Health Assessment Exam 3

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servinggod247
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267921
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Health Assessment Exam 3
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2014-03-25 16:41:04
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health assessment
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  1. at risk for aspiration of foreign bodies
    Right mainstream bronchus/Right lung
  2. most appropriate lighting for inspection
    Bright tangential lighting
  3. how to assess respirations
    • rate
    • quality 
    • pattern
    • while palpating pulse
    • chest rise
  4. normal respiration rate
    regular and comfortable 12-20
  5. bradypnea
    slower than 12
  6. tachypnea
    faster than 20
  7. hyperventilation
    faster than 20 with deep breathing
  8. breath sounds are characterized by
    pitch, intensity, quality, and relative duration of their inspiratory and expiratory phases
  9. Vesicular breath sounds
    breach sounds that are low-pitched, low-intensity sounds heard over healthy lung tissue
  10. Bronchovesicular breath sounds
    sounds are heard over the major bronchi and are typically moderate
  11. sighing
    frequently interspersed deeper breath
  12. air trapping
    increasing difficulty in getting breath out
  13. Cheyne-Stokes-
    varying periods of increasing depth interspersed with apnea
  14. Kussmaul
    rapid, deep, labored
  15. biot
    irregularly interspersed periods of apnea in a disorganized sequence of breaths
  16. ataxic
    significant disorganization with irregular and varying depths of respiration
  17. which sounds are heard best with which part of the stethoscope
    diaphram- apex to base for lungs- high pitched sounds
  18. Most effective percussion position
    patient sitting with head bent forward, arms bent forward, arms in front folded
  19. Fine crackles
    high pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by cough
  20. medium crackles
    lower, more moist sound heard during the midstage of inspiration
  21. Coarse crackles
    loud, bubbly noise heard during inspiration; not cleared by cough
  22. Rhonchi (sonorous wheeze)
    loud, low coarse sounds like a snore most often heard continuously during inspiration or expiration: coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)
  23. Wheeze (sibilant wheeze)
    musical noise sounding like a squeak; most often heard continuously during inspiration or expiration
  24. Pleural friction rub
    dry, rubbing, or grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface
  25. liver location
    upper right quadrent
  26. pancreas location
    under and behind stomach
  27. spleen location
    upper left quad below kidney
  28. stomach location
    transverse upper abdomen below diaphragm
  29. gallbladder location
    below liver margin at lateral border of the rectus muscle; pear-shaped, saclike organ about 4 inches long recessed in liver
  30. kidneys location
    bilaterally in retroperitoneum and connected to bladder via ureters
  31. 1st thing a pt should do before performing an abdomen exam
    have patient empty his/her bladder before examination
  32. how to relax the abdomen
    use supportive pillows
  33. order of assessment
    • inspection
    • auscultation 
    • percussion
    • palpation
  34. When auscultating for bowel sounds
    • use diaphragm of stethoscope
    • Note frequency and character
    • Clicks and gurgles happen 5-35 per minute
    • Can listen in one place
    • Stomach growling- borborygami
    • Intestinal fluid and air under pressure in early obstruction-high pitched tinkling sounds
    • listen for 5 minutes without sounds
  35. Function of intestine and stomach
    ingest and digest foods; absorb nutrients, electrolytes, and water; and excrete waste
  36. function of stomach
    • Secretes hydrochloric acid and digestive enzymes that breakdown fats and proteins
    • Pepsin-protein
    • Lipase-fats
    • Little absorption takes place in stomach
  37. Connects the stomach to the large intestine.
  38. Completes digestion through the action of pancreatic enzymes, bile, and other enzymes
  39. Nutrients absorbed through the mucosa
  40. Most absorption occurs in the circular folds and villi.
  • Alkaline mucous lubricate the intestinal contents and neutralize acids
  • Live bacteria decompose undigested food residue, unabsorbed amino acids, cell debris, and dead bacteria through a process of putrefaction
  • Connects small intestine to the anus, and water absorption.
  • peristalsis
    moves food along tract under autonomic nervous system controls
  • tendons
    muscles to bones
  • ligaments
    bone to bone
  • synarthrosis
    no movement permitted ex: Cranial suture
  • Synchrondrosis
    joint between epiphysis and diaphysis of long bones
  • Amphiarthrosis
    slightly moveable ex: symphysis pubis, and radius-ulna articulation
  • Diarthrosis (synovial)
    • freely moveable
    • ball and socket, hinge, pivot, condyloid, saddle, gliding, diarthrodial
  • ball and socket
    hip and sholder
  • hinge
    elbow
  • pivot
    atlantoaxial
  • condyloid
    wrist between radius and carpals
  • saddle
    thumb at carpal-metacarpal joint
  • gliding
    intervertebral
  • Fibrous capsule, cartilage, and ligaments (covers ends of opposing bones). Synovial membrane: lines the articular cavity. Synovial fluid: provides lubrication. Bursae—promote ease of motion at points where fiction would otherwise occur. 
  • spinal column
    • cervical
    • thoracic
    • lumber
    • sacral vertebrea
  • goniometer
    measures the angle of the extremity
  • Inspect the wrist for—Contour, position, shape, number and completeness of digits, and finger deviation. Palpate the joints for—Texture, swelling, tenderness, bogginess (squishy), nodules, and bony overgrowths. Assess ROM—Flexion of fingers: expect 90 degrees, Hyperextension of fingers: expect 30 degrees, Flexion of wrist: expect 90 degrees (bend forward), Hyperextension of wrist: expect 70 degrees (up), Rotation of hand: expect radial motion of 20 degrees, ulnar motion of 55 degrees. Assess muscle strength and grip.  
  • s1
    • results from closure of the AV valves
    • indicates the beginning of systole
    • best heard toward the apex where it is usually louder than s2
    • At the base s1 is louder on the left than on the right but softer than s2 in both areas. 
    • It is lower in pitch and a bit longer than s2, and it occurs immediately after diastole
  • the result of closure of the semilunar valves. It indicates the end of systole and is best heard in the aortic and pulmonic areas. It is higher in pitch and shorter in duration than S1. S2 is louder than S1 at the base of the heart, still it is usually softer than S1 at the apex.
  • 1.)   Aortic valve area: second right intercostal space at the right sternal border
  • 2.)   Pulmonic valve area: second left intercostal space at the left sternal border
  • 3.)   Second pulmonic area: third left intercostal space at the left sternal border  
  • 4.)   Tricuspid area:  fourth left intercostal space along the lower left sternal border
  • 5.)   Mitral (apical) area: at the apex of the heart in the fifth left intercostal space at the midclavicular line
  • Thrill
    fine palpable rushing vibration (murmer)
  • Heave
    apical pulse more vigorous than expected
  • Systolic
    closing of valves (AV and semilunar) (Asynchrony-splitting)
  • Diastolic
    filling of ventricals (intensity gallop) inceasing venous return or arterial pressure (client raises leg or squeezes your hand) easier to hear low diastolic sounds. Systolic is loud closing of valves, diastole more quiet from passive filling of blood
  • Closure of aortic valve and closure of pulmonic valve not happening simultaneously.  Heard best during inspiration
  • Feel for the apical impulse and identify its location by the intercostal space and the distance from the midsternal line. The apical impulse should be visible at about the midclavivular line in the fifth left intercostal space but it is easily obscured by obesity, large breasts, or muscularity. The point at which the apical impulse is most readily seen or felt should be described as the point of maximal impulse (PMI)
  • Highest- systole: Lowest-diastole
  • Local obstruction of arteries, just above medial end of clavicle and anterior margin of SCM.  Heart murmur sounds are prolonged extra sounds during systole and diastole caused by insufficient valves while bruits is obstruction in blood flow
  • 4-bounding, aneurysmal          3- full increased           2-expected       1-diminished,barely palable                0-absent, not palpable
  • Be familiar with the 12 cranial nerves and how you would assess them
    • 1-olfactory-smell       
    • 2-optic (vision) snellen and rosenbaum         
    • 3-oculomotor (eye movement) confrontation test                 
    • 4-trochlear (downward eye movement) droopy eyelid                 
    • 5-abducen (lateral eye movement) PERRLA          
    •     6-trigeminal (jaw move) temp, pain, corneal reflex, tremors  7-facial (expressions) symmetry of face, salt/sweet   
    •    8-acoustic (hearing, equilibrium) whisper test, Rinnes test  9-glossopharyngeal (swallow, gag) sour bitter, gag relex           

    10-vagus (reflex) gag reflex

    11- Accessory (movement) traps/ SCM strength           

    12-hypoglossal (speech) tongue movement
  • 1.     Body orients itself to its position in the environment (space)
  • 1.     The sensory and motor fibers at each spinal nerve supply and receive info in a specific body distributution
  • What is included in assessing sensory function?  Coordination and balance? Fine motor skills?
    • 1.     Sensory- Primary: touch, pain, temp, deep pressure, vibration, joint position
    • Cortical: sterognosis, 2 point discrimination, extinction phenomenon
    • Balance- Romberg test, Gait
    • Coordination- rapid rhythmic alternating movement
  • (flex leg at knee and hip when pt is supine then attempt to straighten leg- pain in lower back = positive), 
  • flex knee slightly w one hand and with other hand dorsiflex food- calf pain = positive), 
  • (ask patient with eyes open and then closed to stand w feet together arms at side.  Slight swaying is expected but not to extent of falling-loss of balance = positive), 
  • (hand the pt a familiar object to identify by touch and manipulation), 
  • (blunt pen draw a letter on palm of pt hand for them to recognize)
  • DTR grade
    • 0  no response
    • 1+  sluggish or diminished
    • 2+  active or expected response
    • 3+  more brisk than expected, slightly hyperactive
    • 4+  Brisk, hyperactive, with intermittent or transient clonus
  • Superficial reflexes
    • abdominal
    • cremasteric 
    • plantar
  • Abdominal reflex
    • Patient supine
    • storke each quadrent with end of relfex hammer or edge of tongue blade
    • upper- stroke upward and away from umbilicus
    • lower- stroke downward away from umbilicus
    • Slight movement of the umbilicus toward each area of stimulation should be bilaterally equal
    • A diminished reflex may be present in obese patients
  • Cremasteric reflex
    • stroke inner thigh of male patient (proximal to distal)
    • testicle and scrotum should rise on the stroked side
  • Plantar reflex
    • use end of reflex hammer to storke later side of he foot from heel to ball and then curve across ball of foot to medial side
    • Patient should have plantar flexion of all toes
    • Babinski sign present in children younger than 2( dorsal flexsion of great toe with or without the other toes)
  • Biceps reflex
    • flex patients arm to 45 degrees at elbow
    • palpate biceps tendon in the antecubital fossa
    • place thumb over tendon and your fings under the elbow
    • strike thumb rather than tendon directly with reflex hammer
    • contraction of biceps muscle causes visible or palpable flexion of the elbow
  • Brachioradial Reflex
    • flex patients arm up to 45 degrees and rest their forearm on your arm with the hand slightly pronated
    • strike the brachioradial tendon ( 1-2 in above wrist) directly with reflex hammer
    • Pronation of the forarm and flexion of the elbow should occur
  • Triceps reflex
    • flex arm at elbow to 90 degrees, support the arm proximal to the antecubital fossa
    • Palpate triceps tendon and strike it directly with the reflex hammer, just above the elbow
    • Contraction of the triceps muscle causes visible or palpable extension of the elbow
  • Patellar Reflex
    • flex the patient's knee to 90 degrees
    • suppor upper leg with your hand and allow the lower leg to hang loosely
    • Strike the patellar tendon just below the patella
    • Contraction of the quadriceps muscle causes extension of the lower leg. 
  • Achilles refex
    • patient sitting
    • flex knee to 90 degrees
    • ankle neutral position holding foot in your hand
    • strike tendon at level of ankle malleoli
    • contraction of the gastrocnemius muscle causes plantar flexion of the foot
  • Clonus
    • test for ankle clonus, especially if reflexes are hyperactive
    • Support patients knee in partially flexed position and briskly dorsiflex the foot with your other hand, maintainting the foot in flexion 
    • No rhythmic oscillating movements between dorsiflexion and plantar flexion should be palpated
    • Sustain clonus associated with upper motor neuron disease
  • Monofliament
    • patients eye closed
    • apply in a random pattern in several sites on the plantar surface of the foot and on one site of the dorsal surface
    • Do not test over calluses or broken skin
    • Do not repeat a test site
    • 1.5 seconds per secont
    • When fliament bends, adequate pressure is applied
    • Loss of sensation= peripheral neuropothy 
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