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Health Assessment

12/16/10

Health: a state of well-being Health Assessment includes: -general data (name, address, allergies) -health history -psychosocial status -functional status -present status (where are you right now?) *subjective data (questions, interview) *objective data (physical assessment) Physical Assessment: always starts out with the Initial Observation (how they look, walk, speak) *Initial Observation *Height &Weight *Vital signs *Review of the systems (complete head-to-toe examination) Health Assessment Vocabulary Abdominal: anterior torso below diaphragm Antecubital: depressed area just in front of elbow Buccal: cheek Cephalic: head Cervical: neck Digitals: fingers or toes (thumb & big toe = #1) Dorsal: back Facial: face Frontal: forehead Nasal: nose Orbital or ophthalmic: eyes Zygomatic: upper cheek Femoral: thigh Gluteal: buttock Inguinal: groin Lumbar: lower back between ribs and pelvis Mammary: breast Occipital: back of lower skull Sternum: breastbone Plantar: palm/hand/sole of foot Popliteal: area behind knee

Supraclavicular: area above clavicle Malleolus: ankle Thoraic: chest Umbilical: area around navel/umbilicus Superior: a part is above another or closer to the head Inferior: a part is below another or closer to the feet. Anterior: towards the front Posterior: towards the back Medial: closer to the midline Lateral: away from the midline Proximal: closer to a point of attachment or closer to the trunk Distal: part is farther from point of attachment or from trunk Superficial: situated near the surface Deep: describes parts that are most internal Peripheral: means outwards or near the surface

Anatomical Landmarks Angle of Louis: where the trachea and bronchi divide, 2nd Intercostal Space Xiphoid Process of Sternum: important for CPR Clavicle: inferior to the clavicle is used to find apical pulse Abdomen: broken up into 4 quadrants (LRQ, RUQ, LLQ, RLQ)

MOST ACCURATE *Children-pull pinna out and down *Adults. respiration. blood pressure and pain level *Age variables: newborns have higher pulse than adults *Accurate measurements is an ABSOLUTE must Temperature: heat is a byproduct of normal body metabolism *Normal body temperature ranges from 97.32) X 5/9 = Celsius Celsius Fahrenheit (Celsius x 9/5) + 32 = Fahrenheit -What effects normal heat production? *Normal Basal Metabolic Rate -Increased thyroid production = increased body temperature (and vice versa) -Testosterone. the patient has pyrexia) *Pyrexia: occurs when normal regulation mechanisms cannot keep up with heat produced by the body *Diaphoresis is excessive sweat production in an effect to cool the body .5 for adults *Everyone has their own normal temperature Fahrenheit Celsius (Fahrenheit --. pulse.pull pinna up Other Factors Effecting Temperature: -Early morning your temperature will be the lowest -Age of the patient *Birth & Elderly temperature change rapidly -Physical exercise (temperature goes up) -Menstrual cycle/stress (just before ovulation. mouth-breathing Pyrexia (fever): temperature higher than 100. drinking. more calories are burned off -that s why men lose weight faster than women more testosterone *Hypothalamus senses an increase in heat vasodilation body begin to sweat decreases body temperature Heat transfer: heat loss occurs through the skin s exposure to the environment through: -radiation -conduction -convection: air movement.5-99. fans -evaporation: when moisten skin dries -Heat loss by evaporation results in 800 mL loss of water EACH DAY Measuring Body Temperature: is very dependent on the site *Rectal Temperature: 1 degree F higher than oral temperature -Do NOT take on another that has seizures *Axillary Temperature: 1 degree F lower than oral temperature -most accurate results takes about 5 minutes to take *Tympanic Temperature: approximates core body temperature. bump on the back of the neck Scapula: shoulder blades can be used when assessing lung sounds Chapter 21: Vital Signs 12/16/10 Vital Signs: temperature.C7: cervical 7 vertebra.2F (patient is febrile. Epi/Norepiherine can increase BMR *Higher the temperature. temperature drops) (stress=high temperature ) -Eating.

p. Hypothermia: below-than normal body temperature (94F or below) At this level. *There are several terms to describe the strength of a pulse. with frail elderly base temperature often being 96F. less heat is produced. newborn infants whose skin is exposed to cool temperatures. apical. postoperative patients who have been cooled during surgery.Hyperthermia: above-than-normal body temperature (101. and sleepiness and coma are apt to develop.3F or above). dehydration. femoral. hemorrhage) Common Pulse Points at Arteries: radial. 350 Nursing Interventions to Reduce Fever -Increase fluid intake -Increase rate of circulating air -Control/reduce body activity -Antipyretics (acetaminophen) -Lower room temperature -Remove excessive clothing -Provide sponge bath/cooling blanket Pulse: rate (beats per minute). elderly/debilitated patients. quality (characteristics of pulse-strong. Wearing a hat. temporal. irregular). pedal Factors Affecting Pulse Rate *Age *Body build & size *Blood Pressure *Drugs *Emotions *Blood Loss *Exercise *Increased body temperature *Pain *Hypoxia Average Pulse Rates: Normal 60-100 BPM Some athletes 45-60 BPM Adult Male 72 BPM Adult Female 76-80 BPM Child (age 5 yr) 95 BPM Child (age 1 yr) 110 BPM Newborn 120-160 BPM Normal Pulse rate: 60-100 beats per minute Tachycardia: heart rate greater than 100 beats BPM Bradycardia: a heart rate less than 60 BPM Pulse deficit: difference between the apical and radial pulse Arrhythmia: (irregular pulse) has a period of normal rhythm broken by periods of irregularity or skipped beats. rhythm (regular. *Very elderly patients tend to have a lower base body temperature. Those are risk for hypothermia include. weak) -pulse is produced by cardiac contractions causing a pressure wave against the walls of the arteries *Each contraction propels 60 to 70 mL of blood into the aorta (stroke volume) *Cardiac Output = Heart Rate x Stroke Volume* (approximately 5 L/min for the average adult) -Stroke volume can be decreased by decreased blood volume (dehydration. If an elevation of 2 degrees F occurs. delirium and convulsions may occur. popliteal. carotid. The most common are: . or if its lasts for an extended period of time. those exposed to cold temperatures for prolonged periods. Nursing Care Plan for Alteration of Normal Temperature in DeWit. fever is present. *The elderly & infants lose considerable body heat through the scalp. If the fever is very high. the activity of the cells is reduced. even indoors helps prevent heat loss in cold weather.

or 2+) -Full & Bounding (even beats with strong force. or 1+) -Strong & Regular (even beats with moderate force. but is always considered along with the other vital signs and assessment data. particularly around the mouth & nail beds Respiratory Patterns *Eupnea: normal.-Weak & Regular (even beats with poor force. -Respirations should be counted for 30 seconds X 2 Normal Range of Respirations (respirations per minute) Elderly 16-20 Healthy Adult 12-20 Adolescent 16-20 Child (age 3 yr) 20-30 Infant (age 1 yr) 20-40 Newborn 30-80 *The rate of respirations increases during fever as the body attempts to remove excess heat -Cyanosis: bluish discoloration or skin color changes. soft. or 3+) -Feeble (barely palpable) -Irregular (both strong and weak beats occur within 1 minute) -Thready (generally indicates that it is weak and maybe irregular) -Absent (no pulse palpable or heard by auscultation) Stethoscope *Always clean the ear-tips with Rubbing Alcohol wipes *Turn the diaphragm to make sure you are listening to the bell of the stethoscope *4th Intercostal Space. Midclavicular line = apex of the heart -Describing the apical pulse: loud. relaxed breathing *Dysnea: difficult and labored breathing *Tachypnea: increased or rapid breathing (breathing rate increase about 4 breaths for each 1 degree F increase in temperature) . etc Respiration: a change in respiratory rate may indicate a change in a patient s condition.

*Kussmaul s respirations: have an increased rate and depth with panting and long. Often seen with patients who are severely exerted. *Biot s respirations: are shallow for two or three breaths with a period of variable apnea. -Rhonchi: continuous dry. . earlobes. Sounds like hair rubbed between the fingers next to the ear. during high levels of anxiety or fear. with their feet flat on the floor and rest for at least 5 minutes before blood pressure measurements are taken. Often seen with patients who are under medical sedation. Crossing the legs at the knee causes an elevation in systolic and diastolic pressure. exhalation. These respirations occur in patients with increased intracranial pressure. grunting. It is taken with a sphygmomanometer Classification of Blood Pressure (BP) Systolic/Diastolic Normal < 120 / < 80 Pre-hypertension 120-139 / 80-89 Stage 1 hypertension 140-159 / 90-99 Stage 2 hypertension >160 / >100 *Patients should be allowed to sit in a chair. Kussmaul s respirations are seen in patient with diabetic acidosis and renal failure. with continuation of this cycle. as found in asthma or emphysema. recovering from anesthesia. rattling sounds heard on auscultation of the lungs by partial obstruction -Stertor: snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi -Stridor: crowing sound on inspiration caused by obstruction of the upper air passages. The arm should be elevated in either position so that the brachial artery site for the reading is at the level of the right atrium. This type of breathing often leads to hypoxemia (decreased levels of oxygen in the blood). Prop the arm on a pillow when using the supine position. with fever and metabolic acidosis. then slower and are followed by a period of no breathing. Some Terms Used to Describe Adventitious Lung Sounds -Crackles: abnormal. Respirations are faster and deeper. *Cheyne-Stokes respirations: consists of a pattern of dyspnea followed by a short period of apnea. the patient should rest supine for at least 1 minute before the measurement is taken. used on fingers.*Bradypnea: slow and shallow breathing. Such changes from the normal respiratory pattern or breathing should be reported immediately. It is seen in critically ill patients with brain conditions. *Hyperventilation: pattern of breathing where there is an increase in the rate and the depth of breath and carbon dioxide is expelled. causing the blood level of carbon dioxide to fall. results when a limited amount of air is exchanges and less oxygen is taken in. in patients with heart or kidney failure. If taking a supine pressure. also called rales. toes Blood Pressure: the measure of effectiveness of the heart contractions. as occurs in croup or laryngitis. nonmusical sound heard on auscultation of the lungs during inspiration. Pulse Oximetry: measures oxygen levels (aka O2 sat). -Wheeze: whistling sound of air forced past a partial obstruction. and drug overdoses.

thus increasing BP Head Injury: Injuries to head causes increase to intracranial pressure increasing BP Reduced Blood Volume: Decreased blood volume = decreased blood pressure Increased Blood Volume: Too much fluid in the cardiovascular system = increase BP Pain P-provoking factors (after eating. prostheses -ALLERGIES food. *Medication: Medications that lower blood pressure include: narcotics. worry and stress blood pressure by stimulating the sympathetic nervous system. which causes vasoconstriction and a result of increased heart rate. anti-hypertensives. Left arm Right v. estrogen. It is highest in older adults because of a decrease in the elasticity of vessels. and corticosteroids (prednsone). *Sex *Environment: A hot environment can lower BP.timing (when did it start. dull) R-region/radiate (where?) S. drug.quality (sharp. which causes increase in resistance to blood flow. Left leg: there is a difference of 10-40 mm Hg in systolic blood pressure between measurements taken using the arm and leg. a cold environment can raise BP. Medications that raise blood pressure include: antihistamines. tranquilizers.*The cuff size can lead to errors using the wrong size produces errors as large as 25 mm Hg. VISUAL or HEARING IMPAIRMENTS -dentures. pain. Factors that Influence Blood Pressure *Age: Newborns & infants have the lowest blood pressure.severity (on a scale of 1-10) -any other Symptoms (does your heart beat faster. Vasodilation: Causes blood vessels to increase in diameter. *Stress & Emotions: Anxiety. do you feel shaky) T. *Exercise: BP increases with activity *Body Position: BP is lowest in recumbent positions and highest in the standing position. when you breathe) Q. or other . thus lowering blood pressure Vasoconstriction: Causes blood vessels to decrease in diameter. diuretics. tension. BP increases as age increases. when did it stop?) Chapter 22: Assessing Health Status 12/16/10 3 Types of Health Assessment 1) Complete Health Assessment (MD office or new admission) 2) Focused Health Assessment (emphasis on key 3) Emergency Health Assessment (immediate focus on chief complaint) Assessment *Social Data -martial status. *Right v. occupation.

lean. answers questions *Orientation to person. rashes. amputations. monotone. inappropriate. etc. etc) -Skin color -Dressed appropriate to situation -Describe personal hygiene Breathing -State status/ease of breathing (no respiratory distress. seated. She is attentive and her thought process is coherent and logical. current and past *Reason for admission -Physical data -Head/neck. Palpation: performed using the hands and finger tips to touch and feel various parts of the body *Size.) -Follows commands. sleepy. obese. temperature. etc. clear Distress/Deformities: -Describes if client is in acute distress or not (physical/emotion/mental distress) -Note if deformities are present (kyphosis.-Medications being taken (including OTC and herbal supplements) *Diet (any limitations or special food) *Smoking *Use of Alcohol *Activities of Daily Living *Previous surgeries *Health problems. pressured. calmly. musculoskeletal. lesions. scars. reports anxiety related to upcoming Social Studies test. Her respirations are increased at 28/min with no noted skin or physical bodily deformities. chest. right-handed female: observed unkempt. She is cooperative and appropriate. contour of body. turgor *Presence of muscle spasm/rigidity *Pain. labored breathing) COMAS-Rapid Mental Status Assessment *Describes level of Consciousness and level of Cognition (alert. sitting. asymmetry. no eye contact. time and place *Describes short term Memory and long term memory as intact or impaired *Describes Affect (behaviors in present situation laughing. deformities Initial Observation and Rapid Mental Status Assessment Appearance -Male or female -Describe posture. moisture of skin. flat. sneering.) *Relates if Speech is forced. shape. skin deformities) Example of a quick 2 minute Rapid-Mental Status Assessment: Adolescent Caucasian. loud. body contour (erect. skin tone/color. endocrine Inspection & Observation *Visual-general appearance. reports her mood as frustrated and discouraged: her affect is congruent and her speech is WNL. tenderness or swelling (edema) *Restriction In body part movement . fast. abdomen. She is accompanied by her mother and she is oriented x 3. slouched. clamy/sweaty to touch. position of body parts *Texture. genitourinary.

abdomen (bowel sounds) . heart sounds (use the bell for some abnormal heart sounds).Percussion: another method of obtaining information about body structure. Particularly useful for: lung sounds (all lung lobes). location. Light. quick tapping on the body surface to produce sounds. *Variations in the sounds reflect characteristics of organs or structures below the surface Determines: size. density of organs Auscultation: listening to presence or absence of body sounds using a stethoscope.