N251 Health Assessment Exam #1
Uvula
Stops food from going up, should go up when patient says "Ahhh" Cranial Nerve X
Tension Headache
Stress, pain is like a hand squeezing the head
Nursing Assessment Ears- Weber Test
Strike tuning fork and place in center of the head. Vibrations should be heard equally in both ears. "Vibrations audible bilaterally in ears."
Geriatric Syndromes
Underlying symptoms manifesting a certain disease.
Cluster Headache
Unilateral, in or around the eye
Phonophobia
Sensitivity to sound.
Hordeolum (Stye)
Pus pockule. Treat with eyedrops, ointment, and warm compress.
SPICES- S
Skin Impairment
SPICES- S, 2
Sleep Disturbance
Nursing Assessment Ears- Whisper Test
Stand 1-2 feet behind the client and whisper toward ear that is not covered.
Importance of a Culturally Competent Nurse- Cultural Awareness
Aware, but sometimes what you know is not the truth
Assessment of Mouth- Lead Poisoning
Blue-Black Line
Geriatric Syndrome Categories- Breasts
"Pendulous"- hanging down loosely Increase in fibrotic tissue
Types of Pain
-Acute -Chronic -Cancer
Appropriate Patient Preparation For Comprehensive Health History and Assessment
-Comfort level (warm) -Standard precautions -Gather Equipment -Keep patient informed -Objective data (do height, weight, vital signs first)
Nursing Assessment of Mental Status
-Level of consciousness -General appearance (movement, dress) -Posture -Concentration (memory, hallucinations) -Facial expression -Thought process -Speech pattern -Behavior: mood
Different Methods of Data Collection
-Open and closed ended questions -Active listening -Clarify, summarize -Inspection -Palpation -Percussion -Auscultation
Effect of Nursing Communication on Subjective Data
-Open and closed ended questions -Active listening (quiet distractions) -Judgemental? -Lists -Rephrasing (clarify, summarize) -Communicate at eye level -Culture
Nursing Strategies to Validate and Analyze Data
-Verify data is reliable and accurate Clarify: -is additional info needed? -is info making sense? What is the data telling you? -what are potential problems? Form Conclusions -what is your proof? Form Nursing Diagnosis -is it appropriate? -what should we do?
Pain Assessment Tools
-Visual Analog Scale (VAS) Line -Numeric Pain Intensity (NPI) -Faces pain scale -Face Legs Activity Cry Consolability Scale (FLACC), critical care
Nursing Assessment Eyes- Visual Reflexes
-pupillary light reflex -consensual response -accommodation
Nursing Assessment Eyes
1. Eyelid and eyelashes alignment: equal. 2. Conjunctiva: pink. 3. Sclera: white. Is there discharge? Or redness? 4. Iris and Pupil: Round, equal. 5. Lacrinal Apparatus: Palpate, eyes will get moist. 6. Cornea: Should be clear. Cataract= Cloudy
Daily Recommendation of Calcium for Older Adults
1200 mg
Strabismus
Misalignment of the eyes.
Instrumental Activities of Daily Living
A little more advanced look at daily activities, such as laundry, chores, balance a checkbook, and driving.
Pain Tolerance
Amount of pain a person can endure
Geriatric Syndrome Categories- Heart and Blood Vessels
Arterial thickening Arterial venous insufficiency -Varicose veins Increased systolic blood pressure Increased HR with activity Decreased Reserve -Exercise intolerance
Lymphoma
Cancer
Geriatric Syndrome Categories- Ears
Cerumen- Wax production in ears increases. Presbycusis- Gradual loss of hearing as you age. Harder to hear high frequency sounds.
COLDSPA
Character Onset Location Duration Severity Pattern Associated factors Affect on patient
Importance of a Culturally Competent Nurse- Bias
Check yourself at the door
Nursing Assessment Eyes- Cover Test
Client stares straight ahead and focused on distant object, both eyes should remain fixed straight ahead
SPICES- C
Cognitive Impairment
Geriatric Syndrome Categories- Neurologic
Concentration -Aging brain more vulnerable to deficits in oxygen, nutrition and infection. Increased Risk of Dementia Decreased Temp Regulation Mood -Depression. Family and friends die. Loss of independence Fatigue- Changes in blood sugar?
Possible Nursing Diagnosis- Actual
Currently Noted, Address First Ex. Skin Breakdown, Swelling
Geriatric Syndrome Categories- Genitourinary
Decreased bladder muscle tone -Incontinence -Retention BPH- Benign Prostate Hypertrophy, enlargement UTI- May present without fever or elevation in WBC count, dysuria, or urinary frequency
Geriatric Syndrome Categories- Abdomen
Decreased gastric emptying, causes a feeling of fullness Decreased liver activity, slower metabolism of drugs Rectum and Anus, blood in stool, constipation Increased risk of colon and prostate cancer, Occult Test (colon cancer)
Geriatric Syndrome Categories- Lungs
Decreased respiratory muscle strength; stiffer chest wall Diminished ciliary activity (higher risk for infection) Decreased response to hypoxia and hypercapnia -Increased work of breathing 16-25 Resp -SOB with activity Increased residual volume because of loss of elasticity and weakening chest muscles.
Macular Degeneration
Deterioration of retina. Retina destroyed, nothing for light to bounce off of. Can be hereditary. To prevent: Omega 3 Fatty Acids
Ptosis
Drooping of one eyelid.
SPICES- E
Evidence of falls, or functional decline
Hypotropia
Eye turns down.
Esotropia
Eye turns in.
Exotropia
Eye turns out.
Hypertropia
Eye turns up.
Accurate Nursing History of Patient's Eyes and Ears
Eyes: -eye surgeries -exposure to dust, chemicals, fumes, flying sparks -use of protective eyewear -last eye exam -meds -use of glasses or contact lens *Occupational hazards* Ears: -frequent infections -trauma -hearing aids -medications -family history of hearing loss or congenital rubella -lifestyle (job with loud noises, swimming, effect on ability to socialize, last hearing exam, care or ears)
Palpate Temporomandibular Joint (TMJ)
For range of motion, swelling, tenderness, and crepitation
Palpate Temporal Artery
For tenderness and elasticity. If painful, temporal arteritis
Sinuses
Four pairs, frontal (forehead), maxillary(on either side of nose), ethmoidal, and sphenoidal (bridge of nose) Decreases weight of skull and acts as resonance chamber during speech. Air pockets, filter/humidify air Crump Zones (Air bags of face) Assessment- Palpate for tenderness. Percussion or transillumination for air versus fluid or pus
Possible Nursing Diagnosis- Wellness
Health Promotion, to enhance health Ex. Need to use sunscreen
SPICES- I
Incontinence
Assessment of Mouth- Foul Odor
Indication of dental/GI issue
Assessment of Mouth- Fruity Breath
Indication of hyperglycemia, diabetic ketoacidosis
Assessment of Mouth- Ammonia Breath
Indication of kidney issue
Blepharitis
Inflammation of the eyelid, infection or oil pocket. Treat with warm compress.
Geriatric Syndrome Categories- Skin
Inspect Skin Lesions -fibrous tissue -wrinkles -dryness -skin breakdown -vascular
Tonsils, Tonsilitis
Inspect for color and consistency. Grading scale of (+1, +2, +3, +4)
Physical Assessment: Neck
Inspect movement of neck structures, before you move neck, ask about injuries. Trachea should be midline In older adult, you may feel a nodular thyroid. Palpate lymph nodes of head and neck
Physical Assessment: Head and Face
Inspect size, shape, configuration Consistency Involuntary Movement Inspect symmetry (nasolabial folds and palpebral fissures are ideal for checking symmetry), features, movement, expression, skin condition
Accurate Nursing History of Client's Head, Neck, Mouth, Nose, and Throat
Interview Approach (COLDSPA) -History of current health problem, past health, family Lifestyle and health practices Pain Lesions Headaches Do they drink, smoke? Any pain, swelling, sores? What meds are they on? Salute Signs- Frequent colds and allergies
Nystagmus
Involuntary movements of eye. Can be born with, or develop over time.
Meds That Can Impact Hearing
Lasix, Aspirin, Aminoglycocides (Antibiotic)
Assessment of Mouth- Under Tongue
Leukoplakia or Thrush? Cancer is under the tongue.
Pain Threshold
Level of stimuli required by each individual to create a painful sensation
Ear Exam, Patient <3 years old
Lift ear down and back
Ear Exam, Patient >3 years old
Lift ear up and back
Katz Activity of Daily Living
Looks at person's ability to perform basic needs such as dressing, bathing, and eating.
Geriatric Syndrome Categories- Nose, Mouth, Throat
Mouth -Dentures fit properly? Could be reason for malnutrition Decreased Smell and Taste Decreased Thirst Sensation Weight Loss -Chew, Difficulty swallowing Vitamin Deficiency -B12 Dehydration -Turgor
Internal Nose
Nasal cavity, nasal septum, Kisselbach's area (where nose bleeds occur, epistaxis), superior, middle, and inferior turbinates (warms, filters air entering nares)
Palpate Trigeminal Neuralgia
Nerves from brain to face, can send intermittent pain to face.
Patient-Centered Pain Assessment
Only patient can describe their pain. Signs of pain are: -face -muscles -vitals
Geriatric Syndrome Categories- Musculoskeletal
Osteoporosis -Height and spine Decreased Activity Tolerance -Weakness Posture and Balance -Decreased muscle mass replaced with fat -Arthritis Assistive Devices Falls -Watch gait
Acromegaly
Overgrown, thickened bones. (Andre the Giant)
Migraine Headache
Pain, nausea, visual changes. Sometimes preceded by an aura.
Nursing Assessment Eyes- Position Test EOM
Patient focus on object held 12 inches away, move object through six cardinal positions, observe eye movement.
SPICES- P
Poor Nutrition
Possible Nursing Diagnosis- Risk
Potential Problem, what are you at risk for? Ex. At risk for skin cancer
Photophobia
Sensitivity to light.
Aspects of a Nursing Assessment
Subjective Data -reason for seeking care (what concerns you today?) -past medical history -past surgical history -lifestyle -family history -meds -environment (home, occupation) -social support -vaccines -screen for abuse (do you feel safe?) *Sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the patient.* Objective Data: -vitals -labs -what you see, hear, smell, and touch
Lymphadenopathy
Swollen glands
Geriatric Syndrome Categories- Eyes
Test Vision Tear Production Pupil Size (Decreased) Bags Under Eyes, stretched skin
Romberg Test
Tests equilibrium. Patient closes eyes for 20 seconds, Can do with hands at sides, or out parallel to floor.
Nursing Assessment Ears- Rinne Test
Tuning fork is placed on mastoid process until sounds is no longer heard. Then placed in front of external auditory canal until sound is no longer heard. Document time on bone and time in front of ear separately. "Air conduction is always longer than bone conduction."
Sinus Headache
Usually behind the forehead and/or cheekbones
Nursing Assessment Eyes- Distant Visual Acuity
Utilize eye chart, patient stands 20 feet away, cover one eye. Patient can wear distance glasses, not reading glasses though.
Nursing Assessment Eyes- Near Visual Acuity
Utilize newspaper of Snellen chart, cover one eye. Patient can wear reading glasses, not distance glasses.
Narcotic Naive
Very little amount of pain meds are needed to receive pain
Importance of a Culturally Competent Nurse- Cultural Desire
Want to learn about it.