Health Assessment Blueprint for Exam #1 Chapter 1: Types of Assessment ie Assessment ie initial comprehensive assessment, etc. Initial: subjective, objective; ROS, history, Lifestyles/health practices Ongoing/artial: occurs after !atabase est.; Reassessment; rea!mitte! for the same problem "ocuse!/problem#oriente!: performe! in relation to a speci$c health concern; %hat is the current problem &mergency: '&R( rapi!; performe! in life#threatening situations o &)* %ea+ness on one si!e, car!iac arrest Nursing Process ssessment: collect !ata repare for the assessment o -ollect subjective/ objective !ata o 'ali!ate the information o !ocument o iagnose: analye !ata; ma+e !) lanning: plan of care; care; !etermine outcomes; %hat is the goal an! timeframe Implement: carrying carrying out the plan; monitor &valuate: assess %hether outcomes outcome s has been met; revise if necessary Dierence beteen me!ical an! nursing assessment 0e!ical !): loo+s at the pathological cause/ !isease 1ursing !): loo+s at the response to the health status; loo+ at the functional ability of the pt • • •
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Chapter 2: "nterieing phases Intro!uction: urpose; %ho you are, %hat is occurring, %hat is your role; I12RO; let pt +no% you %ill be ta+ing notes -on$!entiality; ma+e pt comfortable; environment private evelop trust an! rapport 3or+ing 4 SUBJECTIVE SUBJECTI VE DATA DATA 5etting the information from the actual intervie% ocumentation: health insurance, beliefs, un!erstan!ings, family contact Reason for see+ing care; 6) of present health concern 6, "6, ROS, Lifestyles/health practices Summary/-losing Summarie info: 7this is %hat you tol! me8 'ali!ates problems an! goals; I possible plans 9; agreement to information, plan, objectives $ommunication%"nterie s&ills ' erbal an! nonerbal ' eectie an! ineectie &ective: # one ?8 ##@ use the ptAs language; what $o you mean *y…+ •
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Health Assessment 1onverbal communication: posture, facial e)pressions; your behavior !uring the intervie% &mpathetic responses: 1O2: 7I am #orry a*out your mom,# $eath)& (&S: 7It mu#t *e ery heart*rea."n !or you+) 'ali!ation: ac+no%le!ge %hat is occurring; as+ about ho% the patient feels Reassurance: ("t "# o.ay to !ee% %".e th"#) %hen a patient feels angry or in !enial Summariation: this is %hat the pt tol! the nurse; ho% the nurse interprets it; pt shoul! correct the nurse if nee!e! 2ransitions: (now I am o"n to a#. you ue#t"on# a*out+++) &mpo%ering the patient: nurse encourages pt to feel in control; help pt !eal %/ situation; &BLI1 everything Ineective: o not use L&I15
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*hat constitutes as sub+ectie !ata 1(26I15 elicite! by the patient; must be veri$e! by the patient
Health Assessment ROS for current health problem: nee! to as+ about the speci$c systems Lifestyle an! 6ealth practices: 1utrition/ %eight management: meals of the past EF hrs ##Self#concept/self o care/relationships ctivity level/e)ercise/ social activities ## values an! beliefs o Sleep an! rest: naps? ## e!u/%or+; stress o levels/coping 0e!ication an! substance use/ herbal preps o $omplete Health History Giographical !ata ##"6 Reasons for see+ing health care ##ROS 6) of present health concern ##Lifestyle an! health practices 6 ##evelopmental level $,-D.PA -haracter: !escription ## Severity Onset ## attern: %hat ma+es it better/%orse Location ## ssociate! "actors: other symptoms uration • •
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Chapter 4:
Ho to prepare for a physical exam ' examiner) patient repare physical setting: get e
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ositioning -lient H. Sitting a. -an evaluate hea!, nec+, lungs, chest, bac+, breasts, armpits, heart, vital sign, arms E. Supine a. "lat on bac+, Legs together b. &valuate hea!, nec+, chest, breast, armpits, ab!omen, heart, lungs, limbs, peripheral pulses . oral recumbent a. On bac+, +nees bent, legs separate!, feet =at b. 0ost comfortable for people %ith bac+ or ab!omen pain c. ssess: hea!, nec+, chest, armpits, lungs, heart, limbs, breasts, peripheral pulses F. SI0As position a. Lay on si!e; Lo%er leg behin! bo!y an! =e)e!; Cpper leg =e)e! at sharp angle; for%ar! b. Cpper arm bent c. ssess: rectal an! vaginal areas J. Stan!ing a. ssess: posture, balance, gait, maleAs genitalia K. rone a. "lat on stomach, hea! to one si!e b. ssess: hip joint, bac+ c. If car!iac or respiratory problems D !o not use position . Mnee#chest a. Mneeling, N#!egree angle b/% bo!y an! hips; rms above hea!; hea! to one si!e b. ssess: rectum c. o not use %ith el!erly or pt. %ith respiratory or car!iac problems P. Lithotomy a. Lays on bac+, hips at en! of table, feet in strirrups Qat the gyno* b. ssess: female genitalia, repro!uctive tracts, rectum
*hat is ob+ectie !ata nything that can be measure!: physical characteristics, bo!y functions, appearance/behavior, measurements •
Health Assessment
Physical examination techni(ues Inspection: observation 1ote color, patterns, sie, location o o -onsistency, symmetry, movement, behavior O!ors, soun!s o alpate: feel/touch o lightly for surface anomalies me!ium for anomalies un!er the s+in o !eep %/ E han!s to feel organs o 2e)ture: rough or smooth o 2emperature: %arm or col! o o 0obility: $)e!/movable/still/vibrating -onsistency: soft/har!/=ui! $lle! o Strength of pulse: strong/%ea+/threa!y/boun!ing o o Sie: small, me!., large Shape: %ell !e$ne! or irregular o egree of ten!erness o ercussion: ma+e vibrations to> &licit pain, re=e)es o ain: &)* sinuses: if they hurtD in=ame! Re=e)es ##@ !irect: $nger ##@ in!irect: t%o $ngers ##@ blunt: =at han! on bo!y location, other $st hits =at han! &)* feeling the +i!neys etermine location, sie, shape, !ensity of organs; !etect abnormal masses o Organs: &)* percussion over the liver Soun!s o Lungs ##@ resonance/vibration: normal; hyperresonance/e)cessive vibrations: air $lle! Q-O* b!omen ##@ 2ympani; !ullnessD soli! tissue &)* .P-EEN) -"/E0 Gones ##@ =atness uscultation: listening o Intensity: lou! or soft itch: high or lo% o uration: length o o 9uality: musical, crac+ling, raspy Stethoscope: !iaphragm for high pitche! soun!s Qheart, breaths, bo%el* Gell for lo% pitche! soun!s or bruits Qabnormal lou!, blo%ing, murmuring soun!s* •
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Chapter 5:
Purpose of /ali!ation -on$rm/ verify subjective an! objective !ata 1ee! to ma+e sure information is correct to cont. %ith nursing process Data re(uiring ali!ation • •
Health Assessment 5aps b/% subjective/objective !ata, %hat the person says at !ierent points of the conversation "in!ings that are abnormal/ inconsistent %/ other $n!ings etho!s of ali!ation Repeat assessment -larify !ata %/ client# a!!itional
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Chapter 6:
Analy2e !ata -ritical thin+ing I abnormal !ata an! strengths of pt o -luster !ata o ra% inferences o urpose possible nursing !) chec+ for !e$ning characteristics; con$rm/rule out !) o ocument conclusions o Similar to I& ssess areas of concern an! strengths o ) base! on abnormal $n!ings an! ptAs abilities o o lan %hat outcomes an! e)pectations via the !); implement plan Interent"on# come !rom the pro*%em &valuate an! !ocument o •
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Health Assessment Chapter 7:
ental status OneAs orientation an! consciousness Orientation: person, place, time, situation 4 loo+ing for cognitive consciousness o Orientation to time is the H st to be lost Orientation to person is the E n! to be lost 0ental 6ealth assessment Observe the pt; as+ them
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ini ental Not early !ementia
.-3. Early Dementia •
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2est for !ementia; out!ate!# not preferre! •
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Cse %hen pt is !isoriente! No Executie 4unctioning
-onsi!ers e!u. level, language, age &)ecutive functioning
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1o consi!eration for age, culture
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Early signs of lheimerAs !ementia
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&)ecutive function •
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ontreal -onsi!ers e!u level
0il! cog impairment Spatial component •
$A cute onset Inattention isorganie! thin+ing ltere! level of consciousness Gase! on ,B.E0/AT",N 2al+ %/ pt; observe attentiveness; thought process; confusion; consciousness "Ds DE-"0"3
Al2heimer5s 6ui!e ll lheimer is !ementia; not all !ementia is lheimer Lose e)ecutive functioning Repeate!ly as+ the same
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ementia vs. lheimer Dementia 1ot consistent memory lost of recent information# more forgetfulness athological process that can be 7$)e!8; cause of the forgetfulness &)* 2hyroi! problem; +i!ney failure; !iabetes 4 can -CS& the pathological process o of forgetting Al2heimer onAt remember anything of recent memory; consistent recent memory loss • •
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Health Assessment Chapter 8: 6eneral .urey pparent state of health: general observation for acute Qfocuse! assess.* or chronic illness Qfull assess.* Level of consciousness: stages of consciousness lertness: #pea."n to pt "n norma% tone o eyes are open, pt loo+ing at you, respon!s fully an! appropriately Lethargy: Spea."n to pt "n %ou$ o"ce-call ptAs name; 7ho% are you8 o tD !ro%sy; eyes open; loo+s at you; respon!s to
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Health Assessment
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H. ro!uction of speech is intact E. -annot comprehen!, name Qtemporal lobe* GrocaAs: pro!uction of lang. impaire!; can un!erstan! lang. H. "RCS2R2IO1 enhances problem E. 1ot =uent; pro!uction of speech highly impaire! . -omprehension is intact F. cannot name Qalthough the pt +no%s %hat the object is* J. "rontal lobe Goth cannot repeat or %rite 0oo! an! aect: ans%ers an! moo! are appropriate &)* appropriate: in so much pain an! pt is %incing, grimacing, lo% !emeanor o &)* inappropriate: in so much pain an! pt is laughing o -hec+ vital signs 6eight an! %eight G0I
"!eal bo!y eight etermine frame by measuring the %rist# %rist circumference# smallest !istance aroun! the %rist in cm 3rist least place to accumulate fat o "emale: Hlbs for J feet Jlbs for each I1-6 over J ft ##@ 0e!ium frame Subtract HT for Small frame !! HT for Large frame &)* "emale: Jft Kin Jft DHlbs JUKinD lbs Hlbs for a JAK8 female, me!ium frame #HTD HHlbs for JAK8 female small frame HTDHFlbs for JAK8 female large frame •
&)* "emale FAHH8
NJlbs Qsubtract Jlbs from the Jft total QH**
0ale: HKlbs for J feet Klbs for each inch over Jft ##@ me!ium frame Subtract HT for small frame !! HT for large frame &)* 0ale: Jft Kin JftD HKlbs KinDKin QKUK* HFElbs for a JAK8 male, me!ium frame HElbs for a JAK8 male, small frame HJK.Elbs for a JAK male, large frame ercentage of i!eal bo!y %eight
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Actual weight ∗100 = of IBW ideal bodyweight
&)* ctual %eight: Hlbs I!eal bo!y %eight: HJD HJlbs
I!eally you %ant to get close to HT H#HHT D normal o @ HET D obese o o @HHT D over%eight P#NT D lean an! potentially malnourishe! o P#TD mo!erate malnourishe! o o VT D severely malnourishe! Over%eight people: 6igher 2riglyceri!es o 6igher bloo! sugar o 3hat is activity level? Smo+er? o o Increase %eight, increase ris+ for osteoarthritis, respiratory problems, sleep apnea, stro+e
Health Assessment B" 8 categories G0I V HP.J Qun!er%eight*WHP X or less G0I D HP.J to EF.N Qnormal* W HP X to about EJ G0I D EJ#EN.N Qover%eight* W EJ to about G0I @ D obese W s G0I: F e)treme obesity W F • • • • •
*aist circumference t stan!s straight feet together, arms at si!e; measure snugly aroun! %aist at belly button t shoul! be rela)e!, ta+ing normal breaths Recor! on e)halation "emale normal %aist circumference D V J inches; over J D over%eight 0ale normal %aist circumference D V F inches; over F D over%eight • • • • •
Chapter 14: .ub+ectie !ata of s&in) hair) nails : Symptoms, 6, "6, Lifestyles/6abits S."n: S+in problems, s%elling, color change; birthmar+s/moles; change in pain, pressure, touch, temp., bo!y o!or Shots, h) of lesions, tattoos piercings, past treatments on s+in, allergic reactions -ancer: ecema, psoriasis, melanoma; +eloi!s Gathing patterns, type of soap, ho% often; sunbathe; environmental e)posure; se!entary life; self e)am? -olor In=uence! by illness, bo!y temp, pregnancy, genes, arterial bloo! =o%, OE, liver function, melanin 9a"r: 6air loss, change in con!ition of hair 9a"r %o## "n pa#t0 %acerat"on# to the #ca%p 6air care routine, pro!ucts, color treatment a"%# -hange in con!ition an! appearance of nails Infections of nails 3ho cleans them; ho% are they cleane!; salon use sterile proce!ure Ho to perform the physical exam for s&in) hair) nails Strong !irect lighting# s+in assessment o 2angential lighting# si!e light for eyes Qpenlight* o 5loves an! centimeter ruler o
Health Assessment Normal 9 Abnormal :n!ings for physical exam of s&in) hair) nails S+in In#pect"on/;a%pate H. 5eneral s+in coloration o!or a. 1ormal: even colore! s+in tones i. Ol!er people 4pale s+in !ecrease melanin pro!uce!/ !ermal vascularity b. bnormal: i. allor: loss of color H. OE !e$ciency, !ecrease hematocrit nemia, shoc+ ii. -yanosis: %hite s+in 4 blue#tinge! H. -entral cyanosis Qareas near the heart*: car!iopulmonary problem Loo+ at oral mucosa E. eripheral cyanosis: localie!; vasoconstriction, e)posure to col! Loo+ at e)tremities iii. Yaun!ice: yello% s+in tones H. In sclera Q%hites of eyeball*, oral mucosa, palms, soles 6epatic Qliver* !ysfunction iv. &rythematic: Re!ness of s+in H. Increase! bloo! =o%, increase! RG- in area, infection
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%hite patches Qvitiligo# co% patches* bnormalD rash: re! e)* butter=y rash across nose an! chee+s DLupus erythematosus Litchenti$cationD thic+ene! s+in# loo+s li+e !ry pussy s+in "ungus: un!er ultraviolent light =uoresce blue#green c. Go!y o!or i. bnormal H. Strong o!or 4 s%eat glan! !isor!er, poor hygiene# nee! teachings E. 2emperature: use !orsal surface of han! a. bnormal i. -ol! s+in# shoc+, hypotension ii. -ool s+in 4 arterial !isease iii. 'ery %arm s+in 4 febrile state, hyperthyroi!ism Qincrease! movement* . 0oisture: use !orsal si!e of han! a. 1ormal: appropriate amt of moisture i. Ol!er people# !ryer s+in # !ecrease sebum Qoil* pro!uction b. bnormal: i. Increase! moisture, !iaphoresis QS3&2I15* 4 fever, hyperthyroi!ism ii. ecrease! moisture# !ehy!ration, hypothyroi!ism Qslo%%%* iii. -lammy s+in 4 shoc+, hypotension F. 2e)ture# light touch a. bnormal: i. Rough, =a+y, !ry s+in 4 hypothyroi!ism H. Obese people usually complain of !ry, itchy s+in J. 2hic+ness a. 1ormal: normally thin %/ potential calluses in areas constantly e)pose! to pressure b. bnormal: i. '&R( thin 4 arterial insuciency; steroi! therapy K. &!ema: thumbs to press !o%n on s+in or feet an! an+les a. &!ema: s%elling relate! to accumulation of =ui! in the tissue ii. 1ormal: s+in reboun!s; !oes not remain in!ente! %hen pressure is release! iii. bnormal: H. In!entations on s+in . 0obility an! turgor a. 0obility: ho% easily the s+in can be pinche! b. 2urgor: s+inAs elasticity; ho%
Health Assessment !. bnormal: v. !ecrease! mobility e!ema vi. ecrease! turgor slo% return of the s+in 4 !ehy!ration
P. Lesions: Sie, Shape, -olor, 2e)ture, surface relationship, e)u!ate, ten!erness, bo!y location (Sam Sells Coats to SET B)
a. 1ormal: smooth# no lesions; stretch mar+s, heale! scars, frec+les, moles, birthmar+s i. Loo+ aroun! s+in fol!s ii. Ol!er people: common s+in lesions# senile +eratoses Qsmall, raise!, !ar+ sun e)pose! area*/lentigines Q=at ?,!ar+er sun e)pose! s+in*, cherry angiomas, purpura, cutaneous tags b. bnormal i. Local or systemic lesions H. Primary: arise from normal s+in !ue to irritation or !isease Sie: less than .J cm # usually Shape: 0acules/ atch# =at QV/@ H cm*; 3heal# elevate!, re! QEcm* 'esicle/ bulla# blister/=ui! $lle! QV/@ .J* -olor: ustules# %hite/yello%#%hite pus $lle! etechia: re!, roun!, macule Q=at VHcm*; =at; blee!ing from super$cial capillaries urpura: re! to purplish 2e)ture: macules# smooth; %arts# rough; psoriasis# scaly Surface location: =at nonpalpable 4 macules/patches, purpura, ecchymoses Q@petechia*, spi!er angioma Raise! palpable soli!# papule/pla>? pityriasis rosea Q=a+y !ry s+in*
Health Assessment Extensor surfaces; posterior elbo%s; anterior +nee Dermatome lines; osteriform Qcon$guration*# along a nerve root ##@ herpes oster Qshingles* Hairy areas; %here people gro% hair# not scalp ##@ herpes II Qse)ual*, lice
E. .econ!ary: lesion change; lose super$cial epi!ermis# moist areas; rupture vessels &rosion, ulcer, scar, $ssure Qlinear crac+s in s+in* 1e% scars# re! an! raises; ol! scars# %hite or silver ##@ heale! %oun! ressure point areas: Gac+ of the hea!, shoul!er bla!es, elbo%s, iliac crest, sacrum, soles/heels Sitting: behin! +nee; Laying on si!e# ear, trochanter, thigh, lo%er leg, an+les, +nee rone# chin, ribs, +eep cap, big toe Gra!en scale#pre!ict ris+: factors that cause ulcer; CS6 tool# assess: %hat !oes ulcer loo+ li+e bnormal: S+in brea+!o%n# re! area; progresses to serious an! painful pressure ulcer 3lcer scale; I# sores are not open %oun! II#s+in brea+s open, %ears a%ay, ten!er, an! painful III# sore, more pain; e)ten!s into tissue beneath the s+in; forming small crater I'# very !eep; reaching muscle or bone; e)tensive !amage . /ascular: re!!ish#bluish lesions etechia: re!, roun!, macule Q=at VHcm*; =at; blee!ing from super$cial capillaries Meloi!: e)cessive collagen formation F. G-& rule D for mole an! s+in cancer assessment : asymmetry; G: bor!er; -: color; : !iameter; &: elevation/evolution Genign moles/s+in cancer: 0alignant moles/s+in cancer: 1ot asymmetric; symmetric all aroun! asymmetric# t%o si!es !o not match Gor!ers are even bor!ers uneven One color E or more colors Smaller than .Kinch larger than .Kinch oes not change; relatively =at changes in sie, shape, color, elevation iameter is not important if the prece!ing steps present Q* for malignancy Surgery/e)cising: nee! E in aroun! an! Ein !eep to remove •
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J. S+in cancer: primary or secon!ary Gasal cell carcinoma: most common; F#P yrs ol! i. 1o!uleQme!ium soli!*, papule Qsmall soli!*, pearly bor!er; volcano li+e# !epresse! center S
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Scalp an! hair In#pect"on an$ ;a%pat"on H. 5eneral color an! con!ition a. 1ormal: natural hair color# amt of melanin b. bnormal: patchy gray hair nutritional !e$ciencies i. frican merican chil!ren 4 severe malnutrition 4 copper#re! hair E. -leanliness, !ryness, oiliness, parasites, lesions Qte)ture an! lesions*
Health Assessment a. 1ormal: clean an! !ry; sparse !an!ru; hair is smooth an! $rm# some%hat elastic i. ging brings on coarser an! !rier hair ii. frican mericans: !ry scalps; !ry, fragile hair; may use oil or 'aseline pro!uct in hair iii. 1o lesions b. bnormal: i. &)cessive scaliness !ermatitis ii. Raise! lesions infections; tumor gro%th iii. ull, !ry hair hypothyroi!ism; malnutrition iv. oor hygiene v. ustules %/ hair loss in patches D tinea capitis ##@ ring%orm vi. Infections of the hair follicle# folliculitis 4 pus surroun!e! by erythema . mt an! !istribution of scalp, bo!y, a)illae, an! pubic hair a. 1ormal: bal!ing must be symmetrical i. Ol!er people: thinner hair# !ecrease hair follicles; !ecrease in hair %/ aging H. lopecia 4 more in men E. 6air loss moves from periphery of hea! to center . &l!er %omen 4 hair gro%th on chin 4 hormonal changes b. bnormal: i. &)cessive generalie! hair loss infection, nutritional !e$ciencies, hormonal !isor!ers, thyroi!/liver !isease, !rug to)icity, hepatic Qliver*/renal failure; result of chem/ra!iation ii. atchy hair loss infection of scalp, !iscoi! or systemic lups erythematosus; chemo iii. 6irsutism 4 facial hair on females H. -ushingAs !isease 4 increase! facial hair; over pro!uction of -26 by pituitary E. Result of imbalance of a!renal hormones; si!e eect of steroi!
1ails In#pect"on H. 5rooming an! cleanliness a. 1ormal: nails are clean an! manicure! b. bnormal: i. irty, bro+en, jagge! nails 4 poor hygiene H. -oul! be a hobby 4 biting nails E. Occupation 4 electrician E. -olor an! 0ar+ing a. 1ormal: pin+ tones; longitu!inal ri!ging i. ar+ s+inne! people: frec+les or pigmente! strea+s normal b. bnormal: i. ale or cyanotic nails 4 hypo)ia or anemia ii. Splinter hemorrhages# trauma iii. GeauAs lines: occur after acute illness/trauma; eventually gro% out ri!ges iv. (ello% !iscoloration 4 fungal infections . Shape a. bnormal i. &arly clubbing# spongy sensation 4 E !e$ciency ii. Late clubbing# hypo)ia# perfectly straight# no normal slant into cuticle iii. Spoon nails# concave 4 iron !e$ciency anemia Qin!entation*
;a%pat"on H. 2e)ture an! consistency a. 1ormal: har!; immobile i. ar+ s+inne! pt: thic+er ii. Ol!er people: appear thic+ene!, yello%, brittle# !ecrease! circulation b. bnormal: i. 2hic+ene! 4 especially toenails ##@ !ecrease! circulation c. 1ote if nailplate is attache! to nailbe!
Health Assessment i. 1ormal: smooth an! $rm; nailplate $rmly attache! to nailbe! !. bnormal: i. paronychia Qabnormal nail con!ition# in=ammation* 4 local infection ii. !etachment of plate from be! Qonycholysis# nail brea+age* infection/trauma E. 2est capillary re$ll a. ress the nail tip brie=y an! %atch for color change i. 1ormal: pin+ tone returns imme!iately after release of pressure ii. bnormal: slo% re$ll 4 respiratory or car!iovascular !iseases hypo)ia
Health Assessment Chapter 15: .ub+ectie !ata for hea! an! nec&; Symptoms, 6, "6, Lifestyle/6ealth ractices "re Suprac%a"cu%ar no$e: En%are$0 har$0 nonten$er ? meta#ta#"# !rom ma%"nancy "n a*$omen or thora= Hypo> s@ Hyper> Thyroi!ism Hyperthyroi!ism; "ast; overpro!uction of thyroi! hormone Q@rae,# $"#ea#e- mo#t common type- E=ophtha%mo# '*u eye#>> 1ervousness, tremor, %eight loss %/ increase! appetite b/c increase! metabolism; poop more Increase s%eating; lo% heat tolerance, &nlarge! thyroi! Hypothyroi!ism: Thyro"$ hormone $e
Health Assessment Hea!aches -haracter
Onset/triggers
Location
uratio n
Severity
attern
ssoc. "actor s %ome n
0igrain e
1ausea/vomiting Sensitive: noise/lights
'isual/au!itory &yes 'ertigo 2emples 1umbness/tingli -hee+s ng "orehea! &motions/feeling s "oo!/alcohol
"e% !ays
Severe throbbin g Recurrin g
Relief: rest
-luster
2eary/!rooping/ re! eyes Runny nose
Su!!en lcohol
&venin gs nights
Intense stabbin g
Relief: (oung moveme males nt
2ension
n)iety, tension, !epresse!
1o pro!romal stage Stress
ays, months , years
ull, aching, tight; !iuse!
2umor
1eurological/men tal symptoms: nausea/vomiting
1o pro!romal 2umor stage location -oughing/sneei ng, su!!en movements of hea!
0ornin g# for hours
Stea!y aching Intensit y varies
Relief: local heat, massage , me!s Relief: time
&ye/orbit Ra!iates to face/temp le "rontal, temporal, occipital lobes
%ome n
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Physical exam; normal :n!ings 8 abnormal :n!ings ' hea! an! nec& In#pect"on an$ ;a%pat"on o! hea$ H. Inspect hea!# sie, shape, con$guration, involuntary movement a. 1ormal: no visible lesions; symmetrically roun!, erect, mi!line i. -an hol! hea! still an! upright b. bnormal: i. "eatures: Z Larger s+ull an! bones acromegaly 4 increase! pro!uction of 56 Z corn#shape!, enlarge! s+ull bones agetAs !isease of bone ii. 0ovements: Z 2remors# neurological !isor!ers# horiontal jer+ing movement Z Involuntary no!!ing 4 aortic insuciency Z 6ea! tilte! 4 unilateral vision, hearing !e$ciency, sternomastoi! muscle shortening E. alpate hea! a. 1ormal: smooth an! har!# no lesions b. bnormal: lesions, lumps trauma or cancer . Inspect face 4 symmetry, features, movement, e)pression, s+in con!ition a. 1ormal: symmetrically roun!, oval, elongate!, s
Health Assessment v. 7sun+en8 face %/ !epresse! eyes, hollo% chee+s# cache)ia Q%asting a%ay* vi. ale, s%ollen face 4 nephritic syn!rome Q+i!ney* F. alpate temporal artery a. 1ormal: elastic; not ten!er b. bnormal: har!, thic+, ten!er %/ in=ammation 4 temporal arteritis lea! to blin!ness J. alpate temporoman!ibular joint Q20Y* a. s+ pt to open mouth; e)plore ptAs 6) of hea!aches b. 1ormal: no s%elling, ten!erness, or crepitation Qcrac+ing/ soun!* %/ movement i. "ull RO0 of mouth c. bnormal: limite! RO0; s%elling , ten!erness, crepitation 20Y
In#pect"on o! nec. H. Inspect the nec+ 4 slightly e)ten!e! nec+ for symmetry, lumps or masses .i!e lighting a. bnormal: i. S%elling, enlarge! masses/no!ules enlarge! thyroi! glan! Qhuge bulge on anterior nec+* ii. In=ammation of lymph no!es tumor/ infection E. Inspect movement of nec+ structures a. t s%allo%s small sip of %ater; observe movement of thyroi! cartilage/thyroi! glan! i. 1ormal: thyroi! cartilage, cricoi!s cartilage, thyroi! glan! move up an! !o%n ii. bnormal: asymmetric movement or generalie! enlargement of thyroi! glan! . Inspect cervical vertebra a. t =e) nec+# move nec+ in !ierent !irections i. 1ormal: - visible an! palpable; sometimes 2H Z Ol!er people: cervical curvature# increase b/c of +yphosis Qhunchbac+* a. o%agerAs hump# in ol!er %omen ii. bnormal: prominence or s%ellings other than the - vertebrae F. Inspect RO0# move hea! aroun! a. 1ormal: movement is smooth an! controlle! i. Ol!er people: some%hat !ecrease! RO0# arthritis b. bnormal: i. Stiness, rigi!ity, limite! mobility 0uscle spasm, in=ame!, cervical arthritis Z aects !aily functioning
;a%pate H. 2rachea: $ngers on sterna notch; feel each si!e of the notch a. bnormal: i. 1ot mi!line tumor, thyroi! glan! enlargement, aortic aneurysm, pneumothora) Qair or gas in pleural cavity*, atelectasis Qcollapse of lung*, $brosis E. 2hyroi! glan! a. 6yoi! bone# bone that !oes not articulate %ith any other bone; high anterior nec+ b. 2hyroi! cartilage 4 7a!amAs apple8 c. -ricoi! cartilage# above sterna notch i. bnormal: not mi!line!; obscure! masses; abnormal gro%th Z alpable thyroi! if enlarge! hyperthyroi!ism Q5raveAs !isease* o &!emic goiter, thyroi!itis cause! by 5raveAs !isease Rapi! enlargement of a single no!ule malignancy o Thyro"$ Au#cu%tat"on H. Only if enlarge! # Gell on lateral lobes; pt hol!s breath bloo! %or+ i. bnormal: soft, blo%ing, s%ishing hyperthyroi!ism# increase bloo! =o%