Health Assessment Hesi PDF

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Assessment Strategies- 246 HESI Prep Assessment is the first stage of the nursing process. It includes the gathering of a patient’s physiological, psychological, sociological, and spiritual status. Objective and Subjective strategies included. Symptoms- a subjective experience reported by the patient. Signs- an objective finding by the examiner. Inspection-critical observation that requires good lighting. Looks at the color, shape, symmetry, and position of body parts. Palpation- purposeful and careful feeling with hands during the physical examination. Examines size, consistency, texture, location, and tenderness of an organ or body part. Use the palm of hand or fingertips to assess consistency of tissues, alignment and intactness of structures, symmetry of body parts or movements, and transmission of sound and fine vibrations. Back of hand assesses skin temperature. Percussion- method of tapping on a surface to assess the underlying structure’s location, size, or density. The sound changes as the examiner moves from one section to the next. Done with the middle finger of the right hand tapping on the middle finger of the left hand, while the left palm is on the body. Sounds are classified as tympanic, resonant, flat, and dull. A flat/dull sound indicates the presence of a solid mass under the surface. A tympanic/resonant sound indicates hollow, air-containing structures. Auscultation- listening to the internal sounds of the body, usually using a stethoscope. Used to examine the circulatory, respiratory, and gastrointestinal systems. High-pitched tones are best heard with the diaphragm of the stethoscope, while low-pitched tones are best heard with the bell of the stethoscope.

Cardiovascular System AssessPulses (peripheral and JVD) assess bilaterally and compare. Palpable pulses indicate the body and extremities are receiving adequate perfusion. Radial, brachial, femoral, popliteal, tibial, and dorsalis pedal pulses. Capillary refill > 3 seconds Auscultate heart sounds- S1, S2. Listen for intensity, rhythm, duration, and quality of sounds. Evaluate extra heart sounds and murmurs. 5 auscultation points= aortic, pulmonic, Erb’s Point, Tricuspid, and Mitral. Remember that the Apical Pulse is taken at the mitral valve.

Heart rate and rhythm- notice if pulse if increased or decreased with arrhythmias. Blood Pressure- systolic (90-120) and diastolic (60-90). Mean Arterial Pressure (MAP). MAP = x2 diastolic + systolic /3. Example: 120/90 = MAP of 100. Normal range is 70-110. A MAP of 60 and above is necessary to adequately perfuse the kidneys, coronary arteries, and the brain. Report anything under 60. Over 110 indicates excess pressure and should also be addressed. Assess for decreased level of consciousness (LOC) and syncope. A patient that is alert and responsive indicated adequate perfusion to the brain. Urine output- equal of greater than 30 mL per hour. Less than 30 must be reported. Compare intake vs. output and monitor daily weight. Compare,

contrast, and trend all. The kidneys are affected early with decreased perfusion leading to a retention of fluid that puts excess strain on the heart. Moist lung sounds and edema- increased respirations, check oxygen saturation. A patient with heart failure of PVD may have edema or crackly lung sounds present because the pumping action of the heart is not adequate to either return blood to the heart or pump blood to the body. This in combination leads to decreased oxygenation. Pain- angina, MI, PV. Assess to see if pain increases with activity. Chest pain is caused by inadequate oxygen delivery to the heart muscle. Decreased perfusion = decreased oxygenation= chest pain. Skin color- pale, cool extremities, increased temperature (for infections of the heart or heart valve disorders). Pale skin and cool temperatures may indicate inadequate perfusion of the tissues. Labs- electrolytes, CBC, PTT, PT, INR, Platelets, Liver Function Tests, BUN and Creatinine, Lipid Panel, Total Cholesterol Levels, Glucose, C-Reactive Proteins, Homocysteine Level, Urinalysis, Cardiac Enzymes (Myoglobin, Troponin, and CK-MB), BNP. Diagnostic Testing- Electrocardiogram, Echocardiogram, Chest X-ray, Stress Test, Cardiac Catherization, Thallium Scan, Pet Scan, MRI, Transesophageal Echo (TEE), Hemodynamic Monitoring (Art line and telemetry), Central Venous Pressure (CVP) normal is 2-6 mm Hg, Pulmonary Artery Catheter.

Respiratory/Gas Exchange Ischemia- insufficient oxygenated blood flows to the tissues that may lead to cell injury or death. Hypoxia- insufficient oxygen reaches the cells. Anoxia- no oxygen reaches the cells. Hypoxemia- decreased oxygen in the arterial blood. Adventitious breath sounds: Crackles- auscultated during inspiration and does not clear with cough. Occurs when fluid is in airway. Also known as rales. Often heard with pneumonia, heart failure, and atelectasis. Wheezes- constriction. The sounds are from air moving through narrowed passages. Sound is continuous and music-like. Heard with asthma, bronchitis, and/or chronic emphysema (COPD). Pleural Friction Rub- typically on inspiration over inflammation or the pleural area. Described as a grating sound. May present with pain when breathing. Stridor- sounds like a crowing sound. This is high pitched and is heard with croup and epiglottitis. Orthopnea- patient has difficulty breathing unless sitting erect or standing. Results from an increase in pulmonary venous and capillary pressure in the lungs when the patient lies in the supine position and is relieved when the patient is upright. Diminished breath sounds- sound distant due to “trapped air”. Occurs often with COPD. Absent- no breath sounds are heard on the side of a collapsed lung (pneumothorax). Assess lungs with the diaphragm of the stethoscope in both front and back on bare skin if possible. Have patient sit upright unless unable. Start from left to right, comparing and contrasting.

Assess the ABCDsAirway patency Breathing- depressed respirations from anesthesia, lack of mobility, or pain. Circulation decreased- affects oxygenation Developmental changes (LOC). Watch for signs of restlessness or acute confusion, tachycardia, increased or decreased respirations (normal 12-20), elevated BP, color of skin and mucous membranes, shortness of breath (dyspnea).

Labs- ABG, CBC, electrolytes, sputum cultures. Cystic Fibrosis specific labs include sweat chloride test, stool analysis, serum blood glucose for hyperglycemia. Diagnostic testing- pulmonary function test, Chest X-ray, Pulse Oximetry, Chest Physiotherapy, Chest Tubes, Hemodynamic Monitoring, Bronchoscopy, Torancentesis.

Fluid Balance Regulated through intake and output. Intake maintained through the thirst mechanism. The output is regulated by the skin, lungs, GI tract, and kidneys. Watch for deficits and excesses. For deficits (dehydration) assess for:             

Diminished kidney function Elevated temperature Dry mucous membranes Decrease in vascular volume Tachycardia Weight loss Hypotension and syncope Decreased CVP Flattened JVD Decreased urine output or oliguria Decrease skin turgor Decreased peripheral pulse Decreased LOC

Fluid volume excess- assess for:          

Bounding pulse Hypertension Increased CVP Confusion Edema Weight gain Lung crackles Increased respirations and dyspnea, orthopnea Swelling JVD Skin breakdown

Labs: hematocrit, serum osmolality, protein level, BUN, sodium, glucose, urine specific gravity.

Neurological System Problems with perfusion, neurotransmission, and pathology are three categories that affect neurological dysfunction. Assess for signs of cognitive impairment: Significant memory loss, agitation, restlessness Awareness of person, place, time, and situation (Alert and oriented x 4) Can patient identify three or four common objects? Do they show lack of judgment? Can they perform ADLs? Recall the president’s name? Assess for sensory deficits Appearance- manner of dress and grooming Attitude and behavior- appropriate for age? Situation? Mood and affect- emotional state Speech Thought process Perception- hallucinations, illusions Insight- patient’s understanding of their illness Reflex testing Motor assessment- muscle strength, balance, coordination Sensory assessment-sensitivity to touch with various stimuli

If neuro decline is suspected, assess for metabolic changes, UTI, fluid and electrolyte imbalance, glucose regulation imbalance, cardiac output, acidosis, shallow breathing, infection, pneumonia, cerebral edema, hypothermia, or hypothermia.

Cranial Nerve Assessments:          

CN I Olfactory CN II Optic- Snellen chart CN III Oculomotor- pupil size and reaction CN IV and CN VI-Trochlear and Abducens- Check eye movement by following finger movements CN V Trigeminal- palpate jaw and temples while patient clenches teeth. Touch cotton ball to areas of face. CN VII Facial- symmetry and mobility. Frown, smile, lift brows, puff cheeks, ability to identify sour, sweet, salty. CN VIII Acoustic- check hearing acuity CN IX Glossopharyngeal and CN X Vagus- evaluate movement of the uvula and soft palate. Assess gag reflex. CN XI Spinal Accessory- Check movement of head and neck. CN XII Hypoglossal- assess tongue control.

Gastrointestinal Assessment From the mouth headed south! Mouth and throat assessment- inspect for sores, condition of teeth and gums, look under tongue for tumors or lesions, assess for unusual breath odors. Inspect opopharnx for presence/absence of tonsils, and for color, swelling and movement of uvula. Gag reflex. Abdominal assessment- inspect all 4 quadrants for contour, symmetry, abdominal aortic distention, and pulsation. A lower quadrant bulge may indicate a distended bladder. A midline bulge may indicate an umbilical hernia. Assess for abdominal distension. May be caused by obesity, ascites, and obstruction. Obesity- soft and rounded, with sunken umbilicus. Ascites- skin is shiny and glistening, with an everted umbilicus and dilated, prominent veins. Obstruction- visible, marked peristalsis, restlessness, lying with knees flexed, grimacing facial expression and uneven respirations. Auscultation- auscultate BEFORE palpitations and percussion to avoid increasing the frequency of bowel sounds. Bowel sounds best heard with the diaphragm of the stethoscope. Begin in the right lower quadrant and listen to each quadrant in a clockwise pattern for at least 2 minutes. Note the frequency of the bowel sounds. Assess for pain. Assess for frequency and date of last bowel movement. Assess for nausea and vomiting and diarrhea or constipation. Assess for heart burn and acid reflux Watch for signs of bleeding.

Hormone Regulation Pituitary, Adrenal, and Thyroid Glands Assess: Heartrate Respirations Blood pressure Emotional status Temperature Oxygenation Skin Edema Vision Weight loss or gain Sleep patterns Reflexes Peristalsis Energy Appetite Palpation of thyroid gland EKG monitoring Muscle wasting Fluid balance and electrolytes Common Labs and Testing: Thyroid= TSH, T3, and T4, thyroid scan Pituitary= osmolality serum, osmolality urine, assess if client has received contrast agents in the past 4 weeks Adrenal= ACTH stimulation test, Electrocardiogram Critical Values to remember: Overhydration 800 mOsm/kg of H2O Urine Specific Gravity 1.003-1.030 g/mL BUN=8-25 mg/dL

Hormone Regulation Assess: Neuro (Sensory perception)- cerebrovascular disease, vision changes, BP, numbness in distal extremities, facial drooping, arm weakness, speech changes Vision- retinopathy or loss of vision Cardiac (perfusion)- coronary artery disease, hypertension, monitor cholesterol levels, dry skin, cap refill, mottling, EKG (watch for changes in T wave) GI Gastroparesis (Elimination)-assess for constipation and/or signs of obstruction such as vomiting Coping Renal System (elimination)- assess intake and output, creatinine clearance, monitor blood pressure, polyuria, glycosuria, presence of ketones Sensorimotor neuropathy- numbness and tingling, foot ulceration (remember to check between the toes) Knowledge deficit to disease process Nutrition status, polyphagia, muscle wasting Weight gain or loss Infection and immune status- monitor CBC, and signs for infection Fluid balance, increased thirst, electrolyte status (especially potassium) Respiratory status and oxygenation- rate and depth, oxygen saturation Acetone breath Pain- abdominal, neuropathic Skin- redness, breakdown, dryness, wounds (remember to check between the toes) Fatigue and weakness Confusion, agitation Common Labs to remember: Serum Glucose: 70-110 mg/dL (Fasting)

Glycosylated Hemoglobin (HbA1c) Nondiabetic= 4-6% Good diabetic control= 7% Serum Potassium: 3.5-5.0 mEq/L Normal pH=7.35-7.45. < 7.35=acidotic and >7.45= alkalotic

Genitourinary System Fluid balance Pain Signs of infection Tissue/skin integrity- dryness Urinary urgency/incontinence/frequency Cognition/neuro changes Bladder distension Coping skills Electrolytes Urinary retention Nocturia Dehydration or fluid overload Urine color/odor/clear or cloudy Respiratory status- accumulation of lactic acid may result in metabolic acidosis

Labs to remember: Urinalysis Urine culture BUN and Creatinine C-Reactive Protein Erythrocyte Sedimentation Rate Prostate Specific Antigen Blood Cultures 24-hour urine (keep on ice) GFR (Glomerular Filtration Rate) Electrolyte balance CBC/hematocrit and hemoglobin

Mobility History of injury Progression of symptoms Pain Strength, flexibility, joint movement, ambulation, ADLs, trunk support (sitting in chair without support) Oxygenation, respirations, breath sounds, cough, sputum, secretions, use of accessory muscles Bone demineralization, risk of fracture, calcium level, osteoporosis Intake- labs for protein, calcium, pre-albumin. Integumentary, skin breakdown, pressure points, non-blanchable areas, dryness, lesions Lack or decrease in cardiac capacity, vital signs, strength of peripheral pulses, skin color, orthostatic hypotension assessment, look for redness, swelling, pain in legs for signs of deep vein thrombosis (DVT) Elimination- assess bladder and bowel patterns and bowel sounds. Monitor intake and output, urine, and stool. Mentation- boredom, grief, disturbed body image, social needs

HEENT Head: Inspect and palpate for size, shape, and symmetry.   

Hair- growth, distribution, texture Masses- use fingertips to palpate for masses of the scalp, ears, face, throat, and neck Sinuses- palpate for maxillary sinuses and frontal sinuses for tenderness of masses.

Face: observe for symmetry of facial features. Assess CN V and VII Neck:      

Observe movement of cervical spine. Have patient rotate head, shrug shoulders against resistance (CN XI- spinal accessory) Palpate carotid pulses (one at time so you don’t occlude oxygen to the brain) Auscultate carotid with stethoscope for bruits and/or turbulent flow Palpate trachea for midline position Palpate thyroid for masses Palpate lymph nodes for tenderness and swelling

Eyes:         

Inspect and lids, lashes, position, and symmetry of eyes, and symmetry and size of pupils Palpate lacrimal sacs for abnormal tearing or purulent material excretion from the inner canthus area Sclera should be normally white to buff color Conjunctiva should be clear to pink colored, with a shiny appearance Pupils are approximately ¼ the size of the iris. Constrict with light and dilate in the absence of light. Observe for symmetrical reactions Iris-both irises should be the same color, size, and shape Assess CN III (oculomotor), IV (trochlear), and VI (abducens). Convergence=as eyes shift from a far object to a near object, pupils constrict Confrontation- have patient cover one eye and look straight ahead, while you hold your fingers in the peripheral fields; then ask patient to tell you where they see your fingers “upper left, lower right”, etc Visual acuity- Snellen chart for distance. Remember to place them 20 feet from chart. Rosenbaum chart for near vision. Extraocular movements (EOMs)=six movements of the eye which test CN III, IV, and VI. Pupil response= PERRLA (pupils equal, round, reactive to light, and accommodation). Remember that pupils constrict in response to light. Pupils accommodate (constrict) for near vision. Pupils dilate (open) for dimness and distance. Fundoscopic exam would require you

to use a ophthalmoscope to visualize the retina and inner eye structures

Ears: inspect and palpate   

 

Size, shape, position, discharge, or lesion. Tops of ears should line up with the outer corners of the eyes Hearing acuity- normal voice, whisper test, Weber test, Rinne test Otoscopic exam- visualization of the tympanic membrane ™. Normal eardrum/TM is pearly gray in color. Inflamed TM is reddish pink. Assess CN VIII Nose: Observe external structures for shape, size, color, and presence of nasal discharge (note color, amount, and consistency) Palpate for masses or deviations. Occlude one naris (nostril) and assess for obstructions

Mouth and Throat: See Gastrointestinal System

Post-Assessment Strategies Ask patient- “Is there anything else you think it would be important for me to know?” Use nursing instincts to explore intriguing findings in greater depth. Thank the patient for their cooperation. Provide patient with pertinent education. Analyze collected data- abnormal findings and changes since last assessment. Cluster findings into logical groups and localize findings anatomically. Consider the quality of information gathered- is the information reliable? Document the collected data- record the assessment information gathered, record the patient’s health status and treatment, record any patient health education provided and follow-up care....