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NUR2092 Health Assessment /
Health Assessment Exam 1
(Ch. 1,3,4,8,9,10,12,18,27,29)
What does the health history provide? - ANSWER Subjective and objective data What is subjective data? what is an example? - ANSWER SD is what the patient tells you Example: headache, chest pain What is objective data? what is an example? - ANSWER OD are the signs perceived by the examiner through physical examination during assessment Example: rash seen by a nurse, or temp taken with a thermometer
In what order are skills performed during a typical assessment? - ANSWER
- Inspection
- Palpation
- Percussion
- Auscultation If a patient has abdomen pain, what order do you do the assessment? Why? - ANSWER 1. Inspection
- AUSCULTATION
- Palpation
- Percussion Because of pain, don't touch or tap the tender area first. Start by inspecting and then listening before you feel the area. What occurs during inspection, the first step? - ANSWER - ALWAYS COMES FIRST -begins when you first meet a person w/ a general survey -you should start assessment of each body system with inspection -requires: good lighting, adequate exposure, use of instruments including otoscope, opthalmoscope, penlight, or specula What occurs during palpation, the second step? - ANSWER Palpation applies sense of touch to assess Can include: temperature, texture, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, presence of tenderness or pain
During palpation, what type of palpation should you start with and why? What steps are next? - ANSWER 1. start with LIGHT palpation to detect surface characteristics and accustom person to being touched -1 cm
- then deeper palpations when needed -intermittent pressure better than one long continuous palpation -5 to 8 cm or 2-3 in ALSO: bimanual palpation- requires use of both hands to envelop or capture certain body parts or organs such as kidneys, uterus or adnexa for precise delimitation What occurs during percussion, the third step? - ANSWER - consists of tapping a person's skin with short, sharp strokes to assess underlying structures What uses does percussion have? - ANSWER -mapping location and size of organs -signaling density of a structure by a characteristic note -detecting a superficial abnormal mass
- percussion vibrations penetrate about 5 cm deep
- deeper mass would give no change in percussion -eliciting pain if underlying structure is inflamed -eliciting deep tendon reflex using percussion hammer
HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT THAN SOLID
ORGANS - ANSWER
What are the two methods of percussion? - ANSWER 1. Direct, or immediate, which is when the striking hand directly contacts body wall
- Indirect, or mediate, is when you use both hands and the striking hand contacts stationary hand fixed on person's skin In regards to percussion, what is resonance and where does it occur? - ANSWER Resonance is low pitch and it occurs over normal lungs In regards to percussion, what is hyperresonant and where does it occur? - ANSWER Hyperresonant is lower pitch and it occurs over child's lungs In regards to percussion, what is tympany and where does it occur? - ANSWER Tympany is high pitch and it occurs over air filled organs (stomach, intestines)
The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for the examination?
- Palpation, percussion, inspection, auscultation
- Inspection, palpation, auscultation, percussion
- Inspection, auscultation, percussion, palpation - ANSWER 3 Are vital signs subjective or objective data? - ANSWER Objective because they can be measured by a health care professional What are the 5 vital signs? - ANSWER 1. Temperature
- Pulse
- Heart rate
- Respirations
- Blood pressure What are the benefits of taking temperature orally? - ANSWER - It is accurate and convenient -The oral sublingual site has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature
What is a normal oral temperature range? - ANSWER 98. degrees F (37 degrees C) with a range of 96.4 degrees F to 99.1 degrees F (35.8 to 37.3 degrees C) What is a normal rectal temperature range? - ANSWER Rectal measures 0.7 to 1 degrees F (0.4 to 0.5 degrees C) higher What is normal temperature influenced by? - ANSWER - Exercise: moderate to hard exercise increases body temp -Age: wider normal variations occur in infant and young children due to less effective heat control mechanisms; in older adults, temperature usually lower than in other age groups, with a mean of 97.2 degrees F (36.2 degrees C) In regards to taking a temperature, how long should you wait if the patient has just consumed hot or iced liquids? What about if they just smoked? - ANSWER Liquids- 15 minutes Smoking- 2 minutes What is a safe and accurate way to take children's temperature? - ANSWER Axillary temperature
What is stroke volume? What is normal in adults? - ANSWER The amount of blood every heart beat pumps into aorta -70 mL Regarding pulse as a vital sign, what does palpating the peripheral pulse do? - ANSWER It gives rate and rhythm of heartbeat, as well as local data on condition of artery When is the radial pulse usually palpated? - ANSWER When vital signs are measured What should you use and where should you palpate the radial pulse? - ANSWER -Use your first three fingers -Palpate it at the flexor aspect of the wrist laterally along radius bone -Push until strongest pulsation is felt If the heart rhythm is REGULAR, how long should you count the number of beats for? - ANSWER -30 seconds and multiply it by 2
Why is 30 seconds used to take the pulse? - ANSWER because it is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular How long should you count the pulse for if the rhythm is IRREGULAR? - ANSWER 1 full minute -as you begin counting interval, start your count with "zero" for first pulse felt What parts of a pulse should you assess? - ANSWER -rate -rhythm -force -elasticity What is the normal heart rate range in a resting adult? - ANSWER 50 to 90 beats per minute What causes heart rate to vary? - ANSWER -age (more rapid in infants and children but more moderate during adult and older years)
What kind of scale is pulse recorded on? What do the numbers indicate? - ANSWER -A three point scale 3+ full, bounding 2+ normal 1+ weak, thready 0 absent -some agencies use a four point scale "90 bpm 2+" What should someone's breathing be like? How should you monitor respiration? - ANSWER -relaxed, regular, automatic and silent -instead of telling someone you are monitoring their respiration, maintain your position of counting radial pulse and count respirations How long should you count respirations? - ANSWER -Count for 30 seconds or 1 minute if you suspect an abnormality What is the ratio of pulse rate to respiratory rate? - ANSWER 4: -normally both rise as a response to exercise or anxiety
What is blood pressure defined as? - ANSWER Force of blood pushing against side of its container, vessel wall What is systolic pressure? Diastolic? - ANSWER Systolic: maximum pressure felt on artery during LEFT VENTRICULAR CONTRACTION, or systole Diastolic: elastic recoil, or resting, pressure that blood exerts constantly between each contraction What is mean arterial pressure, or map? - ANSWER pressure forcing blood into tissues, averaged over cardiac cycle, measured as diastolic (systolic-diastolic) /3 or diastolic pressure + 1/3 pulse pressure What is average blood pressure in adults? - ANSWER 120/ mm Hg -varies with factors such as age (rise into adult years), gender (females lower than males until after menopause then it switches), race (African American usually higher than white) Arm pressure, person may be sitting or lying, with bare arm supported at heart level. What are the steps of taking blood pressure? - ANSWER 1.
If the BP cuff is too large, what can the reading be? - ANSWER Falsely low When should you not use an automatic BP cuff? - ANSWER -If systolic < 90 mm Hg, irregular heart rate, shivering, tremors or seizures Orthostatic, or postural vital signs: when should you take serial measurements of pulse and blood pressure? - ANSWER -you suspect volume depletion -person known to have hypertension or taking antihypertensive medications -person reports fainting or syncope How should you take postural vital signs? - ANSWER -Have the person rest supine for 2 or 3 minutes and take baseline readings of pulse and BP -Repeat with person sitting -Repeat with person standing -LYING, SITTING, STANDING When should you take orthostatic, or postural vital signs? - ANSWER -When the position changed from supine to standing, normally slight decrease (less than 10 mm Hg) in systolic pressure may occur
-Record BP by using even numbers -Also record person's position, arm used, and cuff size, if different from standard size cuff What is orthostatic hypertension? - ANSWER B/P systolic drop of 20 mm Hg or increase in pulse by 20 beats/min with quick change to standing How should you weigh an infant? - ANSWER -on a platform- type balance scale -by age 2 or 3, use upright scale How should you measure an infant's body length? - ANSWER Measure it supine by using horizontal measuring board What is the best index of a child's general health? - ANSWER Physical growth*** Arteries, aorta, away, oxygen - ANSWER
You should launch a general survey every moment you first encounter someone or a situation. What are some things you should look for? - ANSWER What leaves an immediate impression? -Does the person stand promptly as his or her name is called and walk to meet you? Or do they look sick, rising slowly, with shoulders slumped and eyes downcast? -Is a hospital patient conversing with visitors, involved in reading or television, or lying perfectly still? As you proceed through health history, measurements and vital signs, note following points that will add up to general survey. What are the four areas you should be aware of during a GS? - ANSWER -physical appearance -body structure -mobility -behavior What does physical appearance consist of? - ANSWER -age: person appears his or her stated age -sex: sexual development appropriate for gender and age -level of consciousness: person alert and oriented, attends to your questions and responds appropriately -skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions What does body structure consist of? - ANSWER -facial features: symmetric with movement -no signs of acute distress present
-stature: height appears within normal range for age, genetic heritage -nutrition weight appears within normal range for height and body build; body fat distributed even -symmetry: body parts look equal bilaterally and are in relative proportion posture: person stands comfortably erect as appropriate for age What does mobility consist of? - ANSWER Gait, normally, base is as wide as shoulder width -Foot placement: accurate, walk smooth, even and well balanced, symmetric in things such as arm swing -Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth ad coordinated -No involuntary movement -Toe and heel walking What does behavior consist of? - ANSWER -Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation, e.g. serious, thoughtful or smiling and be sure to note expressions while face is at rest and while person is talking -Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly -Is it appropriate for situation? -Speech: articulation clear and understandable What does dress consist of? - ANSWER -appropriate to climate, looks clean and fits body, and is appropriate to person's culture and age group -for example: Amish women wear clothing from 19th century, Indian women may wear saris
