Health Assessment HESI Notes

Term Definition
What is a good way to gain trust with a toddler during the health assessment? ask about the toy the child is playing with or has brought from home
Levels of immediate priority for treatment ABC, V; airway, breathing, circulatory, cardiac and vital signs
What is the best way to assess mood? How do you feel today?
What are ways to test for mental status? 3 or 4 word recall; draw clock with labels, give a "time" to indicate on the clock
How do you test for cognitive functions? oriented X 3 (person, place, time)
What do you need to know when palpitating hair? If it is dry and brittle, you have to decide if it is disease or chemical processing such as hair coloring
How do you check for adaptation of the eye? You always have your finger so use it
What should you suspect if papillary edema presents capillary congestion and distention? intracranaial pressure; eye is engorged with fluid so brain probably is as well
Conductive hearing loss mechanical dysfunction of middle or inner ear; may be caused by impacted cerumen,foreign bodies, perforated ear drum, pus and otosclerosis (hardening of the ear bones)
What do Rinne and Webber test for? hearing
sensorinureal hearing loss root cause lies in CN 8; can be related to prebycusis (hearing loss that occurs in over 65) and ototoxic drugs
What is a pneumatic bulb used for? used to help dx ear infections in children and infants. If there is no rebound, dx with ear infection; if there is mobility, there is no infection
What is an example of a pathologic reflex? The positive Babinski reflex
What do you need to check for in a patient that is scheduled for an MRI? must screen for any metal implants; fillings & titanium or okay
How do we access level of consciousness? alert & orientation X3; person, place, time
Newborn respiration rates 30-40
1 year respiration rates 20-40
3 year respiration rates 20-30
6 year respirations 16-22
10 year respirations 16-20
17 years respirations 12-20
adult respirations 10-20
bronchophony "99;" normal is soft, muffled, indistinct; abnormal due to pathology, sounds very distinct and close to your ear because of increased lung density
egophony "eee"; normal sounds like "eee"; abnormal sounds like "aaa" over area of consolidation
whispered pectoriloquy whisper "one, two, three"; normal is faint, muffled, and almost inaudible; abnormal is with small amounts of consolidation, whispered voice sounds very clear and distinct but still distant; faint but stills sounds like he is whispering into the stethoscope
normal bronchial (tracheal) breath sounds high, loud, inspiration is less than expiration, harsh, hollow, or tubular, location is trachea and larynx
bronchovesicular breath sounds moderate pitch and amplitude; inspiration = expiration; mixed quality; over major bronchi where there are fewer alveoli are located posterior between scapula especially on right; anterior around upper sternum in 1st and 2nd intercostal spaces
vesicular breath sounds low; soft; inspiration is greater than expiration; rustling sound, like wind in the trees; over peripheral lung fields where air flows through smaller bronchioles and alveoli
What color is associated with tissue hypoxia? blue- cyanosis
What color is associated with carbon monoxide poisoning? cherry red
Fremitus assessment of lungs through vibration intensity felt on chest wall
orthopnea How many pillows do you sleep with? fluid builds up in lungs
rhonchi heard in COPD; low pitched rattling sounds; obstructions or secretions in larger airways
The bell of the stethoscope is used to listen to ________________ pitched sounds low
The diaphragm is used to listen to _________________ pitched sounds high
Hearing impaired and no English speaking people have what types of rights in the hospital environment? Title VI of the Civil Rights Act of 1964
A federal law that mandates that when people with limited English proficiency (LEP) seek health care in health care settings such as hospitals, nursing homes, clinics, daycare, and mental health centers, service cannot be denied.
When using an interpreter with a patient, with whom should the nurse make eye contact with when speaking? the patient
Before sending the patient for an MRI the nurse should assess the patient for? Any metal, or surgical devices
What is the term for ringing in the ears? tennitus
Questions to ask a patient about Tennitus Are you taking any medications?
(pg 330)
How do you know if the antibiotic prescribed for a UTI is working? Ask the patient if they are having any more pain when urinating
What are some reasons a patient would have enlarged lymph nodes? cancer- not painful
infection- painful
Describe PERRL and Accomidation Pupils equal Round and Reflective to light, if just assessing pupils (PERL, or PERRL).
May not have to assess for accommodation but if you did, make sure pupils constrict when eye deviate inward (PERRLA)
what can affect pupil dilation? CNS disease, drugs, and 5% anasocoria
What is the most reliable item to assess a patients 6 cardinal eye movements? your finger
What are the signs of gout? Redness, swelling, heat, pain, and tophi on the toe or ear.
What does the nurse recommend to the patient to help manage gout? Drink lots of water
How does a left ventricular enlargement affect the location of PMI? displaced lower and lateral
What are the signs and symptoms of Heart Failure? fatigue from decreased cardiac output, and worse in the evenings.
Cyanosis or pallor
Edema is dependent when caused by heart failure
Cardiac edema is worse at evening and better in the morning after elevating legs all night
Edema is bilateral
Nocturia
(page 472 blue column)
What valves makes the sound "Lubb" tricuspid and mitral
what valve makes the sound "dupp"? Apical and pulmonary
location of Ulnar artery for Allen tests? occlude both radial and ulnar arteries of one hand. Have patient pump fist till hand turns white, release the ulnar artery if blood flow returns in 2-5 seconds the radial artery is good for cannulation (pg 518)
What does a carotid bruit indicate? turbulent blood flow, as in constricted abnormally dilated, or tortuous vessels (pg 573)
what is the quickest way to assess for perfusion? check the capillary refill
(Process of body delivering blood to the capillary bed)
where is the aortic valve? second right interspace
where is the pulomic valve area? second left interspace
where is the tricuspid valve? left lower sternal boarder
where is the mitral valve? 5th interspace at around left midclaviculare line
when percussing cardiac boarders we are assessing? Heart size
Cyanotic nail beds mean you should assess?
Pink nail beds mean?
O2 saturation /
Normal finding
A clear hallow sound heard over normal lung tissue would make what percussion note? Resonant
How does the disease process affect the nurses assessment of the heart sound? allows listen to the heart where the normal heart sound is supposed to be
What are the anatomical locations to for assessing a patients pulse? Temporal, carotid, apical, brachial, femoral, radial, popliteal, and dorsal pedis
Since Rheumatic fever affects the tricuspid valve, where should you auscultate the TV? at the 4th intercontinental left sternal boarder
How do you assess a patients thyroid? anterior or posterior palpitation
What is a goiter? a chronic enlargement of the thyroid glad due to low amounts of iodine
What is Hirsutism? excessive body hair in females caused my endocrine or metabolic dysfunction (cortocotrophin hormone?)
What are the signs and symptoms for hyperthyroidism? (Graves Disease) shortness of breath, manifested by goiter and exothalamus, heat intolerance, tachycardia, excessive sweating, starring appearance
What are the signs and symptoms of hypothyroidism (Myxedema) edemantous face especially around the eyes, coarse hair, dry skin, puffy hands and feet, coarse facial features, cold intolerance
What type of priority is a patient with sweet fruity breath and why? 1st priority, indicated diabetic ketoacidosis, and is life threatening.
What is Melena? Black stool due to upper GI bleeding
How do you assess Melena? With a H&H Test
(hemoglobin and hematocrit test)
What should you do if you hear borborygmi in the first 2 quadrants of a patient? Continue the assessment in all four quadrants and then document
What is GERD? (Gastroesophegeal reflux disease)
stomach contents leak back up from stomach to the esophagus due to malfunction of LES. Causes erosion to esophageal lining
What is a peptic ulcer? A sore in the lining of the stomach or duodenum caused by corrosion of stomach lining from gastric secretions.
Most commonly caused by H. pylori and long term use of NSAID
Describe an umbilical hernia soft skin covered mass
Protrusion of omentium or intestine through weakened of incomplete closure in the umbilical ring (pg 571)
Where is the gallbladder located, and how does inflammation change it? (pg 574)
Located behind the liver boarder
(smooth, firm, sausage like mass) should be hard to palpate.
An enlarged tender gallbladder indicates acute cholecystitis.
An enlarged non tender gallbladder occurs when its filled with stones or obstruction.
Should be easier to feel if enlarged and should still feel like a sausage.
What reasons would you feel an enlarged spleen? trauma or (pg 574)
acute infection (mononucleosis) moderately enlarged with soft round edges.
Chronic infection will cause the enlargement is firm with sharp edges.
Enlarges down mid-line towards left pelvis
What position is best for a male rectal examination? standing
What is the best position for a female needing only a rectal exam? left lateral
What position should you place a patient needing a vaginal and rectal exam? lithotomy
What is a Murphy sign and what does it indicate? (pg 560)
Indicated inflammation of the gallbladder (cholecystitis).
Place fingers under the liver boarder, then ask the patient to take a deep breath. a possitive sign is the Patient will fill pain and not be able to continue the deep breathing
What should you keep from any patient presenting abdominal complaints? Keep them NPOI
(nothing to eat or drink)
A black stool indicates and a black terry stool (pg 729)
ingestion of iron or bismuth preparations/ upper GI bleeding
A gray or tan stool indicates absent bile pigment (possibly caused by an obstruction)
A pale yellow greasy stool indicates increased fat (steatorrhea) as occurs with malabsorption syndrome
A red stool indicates rectal or colonic bleeding
Jellylike mucus found in stool indicates inflammation
An abnormal enlargement of the spleen is called Splenomegaly
An abnormal enlargement of the liver is called Hepatomegaly
A patient whom only responds to persistent and vigorous shaking and pain has a coma response of? 4 Stupor or Semi Coma
A glasgow coma scale has a total of how many point and the low of how many points? 15 good
3 bad
An abnormal sensation such as burning or tingling is termed Parestesia
On a glasgow coma scale:
Name the eye opening response levels
4 Spontaneous
3 Only to speech
2 To pain
1 no response
On a glasgow coma scale: Name the levels of motor response 6 obeys commands
5 is able to localize pain
4 flexion withdraws from pain
3 Flexion Decorticate Rigidity
2 Flexion Decerebrate Rigidity
1 No response
On a glasgow coma scale: Name the levels of Verbal response 5 Oriented x3
4 conversation is confused
3 Speech is inappropriate (what year is it? lunch)
2 Speech is incomprehension
1 No response
Complete loss of contact between two bone in the joint is dislocation
Two bone in a joint that stay in contact but their alignment is off is sublexation
A shortening of a muscle leading to limited ROM of joint is a contracture
Stiffness or extreme flexion of a joint is termed ankylosis
Name the 4 types of abdominal contours and describe them Flat
Rounded
Scaphoid- abdominal caves in
Protuberant- abdominal distension
how many cigerates are in a pack? 20 (this is for me to remember, lol)
a hemorrhagic spot or blotch in the skin or mucus membrane forming a non elevated rounded bluish purple patch Ecchymosis (bruise)
A minute pinpoint non raised perfectly rounded purplish-red spot caused by intradermal or subcutaneous hemorrhage, which later will turn blue or yellow petechiae
Two pint discrimination test
What are the normal ranges for the following"
Finger
Palm
Forearm
Upper arm
finger: 2-3 mm
Palm: 10 mm
Forearm: 35 mm
Upper Arm: 39 mm
If you are caring for a patient with respiratory distress, the best position to put them in? High Fowlers 90 degree, sitting straight up.
A booming sound that is normal in a young child , but abnormal in an older adult heard over the lungs with increased amount of air as in emphysema is what type of percussion note? Hyperressonant
A musical drum like (kettle drum) sound heard over air filled viscus (such as stomach and intestine) makes what type of percussion note? Tympany
A muffled thud sound heard over a relatively dense organ like the liver or spleen is what type of percussion note? Dull
A dead stop of sound, with absolute dullness heard when no air is present, such as over the thigh muscle, a bone, or a tumor makes what type of percussion note? flat
While examining a patients optic disk you notice redness, congestion, elevation of the disk, blurred margins, hemorrhages, and an absent veniuos pressure, the patient does not seem to have any vision problems. This indicates What, and what is the diagnosis? Indicates intracranial pressure (tumor, hematoma) and diagnosis is Papilledema (choke Disc) (pg 322)
A palpable vibration Generated from the larynx and are transmitted through patent bronchi and the lung parenchyma to the chest wall where they can be felt is called fremitus
When would you see decreased fremitus? When the bronchus is ostructed, pleural effusion or thickening, pneumothorax, or emphysema. Basically any barrier between the sound and the palpation
When would you feel increased fremitus? Occurs with compression or consolidation of the lung tissue (like pneumonia) Increasing the vibration
When stroking a patients sole of their foot there is an extension of the great toe. Indicating there is a type of corticospinal (pyrmidal) tract disease (such as stroke or trauma). What type of reflex is the patient displaying? Babinski reflex
When testing a patients gallbladder, you instruct the patient to to take a deep breath while you press under the liver to palpate the gallbladder. What test is this and what indicates its negative or positive? Murphy sign:
Pain and unable to continue deep breath in is positive.
No pain test is negative
What 3 tests could indicate appendicitis? *Iliopsoas muscle test (patent lay supine, and raises one leg while examiner presses down on thigh)
*Obturator test (patient lays supine with one leg bent at a 90 degree angle with internal and external rotation)
Blumberg sign (rebound tenderness in the RLQ)
What do you call a mosquito bite? Wheal
What do you call hives from an allergic reaction? Urticaria
What things can cause nail clubbing? and what test to you use to evaluate such? Use the profile sign to evaluate.
Occurs with COPD, lung cancer
When conducting a Romberg test you should ask the patient to stand…. with their feet together and eyes closed for 20 seconds.
What can increase the risk of ecchymosis? anticoagulants
Jaundice is caused by an increase in?
And what are the S/S in a light skinned and dark skinned patient?
Increased bilirubin
light skin:
yellow in sclera, hard palate, mucous membrane, and over all the skin
Dark patient:
check sclera near limbus, junction of hand, soft palate, and palms
Carotenemia is caused by an increase in what? And what are the S/S in a light skinned and dark skinned patient? Increase in carotene
light skin:
yellow-orange in forehead, palms, and soles, nasolabial folds. NO yellowing in the sclera or mucous membrane
Dark skin:
yellow orange tinge on palms and soles
How would you assess a patients mood? Ask them:
"How do you feel?"
How do you assess a patients mental status? Ask them:
Name, date ,and place
How do you begin an interview? introduce yourself and state what you will be doing
How do you evaluate a patients judgment? Ask the patient a logical question or goal to show thought process (pg 72)
the 3 or 4 unrelated words test assesses a patients what, and how does it affect people with Alzheimer? ability to lay down new memories (recall every 5, 15, and 30 minutes)
Alzheimer patients can recall 0-1 words
A mini cog test assess a patients what, and how does it affect a patient with dementia? Tests patients ability to plan, manage time, organize activities, and manage working memory.
Dimentia:
1-2 words possible dimentia
0 words = dementia
Drawing abnormal clock indicates cognitive impairment
What are the ranges for BMI?
Underweight
Normal weight
Obesity class 1
Obesity class 2
Extreme obesity
U= <18.5 kg/m
N= 18.5-24.9
OW= 25-29.9
O1= 30-34.9
O2= 35-39.9
EO3= >40
If a patient can not complete one of the tasks on the ADL, they will can not go to the assisted living center, instead they will go to Nursing home
What are the ADL's Bathing
Ambulatory
Toileting
Transfers
Eating
Dressing
What is the purpose of the 24 hour nutritional recall? Its the most popular method for obtaining information about dietary intake
How do you auscultate the lungs of a pediatric patient the same as you would an adult but move accordingly if not sound is heard or faint
if you assess a fever in a pediatric patient what question should you ask the parent? Have you given the child anything to treat the fever?
How would you open the interview during a pediatric assessment? Talk directly to the parent first and essentially "ignore" the child at first to adjust
At what age would it be appropriate to ask the parent of the pediatric patient to leave the room? By age 16
One instrument that's useful for measuring the quality and patterns and is used across the healthcare setting for initial and on going assessment is? The Pittsburg Sleep Quality Assessment (PSQI)
How do you assess cranial nerve I Smell a cotton ball with alcohol or cinnamon on it. One nostril at a time.
Hearing loss caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, or pus is what type of hearing loss? Conductive
Hearing loss caused by presbycusis (a nerve degeneration) that occurs with age or ototoxic drugs is called? Sensorineural
Major blood vessels associated with abdominal bruits aorta, renal artery, iliac and femoral arteries
signs and symptoms of abdominal bruits hypertension; increased back pain; decreased pedal pulses; marked pulsations
2 point discremination fingers 2-3mm; palm 10 mm; forearm 35 mm; upper arm 39 mm; shoulder 41mm
What is the monofilament test used for? thin strip of nylon used to check sensation in peripheral nerves especially in the feet of people with diabetes mellitus or other neuropathic conditions
Signs and symptoms of Parkinsons shuffling gait, pill rolling, tongue protruding, flat affect (masklike); elevated eyebrows, staring gaze, oily skin, drooling
What can affect speech patterns? neurologic, meds, alcohol, sleep deprivation
How can you tell if your patient can speak English? Tell them something and ask them to teach it back to you
What can present with tired face, blood shot eyes, and flat affect? sleep deprivation
What is the relationship between O2 sats and nail clubbing? hypoxia causes nail clubbing; low O2
When you ausculate an adventitious sound in lungs, what else should you assess? get 02 sats
How do you assess cynosis in a darker skin person? mucosa
abnormal findings for posture assessment in bedrest slumping to one side, hunched forward- you would expect them to be sitting upright
cynosis in light skin dusky blue; check nail beds
cyanosis in dark skin dark but dull, lifeless; only sever is apparent in skin; check conjunctivae, oral mucosa, or nail beds
rubar arterial insufficiency
apthous ulcer canker sore; caused by food, stress, fatigue, AIDS patient can get
eschar not a normal finding; check elbows and heels of child, may indicate tying up; suspect abuse
Where can you assess for skin tugor clavical or forearm; abdomen of a baby
arterial ulcer found at toes, metatarsal heads, heels, and ankle; pale ischemic base; well defined edges; no bleeding
venous ulcer found at medial malous; bleeding, uneven edges
kiphosis outward curvature
scolosis s curvature
lordid inward curvature
symptoms of rheumatoid arthritis hurts more in morning; relieved with movement
symptoms of osetoarthritis more pain with movement; heberden and brouchard
How do you assess ROM of knee? flexion and extension in supine position
hot/cold theory the 4 humors : blood, phlegm, black bile, and yellow bile. Describe temperature, moisture, and dryness.
yin/yang health exists when all aspects of a persons life are in balance
natural or holistic forces of nature must be kept in balance or harmony
magicoreligious the world is an arena in which supernatural forces dominate
biomedical or scientific assumes that all events in life have a cause and effect. Human body functions like a machine
amulets are worn to protect from evil eye or evil spirits