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.