Flashcards in HESI Health Assessment Deck (110)
Documentation - History Taking
* Subjective (self reported) vs. Objective (what you measure, inspect, palpate, percuss, and auscultate)
* symptom (subjective sensation felt) vs. sign (objective abnormality that examiner, tests, labs can detect)
* database = history combined with objective data from physical assessment and lab studies. used to make a judgement or diagnosis
* present and past health history
1. biographic data: name, address, phone number, age, birth date, gender, etc .
2. Source of history: who furnishes the information, how reliable is the informant, special circumstances (interpreter?)
3. reason for seeking care: states current symptoms and durations
4. present health or history of present illness: general state of health (healthy person) or chronologic records in terms of reason for seeking care (ill person)
5. past health: childhood illnesses, accidents, injuries, serious or chronic issues, hospitalizations, operations, obstetric history, immunizations, last exam date, allergies, current meds
6. family history:
7. review of systems: all body systems assessed for issues, history
8. functional assessment: activities of daily living, nutrition, exercise, spiritual
eight characteristics of stymtoms
location, quality, severity, timing, setting, aggravating or relieving factors, timing, setting, associated factors, patient's perception
adolescent health assessment
Education and employment
Safety from injury/violence
children health assessment
includes information about specific age and developmental stage of the child.
- developmental history
- nutritional history
- including the pregnancy of the mom and the delivery
older adult health assessment
- address activities of daily living
- encourage postiive health efforts
male bladder evaluation
1. frequency, urgency, and nocturia
- polyuria = excessive quantity
- oliguria = diminished quantity
- nocturia = occurs with frequency and urgency with urinary tract disorders
2. dysuria = pain or burning with urination
3. hesitancy and straining
- loss of force and decreased caliber
* these symptoms suggest progressive prostatic obstruciton
4. urine color
- hematuria = blood in urine, dangerous, nephritis, cystitis, cancer, follows prostate surgery
- cloudy = urinary tract infection, kidney stones
- orange = food dyes, side effect of medicaton, dehydration, jaundice
- amber = dehydration, laxatives, b-complex vitamin supplements
- blue = medication side effect of amitriptyline, indocin; asparagus
- gray = contains melanin, melanuria
- brown = liver disease, blood in urine
5. incontinence: urge (involuntary urine loss from overactive detrusor muscle) and stress (involuntary urine loss with physical strain, sneeze, or cough due to weakness of pelvic floor)
Acute Gout: usually at the first metatarsophalangeal joint (big toe).
- redness, swelling, heat, and extreme tenderness
- metabolic disorder of disturbed purine metabolism, associated with elevated levels of uric acid
- occurs primarily in men older than 40
Tophi with Chronic Gout: hard, painless nodule (tophi) over metatarsophalangeal joint of big toe
- collections of sodium urate crystals due to chronic gout in and around the joint
- extreme swelling and joint deformity
- may burst with chalky discharge
inspection - limb symmetry
- insect and compare both shoulders posteriorly and anteriorly
- check size and contour of joint, compare shoudlers for bony landmarks
* abnormal: redness, inequality of bony landmarks, muscle atrophy, dislocation, swelling, muscle spasms, tenderness or pain, decreased ROM, crepitus with motion
- inspect size and contour of elbow in flexed and extended positions
- look for deformity, redness, swelling
- check olecranon bursa
*Abnormal: buldge or fullness in goove of elbow,
*Wrist and hang
- inspect hands and wrists on dorsal and palmar sides and note position, contour and shape.
*abnormal: subluxation, ulnar deviation, ankylosis (wrist in extreme flexion), swan-neck or boutonniere deformity in fingers, atrophy of thenar eminence, general swelling
- inspect hip joint together with spine a bit later in examination as the person stands.
- note symmetric levels of iliac crests, gluteal folds, and equially sized buttocks
- inspect gait, leg function and length.
- person should remain supine with legs extended (some have them sit on the side of the bed and dangle their leg)
- check for smooth skin with even coloring and no lesions
- inspect lower leg alignment (should extend in same axis as thigh)
- inspect knee shape and contour and normal distinct concavities or hollows; edema or swelling
- check quadriceps for atrophy (important muscle for knee joint stability during weight bearing)
*ankle and foot:
- inspect while person is sitting, non-weight bearing and position and also standing and walking
- compare both feet and toes, contour of joints, and skin characteristics
- foot should align with long axis of of lower leg
- weight-bearing falss on the middle of the foot, from the heel, along the midfoot, to between the second and third toes
- inspect for flat feet, large arch
- toes point forward and lie flat
- ankles are smooth bony prominences, skin is smooth, even coloring, and no lesions.
- note calluses
inspection - anus
- spread buttocks wide apart and observe the perianal region
- anus normally looks moist and hairless with course, folded skin that is more pigmented than perianal skin.
- anal opening is tightly closed
- no lesions present
- inspect sacrococcygeal area, normally smooth and even
* Abnormal: inflammation, lesions or scars, linear split (Fissure), flabby skin sac (hemorrhoid), shiny blue skin sac (thrombosed hemorrhoid).
* inflammation or tenderness, swelling, tuft of hair, or dimple at tip of coccyx may indicate pilondial cyst
* cicular red doughnut of tissue = rectal prolapse
inspection - the mouth
- inspect lips for color, moisture, cracking and lesions
- retract the lips and note inner surface, should be deeper and pinker than facial skin (however african americans have bluish lips and a dark line on the gingivial margin)
- abnormal = circumoral pallor occurs with shock and anemia; cyanosis with hypoxemia and chilling; cherry red lips with carbon monoxide poisoning, acidosis from aspirin poisoning, or ketoacidosis
* teeth and gums
- condition of teeth is an indicator of a person's general health
- note diseased, absent, loose or abnormally positioned teeth
- inspect # of teeth for age (children have less)
- gums should be pink/coral with stippled (dotted) surface
- abnormal = yellow teeth associated with tobacco use, grinding down of teeth surface, malocclusion (poor biting relationship), protrusion of upper or lower incisors, gums bleed with slight pressure (gingivitis)
- check tongue for color, surface characteristics, and moisture. should be pink and even
- doral surface is roughened from papillae
- thin white coating could be normal
- ventral surface should be smooth, glistening, and shows veins
- saliva is present
- inspect for white patches or lesions, if they do occur palpate for induration.
- note white patches, nodules, ulcerations.
- abnormal = enlarge tongue associated with mental retardation, hyperthyroidism, acromegalt; small tongue assocaited with malnutrition; dry mouth and dehydration or fecer; saliva decreases when taking anticholinergic medication; excess saliva/drooling occur with gingivostomatitis and neuro dysfunctions
- oral malignancies likely to occur to develop in u-shaped area under the tongue behind the teeth.
- hold cheek open with wooden tongue blade and check for color, nodules, lesions.
- smooth, pink, moist is normal or patchy hyperpigmentation is common and normal in dark-skinned people
- stensen's duct - expected finding, opening of the parotid salivary gland, caused by teeth closing on the cheek
- leukoedema: benign, milky, bluish white, opaque area, more common in blacks and east indians
- fordyce granules: small, isolated white or yellow papules on the mucosa of cheek, tongue, and lips. these are sebaceous cysts that are painless and not significant
- shine your light on the roof of the mouth. the more anterior hard palate is white with irregular transverse rugae. the posterior soft palate is pinker, smooth, and upwardly moveable.
- torus palatinus is a normal variation and is a nodular bony ridge down the middle of the hard palate.
- observe the uvula , ask the patient to say "ahh" and note the soft palate and uvula rise in midline.
assess - carotid artery
- palpate carotid artery medial t sternomastoid muscle in the neck
- avoid excessive pressure on the carotid sinus are higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults.
- palpate gently, only one artery at a time to aboid compromising arterial blood to the brain
- feel contour and amplitude of the pulse, normally the contour is smooth with a rapid upstroke and slower downstroke, and normal strength is 2+ or moderate
- auscultate carotid artery
- auscultate for bruit in patients with symptoms or signs of cardiovascular disease or middle-aged or older
- bruit is a blowing, swishing sound indicating blood flow tubulence
- keep neck in neutral position and lightly apply the bell of the stethoscope over the carotid artery over 3 levels: 1) angle of the jaw 2) midcervical area 3) base of the neck
- ask person to hold their breath while listening so that breath sounds are not mistaken for bruit
palpation - lymph nodes
- enlarged lymph nodes occue with infection, malignancies, and immunologic diseases
- edema of upper extremeties occus when lymphatic drainage is obstructed (may occur after breath surgery)
- epitrochlear lymph nodes in the depression above and behind the medial confyle of the humerus - shake hands with the person and reach your other hand under the person's elbow to the groove between the biceps and triceps muscle. these nodes are not normally palpable. if they are palpable it can indicate generalized lymphadenopathy.
- inguinal lynph nodes (groin area). it is common to find small, movable, nontender nodes
- unusual or frequent?
- when did this start? how often do they occur?
- where in your head do you feel the headaches? do they seem to be associated with anything else?
*abnormals: a patient who says "this is the worst headache of my life" needs emergency referral to screen cerebrovascular cause
2. Head injury
- ever had a head injury?
- what part of your head was hit?
- did you have loss of consciousness? for how long?
- ever feel light headed, a swimming sensation, or feel like you're going to faint?
- when do you notice this? how often? does it occur with activity or change in position?
- do you feel vertigo (rotational spinning sensation)? does the room spin (objective vertigo) or are you spinning (subjective vertigo)?
- does it come on suddenly or gradually?
*abnormals: syncope, vertigo
- ever had any convulsions? when did they start? how often do they occur?
- warning sign before seizures?
- motor activity during seizures?
- associated signs (lips chance color, LOC, eye fluttering, etc)?
- postictal phase - do you spend time sleeping after the seizure? confusion, weakness, headache, muscle ache after?
- any percipitating factors (seems to bring on a seizure)?
- coping strategies
* abnormals: seizures occur with epilepsy, altered LOC, involuntary muscle movements, and sensory disturbances. an aura can precede a seizure
- tremors in hands or face? when did they start?
- worse with anxiety, intention or rest?
- relieved with rest, activity, alcohol?
- do they affect ADLs?
- weakness or problem moving any body part?
- generalized or local?
- does it occur with any particular movement?
*abnormals: paresis (parietal or incomplete paralysis), paralysis (loss of motor function due to a lesion in the neurologic or muscular system or loss of sensory innervation)
- problem with coordination?
- problem with balance when walking?
- list to one side? fall? legs seem to give?
*abnormals: dysmetria (inability to control distance, power, and speef of muscular action)
- does it feel like pins and needles? when did it start? where do you feel it? does it occur with activity?
*abnormals: paresthesia (abnormal sensation like burning/tingling)
9. difficulty swallowing
- problems with swallowing? occur with solids or liquids? excessive saliva or drooling?
10. difficulty speaking
- problems forming words or saying what you intended to say? when did you first notice this? how long did it last?
*abnormals: dysarthria (difficulty forming words) dysphagia (difficulty with language comprehension or expression)
11. Significant past history
- stroke? spinal cord injury? menningitis, encephalitis? congenital defect? alcoholism?
12. environmental/occupational hazards
- insecticides, organic solvents, lead?
- taking any meds?
- how much alcohol do you drink?
- take mood-altering drugs? marijuana, hypertension, alcohol, drug use, diabetes?
assessment - geriatric pulse
- increase in systolic blood pressure (stiffening of large arteries. this leads to an increase in pules wave velocity because les compliant arteries cannot store the volume ejected
- left ventricular wall thickness increases
- increased pulse pressure (difference between systolic and diastolic as systeolic goes up and diastolic stays the same)
- no change in resting heart rate
- cardiac output at rest is not changed
- decreased ability of the heart to augment cardiac output with exercise. decreased max heart rate with exercise and diminished sympathetic response.
- dysrhythmeias are more common with age which may cause rapid, slow or irregular pulse
- cardiovascular disease rates increase
- rate varies
- worse with voluntary movement as in reaching toward a visually guided target (finger to finger).
- occurs with cerebral disease and M.S.
- essential tremor is a type of intention tremor: most common with older people and is benign (not associated with a disease) but causes emotional stress in busienss or social situations. improves with administration of sedatives, propanolo or alcohol (but discourage alcohol as an aleviator)
posture assessment on bedrest
**not sure exactly about bedrest but below is regular posture stuff **
- normal: convex thoracic curvature and concave lumbar curve
- enhanced lumbar curvature is common in obese/pregnant
- s- shape is scoliosis
- person stands comfortably erect as appropriate for age
- aging person is normal to show kyphosis
- arthritis - rigid spine and neck move as one unit
- shoulders slumped, looks defeated (depression)
- stiff and tense, ready to spring from chair fidgety movements
- Ataxia is defined as a difficulty of gait. It is a very common neurologic complaint, particularly in an elderly population and is often multifactorial. In general terms, ataxia can result from damage to the sensory systems that provide feedback for normal balance, or problems with the several motor systems that are needed to respond to the constantly changing environment while walking
- How long has it been present and did it begin all of sudden? These are common questions in neurology and help distinguish chronic and slowly progressive problems (such as degenerative diseases like Parkinson disease) from acute problems (like stroke).
- When does it occur? It is important to note the circumstances under which the patient's gait is notably abnormal. For example, if walking on irregular surfaces or in the dark markedly worsens the patient’s gait, sensory ataxia should be a major consideration.
- Are there any coexisting symptoms? These may include vertigo, weakness, stiffness or slowness of movement, abnormal movements, cognitive difficulties or significant changes in behavior. These can be clues to vestibular, cerebellar, pyramidal, extrapyramidal or frontal lobe disorders. Feelings of presyncope may require evaluation of factors potentially affecting blood flow to the brain (Chapter 27).
- What have been the functional ramifications of the gait disturbance? For example, has the patient fallen and, if so, in what situations? What has the patient or family done to prevent falls (i.e., restrict movements, etc).
- Is the gait disturbance completely explainable by pain (such as a limp), or by compensation for weakness of a single muscle group? If it is due to weakness, evaluation of this symptom (Chapter 12) will be the most important factor.
- Is the gait disturbance real and have others noticed it? This is important because ataxia can be hysterical in nature. At times this can be recognized by the severity of the gait disturbance (which is often exaggerated and bizarre) and the relative paucity of injuries due to falls, etc. These patients often “catch themselves” in ways that would suggest higher levels of motor performance than their poor gait would indicate. Astasia-abasia is a term that has been applied to the condition in which the patient lurches wildly and only falls when there is someone or something to break the fall. The key to recognizing this is to realize that the ability to catch themselves exceeds that which would be expected of a patient with such severe gait disturbance.
older adults - heart failure
**not sure what they are looking for in this section**
- If older adults have heart failure, you may experience urinary symptoms such as incontinence, urgency, frequency, and nocturia
- One of the common conditions that occurs along with heart failure is renal (kidney) insufficiency—a situation in which your kidneys are not able to filter your blood as well as before.
- If you have chronic heart failure, there is a serious risk that you will suffer from depression at some point.
- Heart failure is among the most common complications of diabetes, a disease in which your body cannot regulate blood sugar (glucose) levels properly.
sensory/ears assessment - older adults
- Hearing loss is common in older adults and usually affects both ears. In general, older adults have more trouble hearing high-frequency sounds, such as consonants (especially p, s, and t) than low-frequency sounds, such as vowels. Refer patients with hearing difficulty to an audiologist.
- in the aging person, cilia lining the ear canal become coarse and stiff. this may caused cerumen to accumulate and oxidize, which greatly reduces hearing.
- impacted cerumen is common in aging adults and also causes issues with hearing aids
- presbycusis occurs with 60% of people 65 and older. it is graual sensorineural loss cuased by nerve degeneration in the inner ear that slowly progresses after the 5th decade.
- hearing loss is accentuated when there is background noise
hip dysfunction - assessment
- pain with palpation
- limited motion
- pain with motion
- positive thomas test: reveals flexion deformity in the opposite hip, normally flexion flattens the lumbar spine
- limited internal rotation of hip is an early and reliable sign of hip disease
- limitation of abduction of the hip while supline is the most common motion dysfunction found in hip disease
history taking - geriatrics
- same health history as an adult with some additional questions that address ADLs, effects of chronic illness, or disability
- There is no specific age to start using these questions, use them when it seems appropriate
- important to recognize positive health measures: what the person has been doing to help themselves to stay well to live to an older age
- ask about recent colonoscopy, mammography, tonometry, current medications, nutrition, exercise, self-esteem, depression, sleep and rest, interpersonal relationships, coping and stress management,
Assessment - point of maximal impact (PMI)
The point of maximal impact (PMI) is the location on the anterior chest wall where the apex of the heart is felt most strongly.
- It can be felt in 70% of individuals in the sitting/standing position orin the left lateral decubitus position.
- Palpate for the PMI as follows:
Place the patient's chest so that the heart is thrust anteriorly either in the upright position (either sitting or standing) or left lateral decubitus position (NOT in the supine position).
Place your fingertips in the fifth intercostal space and the left midclavicular line (PMI is normally within 10 cm ofthe sternum on the left side).
Note the location of the PMI.
Note the size of the PMI (PMI is normally 2-3 cmin diameter).
A large, laterally displaced, or diffuse PMI generally indicates some form of cardiomegaly.
assessment - cardiac sounds S1 & S2
* S1 = closure of AV valves, mitral and tricuspid
- signals the beginning of systole
- first heart sound
- usually heard loudest at apex
- s1 is louder than s2 at the apex
- s1 coincides with the carotid artery pulse. when you feel the carotid artery you feel s1
- s1 coincides with R wave if the person is on an ECG monitor
- you can hear s1 well during inspiration and expiration
- a split s1 is normal (one valve closes before the other)
- the intensity of s1 depends on 3 factors: position of AV valve at the start of systole, structure of the valve leaflets, how quickly pressure rises in the ventricle
* S2 = closure of semilunar valves, aortic and pulmonary
- signals the end of systole
- second heart sound
- loudest at the base
- s2 is louder than s1 at the base
- listen to s1 & s2 separately. note whether they are normal, accentuated, diminished, or split
assessment - carotid bruit
- for persons middle-aged or older or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for the presence of a bruit
- bruit = a blowing, swishing sound indicating blood flow turbulence; normally none present
- keep the neck in a neutral position, lightly apply the bell of the stethoscope over the carotid artery at 3 levels: angle of jaw, midcervical area, base of the neck.
- avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis.
- ask the person to take a breath, exhale and then hold it so that tracheal breath sounds don't interfere
- a bruit is audible when the lumen is ocluded 1/2 to 2/3. bruit loudness increases as the atherosclerosis worsens until the lumen is occulded by 2/3. after that the bruit loudness decreases
- ask person to stand with feet together and arms at sides then close eyes. wait 20 seconds. if they sway too much ( a little is normal) or fall or widen base of stance then it is positive.
sing of deep vein thrombosis (DVT)
- positive is pain in calf and abrupt dorsifelxion of ankle
- not really a reliable test today
Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident)
- absence of reflex, is a lower motor neuron problem
- occurs with interuption of sensory aafferents or destruction of motor efferents and anterior horn cells (spinal cord injury)
set of rapid, rhythmic contractions of the same muscle