Let's survey
4 types of health assessment
Complete, focused, rapid, follow up
What are the 5 vital signs?
Temperature, pulse/HR, respirations, BP, oxygen sat
PERRLA
Pupils are Equal, Round, Reaction to Light and Accommodation
Location of the apical impulse?
5th intercostal space, mid-sternal line
How many lung lobes on the right side vs left side?
right lung (3 lobes, RUL, RML, RLL), left lung (LUL, LLL).
What is the review of systems?
Signs & symptoms communicated by client
What factors might affect the temperature?
illness/fever, taking temperature incorrectly, client took a hot/cold drink 15 minutes before oral temp (example), exercise
What is the normal finding for pupils? How do you check the reactive?
equal, round, 3-5mm
Shin pen light from the side moving to the pupil then back to the side, normal constrict/smaller
What are some external factors that affect the heart?
weight, diet, smoking, alcohol
children subjected to second hand smoke are at risk for?
•High risk for SIDS, pre-term birth, low birth weight
•Otitis Media
•Asthma
Allergies
What are the 4 areas of a general survey?
•Physical Appearance
•Body Structure
•Mobility
•Behavior
Name 4 different pulse sites?
Radial, Carotid, brachial, femoral, etc. other sites can be named
What does the normal tympanic membrane look like?
◦Translucent, pearly gray in color
What is the best position to assess for JVD (jugular venous distention)?
client lie supine and elevate the HOB 30-45 degrees, with head turned to the side away from the evaluator.
What are the 4 main functions of the respiratory system?
supply oxygen
remove carbon dioxide
maintain homeostasis
maintains heat exchange
What are the 4 assessment techniques?
Inspection, Palpation, percussion, auscultation,
What is the normal respiratory rate? Describe tachypnea vs bradypnea
Normal 12-20
tachypnea >20
bradypnea <12
What is the job of the nose?
Warms, moistens, filters inhaled air
sensory for smell
What symptoms found for right and left heart failure?
Right-dependent edema of lower extremities, enlarged spleen and liver, JVD, ascites
Left-backs up into the lungs, can result in dyspnea, wheezing, productive cough.
type of hyperventilation with deep, rapid breathing may be seen in DKA
Kussmauls
What assessment technique is used when assessing color, symmetry, scars
inspection
Rate the edema that is deep pitting, indentation remains for a short time, leg looks swollen
3+
You are inspecting the mouth of a child. What education can you give the parent/child?
Dental care including visit with dentist
What is the procedure for listening to heart sounds?
With the diaphragm-
Aortic - 2nd ICS R sternal border
Pulmonic - 2nd ICS L sternal border
Erb’s - 3rd ICS L sternal border
Tricuspid - 4th ICS L sternal border
Mitral - 5th ICS L MCL
•Apical impulse = 4th or 5th L MCL
Do it again with the bell
What chest shape might be seen with COPD?
barrel chest
What assessment technique is used when assessing skin temperature, moisture, lumps or masses
Palpation
What should nails be inspected for? How do you perform a capillary refill time?
Inspect the nails for shape and contour
Depress the nail bed and watch for the return of color in 2 or less seconds
define Cataracts, Glaucoma, Macular Degeneration, Diabetic Retinopathy
Glaucoma-cause vision loss/blindness d/t damage to optic nerve
Cataracts – clouding of eye lens
Macular Degeneration disease affects central vision
Diabetic Retinopathy – *eye condition causes vision loss and blindness with diabetics. Affects blood vessels in retina
Name 3 developmental heart changes in older adults?
uLeft ventricular wall thickness increases
uIncreased systolic BP
uDecreased diastolic BP
uRisk for orthostatic hypotension
uAge related changes in the ECG
uCVD is leading cause of death in folks over 65 years
How should the anterior and posterior lungs be auscultated?
Side to side comparison Client should be breathing in each time you move your stethoscope
Anterior--5 lines
Posterior--9 lines