Adult Health Assessment Study Guide for Exam 1, Study Guides, Projects, Research of Nursing

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Adult Health Assessment Study Guide for Exam 1

Content: Chapters 1-4, 8-11 & 13

Note: remember this is a guide and does not encompass your entire exam. Every class and professor is different. Chapter 1: Evidence-Based Assessment

1. Subjective and Objective Data: ● Subjective data: what the person says about himself or herself during history taking (e.g., I have a headache) ● Objective data: what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination ● Together with the patient’s record and laboratory studies, these elements form the database which we use to formulate a clinical judgement or diagnosis. Chapter 2: Cultural Assessment
2. Know different cultures and we need to respect them, what is normal in other cultures? Cultural assessment Understanding the basics of a variety of cultures is important in health assessment. It is important to provide culturally relevant health care that incorporates cultural beliefs and practices. By providing culturally competent care, we are able to provide high quality care to our patients including their beliefs. ● Asians: believe in the yin/yang theory, in which health exists when all aspects of the person are in perfect balance. It states that all organisms and objects in the universe consist of yin and yang energy forces. Yin energy represents the female and negative, yang energy represents are male and positive. Asians may visit herbalists, acupuncturists, or bonesetters ● Many Hispanic, Arab, and Asian groups embrace the hot/cold theory, which consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. According to this theory, the person is a whole

● Hispanics may rely on curandero (ra), espiritualista (spiritualist), yerbo (ba), (herbalist), or partera (lay midwife) ● Blacks may mention having assistance from a houngan (a voodoo priest or priestess), spiritualist, or “old lady” ● American Indians may seek assistance from a shaman or a medicine man or woman ● Amish: the term braucher refers to folk healers who use herbs and tonics ● Native American: shaman or medicine man or woman ● Making direct eye contact with others is offensive in many cultures Cultural assessment: instead of narrowly defining what to expect from a certain race or ethnic group, health care providers should complete a cultural assessment by asking questions and providing culturally congruent care. Chapter 3: The Interview & Chapter 4: The Complete Health History

3. Know the difference between verbal and nonverbal behaviors. ● Nonverbal communication: is as important as verbal communication. Includes posture, gesture, face expression, eye contact, foot tapping. nonverbal communication is under less conscious control than verbal communication, it may be more reflective of true feelings. ● Verbal communication: The words you speak, vocalization and tone of voice.
4. What is empathy? Empathy means viewing the world from the other person's perspective while remaining in you. Recognition and acceptance of the other person's feelings without criticism. Empathy is the ability to recognize how someone perceives his or her world. This is helpful when treating patients so you can understand them and their culture.

5. Know what to ask during the interview process, know past medical history, what are you evaluating? This is the interview process ● Interview Process : introduce yourself and state your role, state location, time, cost, expectation, purpose and participation ● Working Phase : gathering data phase, use combination of open ended and closed ended questions ● Termination Phase : ending of an interview. Typically ask the patient if they have any questions before leaving the room and let them know when you will return. Past Health History: surgeries, illness including childhood and chronic illnesses, accidents or injuries, obstetric history, immunizations, last examination date, prescription medications, herbal supplements, and over the counter drugs. Allergies, food, latex, drugs, or contact agents. Use of tobacco, caffeine, or recreational drugs. ● Family History: includes immediate and blood relatives. ● Psychosocial History: patient’s support system and how they cope with stress. ● Spiritual Health: assess rituals and religious practice that patients use to express their spirituality. ● Review of systems (ROS): ask the patient about the normal functioning of each body system and any noted changes. ● Observation and Patient Behavior: observation includes a patient’s level of function, their physical, developmental, psychological, and social aspects of everyday living. ● Diagnostic and Lab Data: the results of diagnostic or lab tests.
6. Open and closed questions & examples ● Open-Ended Questions: asks for narrative information. ➔ Do you have any religious/spiritual preferences that we can support? ➔ What brings you to the hospital? ➔ How does this make you feel?

● Closed or Direct Questions: ask for specific information. The answer could be a “two-word answer”, a “yes” or “no”, or a forced choice. ➔ Are you angry? ➔ Are you Catholic or Christian? ➔ Do you exercise? Chapter 8: Assessment Techniques

7. What are the skills you need to use to get your data during assessment? Physical examination requires use of technical skills through senses to obtain data (sight, smell, touch, hearing). The skills necessary for the physical examination are: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation
8. What is the most common assessment tool you use? How to inspect? The most common assessment tool is inspection, it always comes first. When you inspect, you use your eyes and sense of sight, it is concentrated watching. 9. Know the order of assessment, what skill goes with what sense? (e.g., palpation=touch) Order of assessment: Regular: 1. Inspection: Eyes, sense of sight. 2. Palpation: Hands, sense of touch. 3. Percussion: Ears, sense of hearing. 4. Auscultation: Ears, sense of hearing. When you start with the abdomen: ● Inspection ● Auscultation ● Palpation ● Percussion

How to inspect, palpate (light and deep), percurse, and auscultate? Note: always educate your patients, one method you could use is the teach-back method. ● Inspection: Eyes, sense of sight. ○ Concentrated watching ○ Close careful scrutiny of the individual as a whole and then of each body system ○ Inspection always comes first ○ Requires good lighting, adequate exposure, and occasional use of certain instruments to enlarge the view. ● Palpation: Hands, sense of touch. ○ Assess the following: ■ Texture, temperature, moisture ■ Organ location and size ■ Swelling, vibration, pulsation, or crepitation ■ Rigidity or spasticity ■ Presence of lumps or masses ■ Presence of tenderness or pain ○ Palpation should be performed slowly and systematically. Always begin with light palpation to detect surface characteristics and to accustom the person to being touched. Then perform deep. With deep palpation (as for abdominal contents), intermittent pressure is better than one long, continuous palpation. ○ Different parts of the hands are best suited for assessing different factors: ■ Fingertips: fine tactile discrimination of skin texture, swelling, pulsation, lumps ■ A grasping action of the finger and thumb: detect the position, shape, and consistency of an organ or mass ■ The dorsa of hands and fingers: determine temperature ■ Base of fingers or ulna surface of the hand: for vibrations ● Percussion: Ears, sense of hearing.

○ Tapping the client’s skin with short, sharp, strokes to assess underlying structures. ○ The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ. ○ Percussion has the following uses: ■ Mapping out the location and size of an organ by listening where the percussion note changes ■ Signaling the density (air, fluid, or solid) of a structure by a characteristic note ■ Detecting an abnormal mass if it is fairly superficial (percussion vibration penetrate about 5cm deep) ■ Eliciting a deep tendon reflex using the percussion hammer ○ Percussion Method: ■ Hyperextend the middle finger (sometimes called the pleximeter) and place its distal portion firmly against the person’s skin. ■ Use the middle finger of your dominant hand as the striking finger (sometimes called the plexor. Spread your fingers, swish your wrist and bounce your middle finger off the stationary one. ■ Aim for just behind the nail bed or at the distal interphalangeal joints. ■ The goal is to hit the portion of the finger that is pushing the hardest into the skin surface. ■ Percuss two times in this location using even, staccato blows. Lift the striking finger off quickly; a resting finger dampens the vibration.

● Auscultation: Ears, sense of hearing. ○ Listening to sounds produced by the body with a stethoscope ○ The diaphragm is used most often for high pitched sounds-breath, bowel and normal heart sounds ○ Hold it firmly against the person’s skin ○ The bell is used mostly for soft, low pitched sounds such as extra heart sounds or murmurs ○ Hold it lightly against the persons skin Chapter 9: General Survey

10. General Survey Subjective and Objective Data: ● Subjective data: what the person says about himself or herself ● Objective data: what you measure and observe ➔ Physical appearance: ◆ Age: appears his or her stated age ◆ Sex: sexual development is appropriate for gender and age

◆ Level of Consciousness (LOC): patient is alert and oriented, able to answer questions appropriately ◆ Skin color: color tone is even, pigmentation varies based on genetic background, skin intact with no obvious lesions ◆ Facial features: symmetric with movement ◆ Overall appearance: provide a general state related to presence or absence of distress ➔ Body Structure & Mobility: ◆ Stature: height appears within normal range for age ◆ Nutrition: weight appears within normal range for height and body build, body fat is distributed evenly ◆ Symmetry: body parts look equal bilaterally and are in relative proportion ◆ Posture: person stands comfortably erect as appropriate for age ◆ Position: description of patient's position during assessment ◆ Gait: normal base/foot placement, smooth and balanced walk ◆ Range of Motion (ROM): note full ROM, no involuntary movements ➔ Behavior: ◆ Facial expression-maintains eye contact, expression are appropriate to situation ◆ Mood and affect: patient comfortable and cooperative ◆ Speech: able to articulate words ◆ Dress: appropriate to climate, looks clean, appropriate for patient’s culture ○ Amish: clothes from 19th century ○ Indian women: may wear saris ○ Dress determined by culture should not be labeled as bizarre ◆ Personal hygiene: patient appears clean and groomed appropriately ➔ Measurements: ◆ Weight: measure weight and compare to previous visit ◆ Height ◆ Body Mass Index (BMI): practical marker of optimal weight for height and an indicator for obesity or malnutrition ◆ Waist Circumference: note the measurement at the end of normal expiration. Assess body fat distribution as indicator for health risk

11. Different diseases and deformations (general details, not specific) ● Hypopituitary Dwarfism: Below average growth, immature appearance, chubby body build, prominent forehead. ● Achondroplastic Dwarfism: Most common form of short-limb dwarfism, macrocephaly, spinal lordosis, leg deformity.

● Gigantism: Abnormally large growth due to an excess of growth hormone, excessive growth in height, muscles, and organs.

● Acromegaly: Symptoms include enlargement of the face, hands, and feet. Hormonal disorder that develops when your pituitary gland produces too much growth hormone during adulthood. ● Anorexia Nervosa: Characterized by a distorted body image with an unwanted fear of being overweight. Symptoms include trying to maintain a below normal weight through starvation or too much exercise.

● Endogenous Obesity-Cushing Syndrome: Moon facies, supraclavicular fat pads, buffalo hump, truncal obesity, caused by the adrenal glands producing too much cortisol. Chapter 10: Vital Signs

12. Know normal adult vital signs ● Respiratory rate: 12-20 breaths/min — Don’t let patient know when you’re counting respirations ○ Count for 30 sec and multiply by 2 if respirations are normal, if not, count for a full minute ● Heart rate / Pulse: 60-100 beats/min — Count for 30 sec and multiply by 2 if pulse is normal, if not, count for a full minute ● Temperature: 98.6 F, 37.2 C — Hyperthermia: fever >38.0 C ○ Hypothermia: exposure to cold <36.0 C ● Blood pressure: <120/< mm Hg 13.Know pulse force (0, 1, 2, 3 +) The force of the pulse shows the strength of the heart’s stroke volume. The pulse force is recorded using a three- point scale: 3+: full, bounding 2+: normal 1+: weak, thready (reflects a decreased stroke volume, e.g. hemorrhagic shock) 0: absent
13. Normal blood pressure: systolic & diastolic ● Systolic is the maximum pressure felt on the artery during left ventricular contraction or systole ● Diastolic is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction ● Pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume Normal BP: <120/<80 mm Hg

(First number is systolic pressure, second number is diastolic pressure) 15.Know medical terminology: ● Hypertension: abnormally high blood pressure ● Hypotension: abnormally low blood pressure (acute myocardial infarction “AMI”, shock, hemorrhage, vasodilation, and/or Addison’s disease) ● Orthostatic Hypotension: a drop in systolic pressure of > mm Hg or diastolic pressure >10 mm Hg after changing to a standing position ● Tachycardia: a more rapid heart rate, over 100 beats/min. ○ Occurs normally with anxiety, increased exercise, fever, sepsis, pneumonia, myocardial infarction, and pancreatitis ● Bradycardia: in the adult a resting heart rate is less than 60 beats/min. ○ It may be normal in patients with heart disease who are taking medications with chronotropic. ○ It also occurs normally in the well-trained athlete. ● Tachypnea: rapid respiratory rate ● Hyperventilation: rapid or deep breathing, usually caused by anxiety or panic ● Hypoventilation: breathing that is too shallow or too slow Chapter 11: Pain Assessment

16. Know the scales of pain assessment (focus on numeric and face pain scales) Pain-rating scales are unidimensional and intended to reflect pain intensity. ● Numeric rating scales: ask the patient to choose a number that rates the level of pain for each painful site, with 0 being no pain and 10 indicating the worst pain ever experienced

● Verbal Descriptor Scale: uses words to describe the patient’s feelings and the meaning of the pain for the person ● Visual Analogue Scale: lets the patient make a mark along a 10 cam horizontal line from “no pain” to “worst pain imaginable” ● Simple Descriptor Scale: lists words that describe different levels of pain intensity such as no pain, mild pain, moderate pain, and severe pain. It is alternative for older adults that find the numeric rating scale difficult ● Face Pain Scale-Revised (FPS-R) has six drawings of faces that show pain intensity, from “no pain” on the left (score of 0) to “very much pain” on the right (score of 10). We usually use it with kids or with patients that can not talk

17. What is referred pain? Referred pain is pain that is felt at a particular site but originates from another location Chapter 13: Skin, Hair, and Nails 18.Know assessment of the skin ● Inspect and palpate: ○ General pigment: observe skin tone. Is it even and consistent with genetic background? General pigmentation is darker in sun- exposed areas. ○ Widespread color change: note color changes such as erythema (red), cyanosis (blue), jaundice (yellow), pallor (white). In dark skinned people the amount of normal pigment may mask color changes. Reliable sites to check for changes are under the tongue, the buccal mucosa, the palpebral conjunctiva, and the sclera. ● Use ABCDE to determine abnormal characteristics of pigmented lesions (see question 27) ● Temperature (use back of hands to palpate) ○ Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status. ○ Hands and feet may be slightly cooler in a cool environment.

● Moisture: normally, skin is dry to the touch. ○ Diaphoresis: profuse sweating ○ Dehydration: lack of moisture ● Texture: normal skin feels smooth, firm, and even ● Thickness: epidermis is uniformly thin ● Assess for edema. Edema is fluid accumulating in the intercellular spaces. To check for edema, imprint thumbs firmly against the ankle malleolus or the tibia. Normally the skin surface stays smooth. If your pressure leaves a dent in the skin, “pitting” edema is present. -Edema scale rate: 1+ Slight/mild indentation. No noticeable swelling 2+ Moderate indentation subsides rapidly 3+ Deep pitting, indentation remain for a short time 4+ extreme deep pitting, indentation lasts for a long time ● Assess mobility & turgor: pinch up a large fold of skin on the anterior chest. ○ Mobility is the skin’s ease of rising ○ Turgor is the skin’s ability to return to place when released ● Assess vascularity or bruising: any bruising should be consistent with the expected trauma. Document the presence of any tattoos on the patient's chart. ● If any lesions are present, note the: ■ Color ■ Elevation: flat, raised, or pedunculated ■ Pattern or shape: the grouping or distinctness of each lesion (e.g., annular, grouped, confluent, linear). The pattern may be characteristic of a certain disease ■ Size: in centimeters, use a ruler to measure. Avoid household descriptions (e.g., pea size) ■ Location and distribution: is it generalized or localized to area?

■ Exudate: note its color and any odor Lesions are classified into primary and secondary. (Refer to questions 35 & 36) ● Detect any changes in light and dark skin. Be aware of normal variations for the following variables: (refer to question 33) ➔ Pallor (white) ➔ Cyanosis (blue) ➔ Erythema (red) ➔ Jaundice (yellow) ➔ Brown-tan (brown)

19. Know the skin layers, what lies in each layer and what they contain (slide 4)? -Epidermis: ● Most superficial layer, thin/tough protective barrier. ● Major Components: Melanin (Responsible for color/tone of skin and protect against harmful UV Rays) & Keratin (waterproof). Also contain langerhans and merkel cells ● Replaced every 4 weeks -Dermis: ● Beneath the epidermis as an inner supportive layer. ● Consist of Collagen ● Contains blood vessels, nerves, sensory receptors, hair follicles, sebaceous (secrete sebum through the hair follicles in scalp, chin, and face) and sweat glands

-Hypodermis (AKA subcutaneous tissue) ● Stores fat for energy ● Provide insulation for temperature control ● Aids in protection with its cushioning effect ● Contain adipose/fatty tissue Integumentary System

20. Know sweat glands and sebaceous glands Sweet glands:

● Eccrine Gland: are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Produce sweat through the pores. NOT connected to the hair follicles. ● Apocrine Gland: produce a thick, milky secretion and open into the hair follicles. They are located in the axillae, anogenital area, nipples and navel. They become active during puberty. Bacteria feed on the gland, producing body odor. Connected to the hair follicle. Sebaceous glands: connected to the hair follicle and secretes sebum which lubricates the hair. They are NOT sweat glands.

21. What is the epidermis made of? Melanin and Keratin 22.Nails are made of Keratin

23. Hair types: terminal, vellus hair. ● Terminal: the darker, thicker hair that grows on chin, face, chest, eyebrows, pubic area. It is seen after puberty. ● Vellus: fine hair, faint that covers most of the body except palms and soles.
24. What are the functions of the skin? ● Regulate body temperature ● Prevents Penetration (barrier that prevents microorganism to enter) ● Wound Repair ● Communication (Emotions expressed in the sign of face and body posture) ○ Ex. Blushing/blanching ● Absorption and excretion (Ex. minerals, sugars, amino acids, cholesterol ● Production of vitamin D (Light UV converts cholesterol to vitamin D) ● Identification (self image, facial characteristics) ● Skin is waterproof because of the keratin, protective, and adaptive 25.Skin in the aging adult ● Elasticity: with aging, the adult loses elasticity resulting in skin folds and sags. The skin recedes slowly or “tents” and stands by itself

● Sweat and sebaceous glands decrease in number and function, leaving skin dry ● Wound healing is delayed ● Skin turgor decreases in older adults due to less elasticity ● A loss of elastin, collagen, and subcutaneous fat and reduction in muscle tone occur. The loss of collagen increases the risk for shearing, tearing injuries ● Senile purpura: discoloration due to increasing capillary fragility ● Skin breakdown due to multiple factors: cell replacement is slower and wound healing is delayed ● Hair: functioning melanocytes decrease, leading to gray fine hair. Starts to feel thin and fine. ● Senile Lentigiles are a common variation of hyperpgimation. They are clusters of melanocytes that appear after extensive sun exposure.

● Keratoses: are raised, thickened areas of pigmentation that look crusted, scaly and wary. ○ One type is: Seborrheic Keratoses (looks dark, greasy and stuck on). They don't become cancerogenous ○ Another type is: Actinic (senile or solar) keratosis is less common. These lesions are red-tan scaly plaques that increase over the years. They occur on sun exposure surfaces. They are premalignant and may develop into squamous cell carcinoma

● Acrochordons: or skin tags are overgrowth of normal skin that form a stalk and are polyp-like. They occur frequently on eyelids, cheeks and neck, axillae, and trunk ● Sebaceous hyperplasia: raised yellow papules with a central depression. They are more common in men, occurring over the forehead, nose, or cheeks. They have a pebbly look

26. How to assess subjective and objective data for skin? Subjective Data Questions: ➔ Past history of skin disease, allergies, hives, psoriasis, or eczema ➔ Change in pigmentation ➔ Change on mole (size or color) ➔ Excessive dryness or moisture ➔ Pruritus ➔ Excessive bruising ➔ Rash or lesions ➔ Medications ➔ Environmental or occupational hazards ➔ Skin problems: pimples, blackheads (adolescents) ➔ Aging adults: what changes have you noticed in your skin in the past few years? Any delay in wound healing? Any change in feet?, Any falling?, History of diabetes or peripheral vascular disease Objective Data: ➔ Try to control external variables that may influence skin color ➔ The skin holds information about the body’s circulation, nutritional status, and signs of systemic diseases ➔ Skin assessment is integrated throughout the complete exam ➔ At the beginning of the exam, assessing the person’s hands and fingernails is a nonthreatening way to accustom him/her to your touch ➔ As you move through the exam, scrutinize the outer skin surface first before you concentrate on the underlying structures