectar consistency = thicker than water but can be sipped through a straw Honey consistency = can be eaten with a spoon but does  not hold its shape Spoon thickened = pudding consistency Recording intake - Using mL - Fluids the client drinks - Tube feedings - Parenteral fluids Recording output - Urine - Emesis - Liquid feces - All tube drainage - Wound drainage Important components of nutrition Carbohydrates Energy! Protein Builds and repairs, muscle Fats Storage Vitamins/minerals Fat-soluble vitamins (A,D,E,K) stored in the body Water-soluble vitamins (B,C) not stored in the body Water Regulates temp, restores fluid, waste, cell function Parenteral nutrition - Delivery of nutrient through central line catheter for clients who do not have a functioning GI system or have a critical illness or major trauma - Solutions consists of protein, carbohydrate, fat, electrolytes, vitamins, and trace elements in sterile water Enteral nutrition - Helps meet calorie and protein requires for client who cannot consume adequate nutrients but has a functioning GI system - Short-term therapy (less than 4 weeks) = nasointestinal tube - Long-term therapy = gastrostomy or jejunostomy tube Types of enteral formula 1) Polymeric = can only be used with client who have ability to absorb full nutrients 2) Modular = do not provide complete nutrition, but contain single macronutrients 3) Elemental = easier for client who has partially dysfunctional GI tract to absorb because nutrients are predigested 4) Specialty = designed to meet specific nutritional needs related to specific illness Elimination Bedpans - Used for clients who are on bed rest or immobilization or are unable to use the bathroom or a bedside commode - Regular bedpan or fracture bedpan (easier to slide onto) Enema = instilling a solution into the rectum and the sigmoid colon to stimulate peristalsis and promote defecation Types of enemas Cleansing enema - Can be large- or small- volume - Solution instilled → bowel wall is stretched → stimulates peristalsis - Tap water, normal saline, soapsuds solution Oil retention enema - Lubricate rectum and colon - Administered at room temp - Oil is absorbed by feces making them soft and easier to pass - Client must retain enema for as long as possible for maximum effectiveness (minimum of 30 minutes) Medicated enema - Given for local effect on rectal mucosa - Can also produce systemic effect Urinary catheters - Used for clients who are unable to void or need constant monitoring of fluid status - Requires doctor’s order - Usually temporary  Types of catheters Straight catheters One-time use and removed immediately after insertion and drainage of urine Indwelling (Foley) catheters Used short-term and provide closed drainage system Retention catheters Commonly used postoperatively Coude catheters Used for clients with prostatic hyperplasia because of its curved tip Suprapubic catheters Placed through surgical opening in abdomen Condom catheters Latex or silicone sheath over penis Terminology Term Meaning A or an Without/lack of Ab Away from Ad Near/toward Bi Two/both Dys Difficult/painful Ecto Outside Endo Inside Epi Upon/over Hypo Beneath Hyper Excessive Latero Side Anterior Front Posterior Back Inter Between Intra Within/inside Medi Middle Derma Skin study Cut Skin layer Epi Upon Lipo Fat Melan Dark/black Pachy Thick Ped Foot Sclero Hard/tough Sudor Sweat Integument Skin system Onych Nail Erythro Redness Cyan Blue Diaphor Profuse sweating Kerat Horny/hard -ology Study of -ous/-ac Pertaining to -aemia Condition of blood -ectomy Excision/removal -pathy Disease/condition -oma Tumor -itis Inflammation -algia Pain -ologist Specialist -osis Abnormal condition Olig Small amount, few Hydro Water Ur/o Urine -pexy Surgically reattach to fix into a normal position Neph/nephro Relating to kidney Pyelo Renal ducts Ren/renal Kidney Chole Bile/gallbladder -tomy Cutting into, surgical removal -ostomy Create an opening Gastr Stomach Hepato Liver Procto Anus/rectum Cysto Bladder/sac -ectomy Surgical removal Allo Other (nonself) Anti Against, oppose Ambi Both Hemi Half Ent Within Epi On, up, high Micro Small Mega Large Intra Within, inside, during Macro Large Iso Equal, same Medi Middle Dys Bad, difficult Pnea Breathing Ante Before, forwards