NUR 2092 Final Exam Concepts: Health Assessment Latest Update 2023/2024

NUR 2092 Final Exam Concepts: Health Assessment 1. Know the difference between subjective and objective data. (I will scream if you all get these wrong! :)) • Subjective: What a person says about themselves o Example: “My BP was 118/90 yesterday” and pain • Objective: What you observe through measurement, inspection, palpation, percussion, and auscultation o Examples: Meter readings, vital signs, and measurements 2. Barriers to communication. What are they? • The use of jargon • Emotional barriers and taboo • Lack of attention, interest, distractions, or irrelevance to the receiver • Difference in viewpoint • Physical barriers to non-verbal communication • Physical or mental disabilities (Physical: Hearing problems. Mental: Down Syndrome) • Language differences and difficulty understanding unfamiliar accents • Cultural difference. 3. Traps of interviewing-Chapter 3 • Providing false assurance or reassurance • Giving unwanted advice • Using authority • Using avoidance language • Distancing • Using professional jargon • Using leading or bias questions • Talking too much • Interrupting • Using “why” questions 4.Open ended questions vs closed ended questions. Know the difference and when to use them during the interview process. • Open ended: Questions asking for narrative information o When to use them: ▪ Use it to begin the interview ▪ Introduce a new section of questions ▪ Whenever the person introduces a new topic • Closed (direct) questions: Asking for specific information. Elicit a short, one- or two-word answer, a “yes” or “no” or a forced choice. o Used in an emergengy to obtain information quickly 5. Components of a Health History -Chapter 4. Know this Chapter!! • Initial information • Chief complaint • Past medical history • Family history • Social history • Review of systems • Physical exam 6. General survey and what it consists of. • Initial inspection • Observe posture • Hygeine • Facial expression • Assess breathing • Behaviors • Body language o Appearance o Body Structure and mobility o Behavior 7. Skills requisite of physical exam. Chapter 8. Know the correct order for assessment. (Inspection, palpation etc). Know the different order for abdominal exam. • Order: o Inspect o Palpation o Percussion o Auscultation ▪ Abdomen: • Inspect • Auscultation • Percussion • Palpation 8. Know the normal range of respirations. Above and below that range, what's it called? • Normal Range: 12-20(21) • Dyspnea: Shortness of breath; 12 • Tachypnea: Abnormally rapid breathing; 21 9. Lung sounds- Know difference between normal vs abnormal and where they are heard. 10. Characteristics of pulse and how to document it. • Rhythm: Normal regular, even tempo o Rating: ▪ Force: • 3+: Full, bounding • 2+: Normal • 1+: Weak, thread • 0: Absent 11. Blood pressure cuff sizes and impact on blood pressure readings. • Cuff sizes: o Too small: Falsely high BP due to extra pressure to compress artery o Too large: Falsely low BP due to not being able to cut off blood vessel properly 12. Changes in blood pressure in the elderly caused by what? 13. Assessment of ALL pulses and their locations. (Apical, radial, popliteal, etc) • Temporal • Carotid • Apical (5th ICS, L Mid clavicular) • Brachial • Radial • Femoral • Popliteal • Posterior Tibial • Dorsalis pedis 14. Carotid pulse- location and abnormality is called? 15. How does the physical assessment differ of newborn , toddler, adolescent and elderly. What is important to consider with each stage? What to do differently when performing exam with each age group? 16. Diastolic vs Systolic. Know the differences. • Systolic: Pressure is maximum pressure felt on the artery during left ventricular contraction • Diastolic: Pressure is the elastic recoil, resting, pressure that the blood exerts constantly between each contraction 17. What is PERRLA? 18. Psoriasis- what is it? Location on body commonly found? 19. Musculoskeletal -know different muscle movements. (Flexion, extension, etc) 20. Skin lesions- Malignant vs Non Malignant and their characteristics. 21. Know differences of Lordosis, Kyphosis, Scoliosis and Spondylosis. • Lordosis: Excessive inward curvature of the spine • Kyphosis: Forward rounding of the back • Scoliosis: Sideways curvature of the spine that occurs most often during the growth spurt just before puberty • Spondylosis: Osteoarthritis of the spine 22. Functional ability- what is it in the elderly population? What does it mean? How is it addressed? 23. Skin lesions-Chapter 12- know vesicles, papules, macules, cysts, wheals, pustules and know psoriasis as above. How do you document these? Using what to document them? Also, know common shapes and configurations of lesions. 24. Headaches-Migraine vs cluster- signs and symptoms of each 25. Tonsillitis-what is it? Know grading scale used to document them. • Two lymph nodes located on each side of the back of the throat that become inflamed. o Grading ▪ 1+ Visible ▪ 2+ Halfway between tonsillar pillars and uvula ▪ 3+ touching uvula ▪ 4+ touching each other 26. Edema and grading scale used to document the findings. • Fluid accumulating in the interstitial spaces: it is not present normally. o Grading scale: ▪ 1+ Mild pitting; slight indentation; no perceptible swelling ▪ 2+ Moderate pitting; indentation subsides rapidly ▪ 3+ Pitting (Deep); indentation remains for a short time; legs look swollen ▪ 4+ Very deep pitting; Indentation lasts a long time; leg is very swollen 27. Cardiac sounds and location of each. • Aortic (Right 2nd intercostal space) • Pulmonic (Left 2nd intercostal space) • Erb’s point (Left 3rd intercostal space) • Tricuspid (Lower Left sternal border 4th intercostal) • Mitral (Left 5th intercostal; medial to midclavicular line) 28. What is the Glascow coma scale? • Scoring system used to describe the level of consciousness in a person following a traumatic brain injury 29. Cerebellar function tests. • Ask the patient to stand up, place feet together, and close their eyes o Normal findings: Able to stand still without any problem maintaining their position o Abnormal function: Swaying, problems maintaining position • Causes: o Cerebellar ataxia (lack of voluntary coordination of muscle movements) o Aging causes changes in the cerebellum which may manifest problems o Tumors in the cerebellum can disrupt function 30. Cranial nerves and their functions and how to test them. • Cranial Nerve 1: Olfactory; Smell (Sensory) • Cranial Nerve 2: Optic; Vision (Sensory) • Cranial Nerve 3: Oculomotor; Motor- Most EOM movement, opening eyelids. Parasympathetic- Pupil constriction, lens shape (Mixed) • Cranial Nerve 4: Trochlear; Down and inward movement of eye (Motor) • Cranial Nerve 5: Trigeminal; Motor- Muscles of mastication, Sensory- Sensation of face and scalp, cornea, mucous membranes of mouth and nose (Mixed) • Cranial Nerve 6: Abducens; Lateral eye movement (Motor) • Cranial Nerve 7: Facial; Motor- facial muscles, close eye, labial speech, close mouth. Sensory- Taste (sweet, salty, sour, and bitter) on anterior two thirds of tongue. Parasympathetic- tear and saliva secretion (Mixed) • Cranial Nerve 8: Acoustic; Hearing and equilibrium (Sensory) • Cranial Nerve 9: Glossopharyngeal; Motor- pharynx (phonation and swallowing), sensory- taste on posterior one third of tongue, pharynx (gag reflex), parasympathetic- parotid gland, carotid reflex (Mixed) • Cranial Nerve 10: Vagus; Motor- Pharynx and larynx (talking and swallowing). Sensory- general sensation from carotid body, carotid sinus, pharynx, viscera. Parasympathetic- carotid reflex (Mixed) • Cranial Nerve 11: Spinal Accessory; Movement of trapezius and sternomastoid muscles (Motor) • Cranial Nerve 12: Hypoglossal; Movement of tongue (Motor) 31. Testing reflexes and ALL superficial reflexes. 0 No evidence of contraction 1+ Decreased, but still present (hypo-reflexic) 2+ Normal 3+ Super-normal (hyper-reflexic) 4+ Clonus: Repetitive shortening of the muscle after a single stimulation • • Superficial reflex: any withdrawal reflex elicited by noxious or tactile stimulation of the skin, cornea, or mucous membrane, including the corneal, pharyngeal, and cremasteric reflexes. 32. Abdominal exam- What organs are found in each quadrant. • RUQ: o Liver o Gallbladder o Duodenum o R kidney o Adrenal Gland o Head of Pancrease • LUQ: o Stomach o Spleen o L Kidney o Adrenal gland o Body of pancreas • RLQ: o Cecum o Appendix o R ovary and tube o R ureter o R spermatic cord • LLQ: o Part of descending colon o Sigmoid colon o L ovary and tube o L ureter o L spermatic cord 33. Bowel sounds-normal vs abnormal. • High pitched • Gurgling • Cascading sounds • Occur irregularly anywhere from 5-30 times per minutes o Hyperperistalsis- “Stomach growling” (borborygmus) o Hypoperistalsis- lacking sounds within stomach 34. Pain level assessments and differences in the elderly. • Assessments: o Wong-Baker FACES pain rating scale o 0-10 Numeric Pain Rating Scale • Differences: o It is believed to be a normal part of aging o They do NOT want to be a nuisance o Reporting pain will lead to expensive testing or hospitalization o They are hesitant to take pain meds. 35. Range of motion- active vs passive. • Passive range of motion- Amount of motion at a given joint when the joint is moved by an external force or therapist • Active range of motion- When patient moves their limbs by themselves without assistance 36. Know difference between- Tinnitus, vertigo and otitis media • Tinnitus- Ringing or buzzing in the ears • Vertigo- A sensation of whirling and loss of balance; associated with looking from a great height or caused by disease affecting the inner ear or the vestibular nerve • Otitis media- Inflammation of the ear, usually distinguished as otitis externa (of the passage of the outer ear), otitis media (of the middle ear), and otitis interna (of the inner ear; labyrinthitis) 37. Cataract vs glaucoma vs conjunctivitis. • Cataract- Medical condition in which the lens of the eye becomes progressively opaque, resulting in blurred vision • Glaucoma- condition of increased pressure within the eyeball, causing gradual loss of sight • Conjunctivitis- Inflammation of the conjunctiva of the eye (pink eye) 38. Tests used for visual acuity and the difference tests used for toddlers, adolescents, elderly etc. • Test light perception using the blink reflex; the neonate blinks in response to bright light. The pupillary light reflex also shows that the pupils constrict in response to light. These reflexes indicate that the lower portion of the visual apparatus is intact. But you cannot infer that the infant can see; this requires later observation to show that the brain has received images and can interpret them. • 39. Instrumental Activities of Daily Living in the older adult. What activities are considered these? • Instrumental Activities of Daily living o Managing finances o Handling transportation (driving or navigating public transit) o Shopping o Preparing meals o Using the telephone and other communication devices o Managing medications o Housework and basic home maintenance 40. Arterial vs venous insufficiency and changes found in regards to skin. • Arterial insufficiency: wounds occur secondary to ischemia from inadequate circulation of oxygenated blood • Venous insufficiency: wounds occur secondary to inadequate functioning of the venous system 41. Care giver burn out-signs of this? • Withdrawal from friends, family, and other loved ones • Loss of interest in activities previously enjoyed • Feeling blue, irritable, hopeless, and helpless • Changes in appetite, weight , or both • Changes in sleep patterns • Getting sick more often • Feelings of wanting to hurt yourself or the person for whom you are caring • Emotional and physical exhaustion • Irritability 42. Assessing the differences between adult and child's ear canals. 43. Stroke prevention and common symptoms. • ABC’s of stroke prevention o Aspirin; May help lower risk o Blood pressure: control blood pressure o Cholesterol: control cholesterol o Smoking; quit smoking or don’t start • Signs: o Sudden numbness or weakness of face, arm or leg, especially on one side of the body o Sudden confusion, trouble speaking or understanding o Sudden trouble seeing in one or both eyes o Sudden trouble walking, dizziness, loss of balance or coordination o Sudden severe headache with no known cause