HESI TOPICS HEALTH ASSESSMENT

HESI TOPICS HEALTH ASSESSMENT 1. Interviewing skills and documentation (open ended questions) The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. Use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. “Tell me how I can help you.” “What brings you to the hospital?” “You mentioned shortness of breath. Tell me more about that.” “How have you been feeling since your last appointment?” The open-ended question is unbiased; it leaves the person free to answer in any way. This question encourages the person to respond in paragraphs and give a spontaneous account in any order chosen. It lets the person express himself or herself fully. As the person answers, make eye contact and listen. Typically he or she will provide a short answer, pause, and then look at you for direction on whether to continue. How you respond to this nonverbal question is key. If you pose new questions on other topics, you may lose much of the initial story. Instead lean forward slightly toward the client and make eye contact, looking interested. With your posture indicating interest, the person will likely continue his or her story. If not, you can respond to his or her statement with, “Tell me about it,” or “Anything else?” Comparison of Open-Ended and Closed Questions 2. Palpate pulses the pads of your first three fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone (Fig. 9-4). If the rhythm is regular, count the number of beats in 30 seconds and multiply by 2. Although the 15-second interval is frequently practiced, any onebeat error in counting results in a recorded error of 4 beats/min. The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. However, if the rhythm is irregular, count for a full minute. As you begin the counting interval, start your count with “zero” for the first pulse felt. The second pulse felt is “one,” and so on. Assess the pulse, including (1) rate, (2) rhythm, and (3) force usually is not necessary to palpate the ulnar pulses. If indicated, reach your hand under the person's arm and palpate along the medial side of the inner forearm (Fig. 20-9), although the ulnar pulses often are not palpable in the healthy person. Palpate the brachial pulses if you suspect arterial insufficiency—their force should be equal bilaterally Palpate these peripheral arteries in both legs: femoral, popliteal, dorsalis pedis, and posterior tibial. Grade the force on the three-point scale. Locate the femoral arteries just below the inguinal ligament halfway between the pubis and anterior superior iliac spines (Fig. 20-15). To help expose the femoral area, particularly in obese people, ask the person to bend his or her knees to the side in a froglike position. Press firmly and then slowly release, noting the pulse tap under your fingertips. If this pulse is weak or diminished, auscultate the site for a bruit. The popliteal pulse is a more diffuse pulse and can be difficult to localize. With the leg extended but relaxed, anchor your thumbs on the knee and curl your fingers around into the popliteal fossa (Fig. 20-16). Press your fingers forward hard to compress the artery against the bone (the lower edge of the femur or the upper edge of the tibia). Often it is just lateral to the medial tendon For the posterior tibial pulse, curve your fingers around the medial malleolus (Fig. 20-18). Press softly. You will feel the tapping right behind it in the groove between the malleolus and the Achilles tendon. If you cannot, try passive dorsiflexion of the foot to make the pulse more accessible The dorsalis pedis pulse requires a very light touch. Normally it is just lateral to and parallel with the extensor tendon of the big toe (Fig. 20-19). Do not mistake the pulse in your own fingertips for that of the person. Do not palpate carotid artery pulses at the same time; can lead to syncope. 3. Apical pulse Aortic-2nd incs right medial sternal, pulmonic-2nd incs left medial sternal, erb’s-3 incs medial sternal, tricuspid-4/5 incs medial sternal, mitral-5 incs mid clavicular. When you notice any irregularity, check for a pulse deficit by auscultating the apical beat while simultaneously palpating the radial pulse. Count a serial measurement (one after the other) of apical beat and radial pulse. Normally every beat you hear at the apex should perfuse to the periphery and be palpable. The two counts should be identical. When different, subtract the radial rate from the apical, and record the remainder as the pulse deficit. Count apical pulse for a full minute. 4. Cardiac sounds S1 and S2 S1 is the start of systole and thus serves as the reference point for the timing of all other cardiac sounds. You must learn to distinguish systole from diastole before you can attach meaning to all other sounds. Usually you can identify S1 instantly because you hear a pair of sounds close together (lub-dup) and S1 is the first of the pair. This guideline works, except in the cases of the tachydysrhythmias (rates >100 beats/min). Then the diastolic filling time is shortened, and the beats are too close together to distinguish. S1 is louder than S2 at the apex; S2 is louder than S1 at the base. • S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1 (Fig. 19-23). • S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor. First Heart Sound (S1). Caused by closure of the AV valves, S1 signals the beginning of  systole. You can hear it over the entire precordium, although it is loudest at the apex (Fig. 1924). (Sometimes the two sounds are equally loud at the apex because S1 is lower pitched than S2.) ● You can hear S1 with the diaphragm with the person in any position and equally well in inspiration and expiration. A split S1 is normal, but it occurs rarely. A split S1 means that you are hearing the mitral and tricuspid components separately. It is audible in the tricuspid valve area, the left lower sternal border. The split is very rapid, with the two components only 0.03 second apart. Second Heart Sound (S2). The S2 is associated with closure of the semilunar valves. You can  hear it with the diaphragm over the entire precordium, although S2 is loudest at the base ● Splitting of S2. A split S2 is a normal phenomenon that occurs toward the end of  inspiration in some people. Recall that closure of the aortic and pulmonic valves is nearly synchronous. Because of the effects of respiration on the heart described earlier, inspiration separates the timing of the two valves' closure, and the aortic valve closes 0.06 second before the pulmonic valve. Instead of one DUP, you hear a split sound—TDUP (Fig. 19-26). During expiration, synchrony returns and the aortic and pulmonic components fuse together. A split S2 is heard only in the pulmonic valve area, the second left interspace. ● When you first hear the split S2, do not be tempted to ask the person to hold his or her breath so you can concentrate on the sounds. Breath holding only equalizes ejection times in the right and left sides of the heart and causes the split to go away. Instead, concentrate on the split as you watch the person's chest rise up and down with breathing. The split S2 occurs about every 4th heartbeat, fading in with inhalation and fading out with exhalation. Both heart sounds are diminished with conditions that place an increased amount of tissue between the heart and your stethoscope: emphysema (hyperinflated lungs), obesity, pericardial fluid.