NURS 2092 Health Assessment Exam 2 Study Guide.

NURS 2092 Health Assessment Exam 2 Study Guide.

Technical Equipment and Uses:

Stethoscope

• Parts of the Stethoscope
• Bell - for low pitch sounds
• Diaphragm - is used for high pitch sounds

• What is Bronchophony?
• Ask the PT to say 99 while you listen with a stethoscope. If abnormal it will sound more distinct through

the stethoscope then normal.

• What is egophony?
• Ask PT to pronounce 'ee-ee-ee--ee" sound. If the noise changes, it is abnormal.

Health Assessment:

Skills; inspection, palpation, percussion, auscultation

• Assessing Abdominal Tenderness
• 1st inspect, 2nd auscultate, 3rd percuss, 4th palpate
• What step do you do first in physical exam of the abdominal?
• Auscultate before percussing or palpating the abdominal

• Skills in order
• Inspection, Palpation, Percussion, Auscultation
• Palpation uses the sense of touch to assess the patient for these factors.

ii. Inspection involves vision iii. Percussion assesses through the use of palpable vibrations and audible sounds iv. Auscultation uses the sense of hearing

• Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling

when the nurse is as sessing a patient?

• Palpation

• Where do you palpate the

pulses? temporal external Carotids Brachi al Radial Ulnar Aortic Femor al Poplit

eal Dorsalis pedis Posterior tibial

• How many steps and names to the steps of Auscultating HEART SOUNDS?
• Acronym is APETM
• Aortic - 2nd intercostal space, right of sternal border
• Pulmonic - 2nd intercostal space left sternal border
• Erb's point- 3rd intercostal space at the left sternal border
• Tricuspid- 4th or 5th intercostal space at the left lower sternal border.
• Mitral- 5th intercostal space near the left midclavicular line, apex of the heart

Other Assessments: hearing, skin, vision, balance

• Hearing/Ear
• Which way to you pull the ear for adult Vs. child?

Pull the pinna up and back on adult or older child. Pull pinna down for child younger than 3.

• What do you try to locate on the tympanic membrane?

Cone of light

• What is the gross hearing test?

Whisper test

• Visual/ Eyes
• How to test for Visual acuity
• Use the Snellen eye chart. Stand 20 feet away from the chart. Test one eye at a time

anything less than 20/40 should be referred for correction

• Sk

i n a .

Techniques of examination of the skin:

• Note

characteristics of:

Color Edema Moisture Temperatur e Texture Mobility and turgor Lesions

ii. ABCDE of skin assessment A- asymmetry B- Border irregularity C- color D- diameter E- evolution or elevation

iii. Color and Pigmentation 1) Senile lentigines are common variations of hyperpigmentation.

a) Commonly called liver spots , these are small, flat, brown macules - forearms and dorsa of

the hands 2) Acrochordons, or “skin tags,”

a) Overgrowths of normal skin that form a stalk and are polyp-like - eyelids, cheeks and

neck, and axillae and trunk 3) Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty, looks dark, greasy, and “stuck on

a) Develop mostly on the trunk but also on the face and hands and on both unexposed and

sun -exposed areas.

• Balance
• Romberg test - balance test

Assessing Pain

• Initial Pain Assessment

location, duration, quality, intensity, and aggravating/relieving factors.

• PQRST method of pain

Provocation/pallia tion Quality/quantity Region/radiation Severity Scale Timing

3. Headaches:

• Tension(head band)
• Migraine (localized spot in front)
• Cluster (stabbing pains/excruciating)

Vital Signs Tests

• Pulse

a.

Asses pulse for the

following:

Rate Rhyth m Force Elastic ity

• Heart rate normal? And

varies with? 60-100 Age, gender What is Systolic blood pressure?Pressure generated by the left ventricle when the LV ejects blood into the aorta and arterial tree What is Diastolic blood pressure?Pressure generated by blood remaining in the arterial tree, when the ventricles relax

• Irregularities

Tachycardia - 100 plus Bradycardia - 60 below

Abnormal and Deficiencies; Signs and Symptoms

• Abnormal findings caused by nutritional deficiencies

Spongy gums= lack of Vitamin C Rickets (bone softening)= Lack of Vitamin D Glossitis (magenta tongue)= lack of Riboflavin Cheilitis (lip inflammation) & Stomatitis (cracked lip corners)= lack of Riboflavin Pitting edema= lack of Protein

• Signs and Symptoms

➢ pallor: loss of color due to hypovolemia or low hemoglobin

➢ cyanosis: blue tinged skin; central cyanosis is a cardiopulmonary issue, peripheral cyanosis is a vasoconstriction issue

➢ jaundice: yellow tinged skin; associated with liver disease

➢ Acanthosis nigricans: roughing or darkening of the skin in localized areas

➢ erythema: redness and warmth; associated with inflammation and infection

➢ edema: swelling; can be local (pitting) or general (nonpitting)

➢ blanchable - when pressed color return

The Body; Organs, Nerves, Glands, Nodes

• Cranial Nerves

Cranial Nerve I - Olfactory- Smell Cranial nerve II - Optic- visual Cranial nerve III - Oculomotor, eye

To Test: track finger movement

Cranial nerve IV - Trochlear, eye

To test: track finger/ movement