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 ▪ 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