HSC1000 CH 20 ASSESSMENT

The___________ sound is when the heart relaxes and is refilling with blood. This is the diastolic phase of the heart.

"dub"

The______________ sound occurs as the heart chambers are contracting at their maximum force to push the blood out of the heart and into the arteries. This is the systolic phase of the heart

"lub"

The process would include an examination in the following order:

1. Head 2. Neck 3. Upper extremities 4. Chest (respiratory and cardiac systems) 5. Abdomen (digestive, urinary, and reproductive systems) 6. Lower extremities

There are two concerns when considering white coat syndrome

1. Patients may put themselves in this category and dismiss the need for treatment, as they feel it only occurs in that particular situation. 2. The high reading in the provider's office is assumed to be the patient's usual pressure and the patient is overtreated

Three observations are made when taking the respiratory rate

1. Rate: This is the number of respiratory cycles that occur in 1 minute. 2. Rhythm: Both the respirations and the intervals between them should be evenly spaced. 3. Respiratory effort: Breathing should occur through the nose, be unlabored, and be without sound;

Noting Variances from Normal

A critical function of the health care professional is to be able to discriminate between normal and abnormal conditions and situations.

1. List 8 examples of questions to use during the general survey of a patient.

Are any odors noted from body or breath? For example, is there a sweet or fruity smell to the breath (may be untreated diabetic or severe restriction of food intake)? Alcohol breath?

1. List 8 examples of questions to use during the general survey of a patient.

Are there any signs of distress? Is the patient moving and communicating freely or is there difficulty breathing, face wincing in pain, sweating or trem-bling, or holding part of the body (hand over area or rubbing area on body may indicate pain)?

The H&P consists of the following information

Chief complaint(s): The primary problem from the patient's view

The H&P consists of the following information

Current health status: Includes a list of allergies and immunizations; normal activity level and diet; current medications

The H&P consists of the following information

Date: The day on which the H&P is done

The H&P consists of the following information

Demographic Data: Includes age, sex, race, place of birth, marital status, occupation, and religion

When incorporating a psychosocial status of patients, along with a general survey, the following questions can guide the health care professional:

Emotional status: What are the emotional responses? For example, is the patient anxious, angry, depressed, indifferent? Are the facial expressions appropriate to what is being discussed?• Mental status: Is the patient's behavior appropriate for his or her age? What is the attention span? Does the patient ask appropriate questions? Can the patient recall information and incorporate new information? Appearance: Is the patient dressed appropriately for the weather? Well groomed? Does the patient have good personal hygiene? (This may give clues on emotional status or ability to care for self.)

The H&P consists of the following information

Family history of illness: Includes the age and health or cause of death of parents, siblings, spouse, and children. The physician will also ask if any family members have, or are experiencing, similar symptoms.(e.g., diabetes, heart disease, high blood pressure, cancer).

The H&P consists of the following information

History of present illness: Includes when the problem first started; how frequently it occurs; how long it lasts; description, location, and severity of symptoms;

The H&P consists of the following information

History: Includes the general state of the patient's health and any previous physical or psychological illnesses, accidents, injuries, surgeries, and hospitalizations.

1. List 8 examples of questions to use during the general survey of a patient.

How does the patient appear? What is the general impression you get from the patient?

The major components of a psychosocial interview include:

Identifying the patient. Chief complaint. History of presenting illness. Psychiatric history. Medical or surgical history. Medication list. Alcohol and drug use. Cultural assessment.

Blood Pressure

Indicates how hard the heart is working to distribute blood to all parts of the body

Respiratory Rates at Various Ages

Infant(Age) *30-60 (*Normal Ranges) Toddler 20-40 Preschool Child 22-34 School-Age Child 18-24 Adolescent-Adult 16-20

4 Skills frequently used during physical assessment are

Inspection: Using the senses of vision, hearing, and smell for observation of patient condition.

Auscultation

Listening to sounds inside the body with the aid of a stethoscope (e.g., lungs, heart, and bowel sounds).

Apical Pulse

Measures how fast the heart is beating by listening over the heart with a stethoscope

Radial Pulse

Measures how fast the heart is beating when felt at the wrist

Respirations

Measures how fast the patient is breathing

Temperature

Measures how much heat is in the body. An elevation may indicate that an infection or other disease process is present

Age Average Pulse Normal Range

Newborn 140 120-160 Infant 110 80-140 Toddler 105 80-130 Preschool Child 100 74-120 School-Age Child 95 70-110 Adolescent-Adult 80 60-90

HOW TO TAKE A MANUAL BLOOD PRESSURE

Place your fingers on the radial artery and inflate the cuff until you can no longer feel the pulse. Note the reading and add 30 to it. For example, if the dial reads 120 when the radial pulsation ceases, add 30 to equal 150. To get an accurate reading, it is necessary to pump the cuff to 30 mm Hg higher than the anticipated systolic pressure. This is the amount of inflation you will use when the blood pressure is taken.

The H&P consists of the following information

Psychosocial history: Includes the home situation and support structure (family and friends) and any significant information that may affect the care of the patient.

The H&P consists of the following information

Review of all systems: Includes height, weight, vital signs, and a review of each body system.

The H&P consists of the following information

Source of referral: Often one physician refers a patient to another because of that individual's expertise in a specific area; if so, it will be stated as such.

The body functions to maintain its temperature within a range that is best for maintaining homeostasis.

Temperature

General Assessment

The physician (or other primary care provider) takes a history and performs a physical exam on patients when they are seen for the first time or when they are admit-ted to the hospital. This is called the history and physical, commonly referred to as the H&P

percussion

Using the fingertips to lightly tap on the exterior of the body to determine the position, size, and consistency of underlying structures

Palpation

Using the hands and fingers on the exterior of the body to detect evidence of abnormalities in the various internal body organs.

1. List 8 examples of questions to use during the general survey of a patient.

What is the body proportion and size? Is the body proportionate and normal in size or is there a noted disproportion, such as very thin or obese, tall or short?

1. List 8 examples of questions to use during the general survey of a patient.

What is the color of the skin? Is the skin normal in tone or pale, flushed (reddish), jaundiced (yellow), or cyanotic (gray, dusty, or blue)? In non-Caucasian patients, the nail beds, whites of the eyes, and mucous membranes should be examined for color changes.

1. List 8 examples of questions to use during the general survey of a patient.

What is the overall impression of the patient? Does he or she appear strong and healthy looking or weak and ill?

1. List 8 examples of questions to use during the general survey of a patient.

What is the posture? Is the patient walking normally with a straight and erect posture or is he or she stooped or limping? Is there paralysis present?

Pulse

When the heart contracts and forces blood out of the heart and into the arteries, it creates a pulsing sensation that can be felt by the health care professional at certain points in the body

When temperature is within the normal range, patients are said to be

afebrile

An ____________________ should be obtained when there is an irregular rate, on cardiac patients, when the radial pulse is difficult to palpate, and with infants and young children

apical pulse

Another method for taking the pulse is to take an______________. This method requires the use of a stethoscope.

apical pulse

Activities of daily living (ADLs)

are the actions done on a regular basis to meet physical needs. These include bathing, eating, toileting, shopping, doing laundry, cleaning the house, paying bills, dressing, turning in bed, getting out of bed, and ambulating (walking).

In the health care workplace, the term____________is restricted to activities performed by licensed health care professionals.

assessment

When the pulse rate is abnormally low, it is called ______________

bradycardia. For example, in an adult patient, a rate of less than 60 beats per minute would be called bradycardia.

If the respiratory rate is below normal it is called_______________

bradypnea.

A ______________ stays elevated over a prolonged period.

continuous fever

When unlicensed health care professionals ask questions and make observations, it is called_________________

data collection.

Normal breathing is called ________________and should be within the normal range, unlabored, and have an even rhythm

eupnea

When the air is expelled back out of the lungs, it is called ____________, and there is a corresponding deflation of the chest cavity as the lungs empty.

exhalation (expiration)

When temperature is elevated above the normal range, they are

febrile.

A ____________ is a defense mechanism against microorganisms. In an effort to kill the invading microorganisms, the body triggers the muscles to shiver, which increases metabolic activity and further increases the temperature.

fever

When performing a _____________, both the physical and psychological aspects of the patient need to be considered

general survey

When air is taken into the lungs it is called____________, and there is a corresponding expansion of the chest as the lungs fill.

inhalation (inspiration)

An _____________means that the temperature rises and falls

intermittent fever

Whitecoat syndrome

is a term that was coined to describe a situation in which patient's blood pressure readings are high in the provider's office but otherwise in the normal range.

stethoscope

is an instrument that ampli-fies sound and allows a health care professional to hear sounds from within the body.

An accurate and thorough H&P

is very important because it provides the data on which the physician bases the initial diagnosis and treatment

When a patient's cardiovascular system is unable to make rapid changes to accommodate changes in position, he or she will experience a condition called

orthostatic (postural) hypotension

Respiration

refers to the process of moving air into and out of the lungs

One full cycle (inhalation and exhalation) is called one

respiration

When the pulse rate is abnormally high, it is called _______________

tachycardia. For example, in an adult patient, a rate of more than 100 beats per minute would be called tachycardia

If the respiratory rate is above the normal range, it is called_________________ ,

tachypnea

Vital signs include

temperature, pulse, respiration, blood pressure