HESI Health Assessment Final Exam Study Guide

History Taking/Documentation Document when doing the initial assessment Includes past medical, surgical, and family history Medications Consists of a complete head to toe assessment Fall – Assessing Afterwards Assess LOC, pain, and skin (bruises, hematoma) Was the pt using all appropriate assistive devices? Assisted Living – Self ADLs Can the pt brush their teeth, get dressed, feed themselves, and toilet? Is the patient a total care patient who requires assistance with most ADLs? Anus – Hemorrhoids Protruding veins from constipation or straining when using the restroom Older pts, pregnant women, and pts on opioids are more at risk Low BMI A BMI of less than 19 indicates the pt is underweight Assess nutrition status in individuals with a low BMI Rectal Findings Any sort of blood found is a bad sign Specific findings – fissures, hemorrhoids, etc. Ataxia – Assessment Uneasy gait Assess by watching the pt walk Ask yourself... ▪ Can the pt bear any weight? ▪ Are they clutching the furniture or wall? ▪ Do they require the use of an assistive device? Nutrition Assessment Important to look at lab values and BMI ▪ Albumin and prealbumin are good indicators of nutrition Carotene Rich Foods The richest sources of beta-carotene are yellow, orange, and green leafy fruits and vegetables Foods high in carotene: ▪ Carrots lOMoARcPSD| ▪ Spinach ▪ Tomatoes ▪ Broccoli ▪ Sweet potatoes Abdomen – Palpation for GERI Light palpation = 1 cm Be cautious of any GI problems the GERI pt has to avoid causing them pain Nail Ridges – GERI Ridges in the fingernails are usually a sign of aging ▪ In some cases, ridges may be a sign of health problems such as vitamin deficiencies or diabetes Clubbing is changes in the areas under and around the toenails and fingernails ▪ Can result from chronic low blood-oxygen levels, cystic fibrosis, and COPD Lymphatics – Assessment Palpate the lymph nodes ▪ Lymph nodes should not be enlarged ▪ Nodes are not palpable in a healthy individual Morning Sickness – Ginger Ginger has been found to be a non-pharmacological way to relieve nausea Pregnancy – Weight Gain Weight gain during pregnancy should be around 25-25 lbs APGAR – 3-1 Minute The APGAR test is performed on a baby at 1 and 5 minutes after birth ▪ The 1-minute score determines how well the baby tolerated the birthing process ▪ The 5-minute score determines how well the baby is doing outside the womb APGAR test includes: ▪ Breathing effort ▪ Heart rate ▪ Muscle tone ▪ Reflexes ▪ Skin color Each category of the APGAR is scored with 0, 1, or 2 A score of 7, 8, or 9 is a sign the baby is in good health A score 7 indicates the baby needs medical attention lOMoARcPSD| An APGAR score of 3 or less at one minute is a useful screening test for clinically significant birth asphyxia (NE) Newborn Assessment – Fractures Clavicle fractures are the most common injury sustained by newborns during birth Factors that increase the risk of a newborn having a clavicle fracture: ▪ Newborn is large in size ▪ Newborn’s shoulder was stuck during delivery ▪ Narrow birth canal ▪ Use of tools to assist with delivery Common signs/symptoms associated with a clavicle fracture in newborns: ▪ Fussiness ▪ Crying with movement of the affected arm ▪ Newborn experiences pain with being lifted by the arms ▪ Newborn may not move the affected arm ▪ Shoulder may appear slightly lower Clavicle fractures on newborns heal very quickly and normally without any problems ▪ Usually, no treatment is required Newborn Temperature Take the temperature axillary Avoid rectal temps because it has increased risk for perforation Newborn – Flaring Nares When a newborn is flaring the nares, it is a sign of respiratory distress ▪ This is a sign the situation is emergent Backache – At 32 Weeks Back pain is very common at 32 weeks due to pressure from the abdomen’s size Ovulation – When it Occurs Ovulation occurs 14 days after the start of your period This is the time the egg is released Goiter – Assessment Seen in patients with hypothyroidism Palpate the goiter to assess it Referred Pain – Appendicitis Referred pain – pain that moves from one area to the next lOMoARcPSD| Individuals with appendicitis will typically experience a sudden onset of pain, beginning in the area behind the navel ▪ It can then shift to the LRQ, where the appendix is Rovsing’s sign – RLQ pain during palpation of the left side of the abdomen or when left-sided rebound tenderness is elicited ▪ This indicates appendicitis Skin Turgor Used to test for dehydration To assess, gently fold the patient’s skin between your fingers and pull up, then release it If the client is dehydrated, the skin will be tented for a longer period Remember, it is common to see poor skin turgor in the elderly population because their skin loses elasticity Done on the dorsal portion of the hand or lower arm The most accurate reflection of skin turgor in adults is on the anterior chest below the midclavicular area Assessing Muscle Strength Rating scale: ▪ 5/5 – Complete range of motion against gravity and full resistance ▪ 4/5 – Complete range of motion against gravity and moderate resistance ▪ 3/5 – Complete range of motion against gravity ▪ 2/5 – Complete range of motion with the joint supported (not against gravity) ▪ 1/5 – Muscle contraction detectable, but no movement of the joint ▪ 0/5 – No visible muscle contraction Assessment should be completed by comparing one side to the other Shoulder ROM Ask the patient to perform forward flexion, extension, hyperextension, abduction, adduction, and internal & external rotation ▪ Place one hand over the pt’s shoulder during ROM to detect crepitus ROM is normal if... ▪ Forward flexion is 180 degrees ▪ Hyperextension is 50 degrees ▪ Abduction is 180 degrees ▪ Adduction is 50 degrees ▪ Internal rotation is 90 degrees ▪ External rotation is 90 degrees Limited ROM, pain, crepitus, and asymmetry may result from arthritis, muscle or joint inflammation, trauma, or sports injury Inability to externally rotate the shoulder suggests a rotator cuff injury Abstract Thinking lOMoARcPSD| The ability to think about complex ideas, make associations, and interpret situations and comments History Taking Approaches Collect demographic data first ▪ Name, DOB, address, billing info Reason for seeking care ▪ Record symptoms, subjective sensations, and objective findings History of present illness ▪ Collect PQRST and pain goal Past health history ▪ Childhood illness and immunization ▪ Past illness ▪ Traumas ▪ Surgeries Current medications with indications Allergies Family history Neurological Assessment – LOC Glascow Coma Scale (GCS) – used to determine if someone’s level of consciousness is impaired ▪ Determines degree of conscious impairment ▪ Evaluates: • Motor responses ◆ Functional response from either upper extremity • Verbal responses ◆ Oriented to conversation, speech, sounds • Eye opening ◆ In response to activity, verbal cues, non-noxious stimuli, or noxious stimuli Order of applying stimulation: ▪ Spontaneous – enter the room and observe arousal ▪ Normal voice – state the patient’s name and ask them to open their eyes ▪ Loud voice – use loud voice if no response to normal voice ▪ Tactile – touch the patient’s shoulder or arm lightly ▪ Noxious stimuli – apply nail bed pressure to elicit pain response Neurological Status – Stuporous Stupor – patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation Tactile Differentiate – Hot and Cold When assessing sensation, it is important the patient’s eyes remain closed lOMoARcPSD| Only used if pain or touch sense is abnormal Breast Examination Involves inspection and palpation ▪ Inspection – sitting ▪ Palpation – supine Must be completed 3 to 5 days after period if non-menopausal Must be completed at the same time every month is postmenopausal Abnormal findings: ▪ Erythema ▪ Hyperpigmentation ▪ Peau d’orange ▪ Firm, hard, enlarged nodes ▪ Tender or warm nodes Vertical pattern is recommended Testicular Self Examination Done monthly starting in adolescence Used to detect testicular cancer Done in or after shower when the scrotal tissue is relaxed Palpate each testicle separately No tenderness, nodules, dilated veins, or thickening should be found Two-Point Discrimination Tests for any nerve damage Place the blunt end of two cotton swabs about 5 cm apart and move them together until the patient feels them as one point Cortical sensory function may be lost with a stroke Auscultation The stethoscope is used for auscultation The bell is used with light skin contact to hear low-frequency sounds such as murmurs or bruits The diaphragm is used with firm skin contact to hear high frequency sounds such as heart and lung sounds When holding the chest piece, place the endpiece between the index and middle fingers, not on top of the stethoscope because it can distort the sound Throat Inspection Use a tongue depressor Assess that the uvula moves up when the pt says “ah” No movement suggests a problem with the vagus nerve Pneumonia – Auscultation Findings lOMoARcPSD| Ronchi – low pitch snoring or gurgling sounds that may clear with coughing Positive bronchophony – hear “99” loud and clear Positive egophony – when the pt says “eee”, you hear “aaa” Positive whispered pectoriloquy – hear pt whisper 1,2,3 loud and clear Pulmonary Assessment – Ask the pt to breathe deeply, in and out, through the mouth each time the stethoscope is felt on the skin ‘Place the diaphragm of the stethoscope firmly on the chest wall to block extraneous noise If patient is SOB, start at the bases and move up the chest wall Palpate Pulses Palpate the brachial and radial pulses and grade them on a scale ▪ Use radial pulse for assessing vital signs ▪ Pulse is graded +2/4 on a 4-point scale Evaluate any pulses that cannot be palpated with the Doppler stethoscope ▪ If pulselessness persists, evaluate the seven P’s to determine if this is an emergency • Pain • Polar • Paresthesia • Paralysis • Pallor • Pulse • Perfusion Palpate the carotid one at a time Allen Test – Ulnar Artery This test assesses the patency of the collateral circulation of the hands Steps: ▪ Ask the pt to make a fist ▪ Occlude the radial and ulnar arteries of the same hand ▪ Have the pt open the hand and release pressure on the ulnar artery ▪ Do the same with the radial artery If color returns within 2 to 5 seconds, there is adequate circulation and a positive Allen sign Done before radial cannulation Assessment of PMI The point of maximal impulse refers to the area where the apical pulsations can be seen or palpated