Hesi health assessment combined PDF

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Hesi health assessment...

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HESI Health Assessment Combined.

Nursing Process

ADPIE

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Assess

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Diagnose

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Outcome identification

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Planning

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Implementation

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Evaluation

1. History Taking and Documentations Subjective – What patient says about their history Collect Medical History Collecting data, 4 types •

Complete Health data base

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Episodic or problem-centered database

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Follow up database

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Emergency Data base

2. Assess Pulse in Geriatric Patients May be irregular 50-90 bpm is normal

3. Male Bladder Evaluation •

Note frequency, urgency and noctuira (pee at night)

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Polyuria – excessive

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Oliguria – diminished quantity

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Dysuria – hurts when peeing

4. Gout – Big Toe •

-accumulation of sodium crytals

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Uric acid crystals and joint destruction of the base of the joint of the big toe.

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Gout is most common in men; in women, it usually occurs after menopause.

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Obesity is among the risk factors for gout.

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Inflammation and redness resulting from acute gouty arthritis on the big toe.

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Uric acid crystals in the finger joints result in painful inflammation and stiffness.

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An example of gout affecting the elbow.

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Fluid is withdrawn from the inflamed joint and analyzed for uric acid crystals.

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Fluid obtained from crystal deposits in a patient with gout.

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Stay well-hydrated and reduce alcohol consumption to prevent gout attacks.

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Additional prevention methods include weight reduction and dietary changes.

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Medications can provide some relief from painful gout attacks. •

Gout is a kind of arthritis caused by a buildup of uric acid crystals in the joints. Uric acid is a breakdown product of purines that are part of many foods we eat. An abnormality in handling uric acid and crystallization of these compounds in joints can cause attacks of painful arthritis, kidney stones, and blockage of the kidney filtering tubules with uric acid crystals, leading to kidney failure. Gout has the unique distinction of being one of the most frequently recorded medical illnesses throughout history.

5. Inspection of Limbic Symmetry o ˜Inspect and palpate neck (cont.) o ØSymmetry

o •Head position is centered in midline, and accessory neck muscles should be symmetrical o •Head should be held erect and still o ØThyroid gland o •Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules

6. Mobility (tremor) o ˜Aging adult o ØTemporal arteries may look twisted and prominent o ØIn some aging adults, a mild rhythmic tremor of head may be normal •

•Test cranial nerve XII, hypoglossal nerve, by asking person to stick out tongue; should protrude in midline; note any tremor, loss of movement, or deviation to side

7. Ataxia (Unsteady gait) lack of voluntary coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum. Several possible causes exist for these patterns of neurological dysfunction. Dystaxia is a mild degree of ataxia. •

Could be because equilibrium is off == can cause unsteady gait

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•Smooth, even gait reflects equal leg lengths and functional hip motion

8. Posture and bed rest •

Posture worsen with bed rest.

9. CV assessment for older adult •

May feel dyspnea on exertion (difficulty breathing)

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Common – gradual rise in systolic blood pressure

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Diastolic pressure remains the same

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Some older adult experience orthostatic hypotension – sudden drop in blood pressure when rising to sit or stand

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˜Aging adult (cont.)

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ØHemodynamic changes with aging

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•From age 20 to 60 years, systolic blood pressure increases by about 20 mm Hg, and by another 20 mm Hg between ages 60 and 80 years

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•This is due to stiffening of large arteries, which, in turn is due to calcification of vessel walls (arteriosclerosis)

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†Creates increase in pulse wave velocity because less compliant arteries cannot store volume ejected

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•Overall size of heart does not increase with age, but left ventricular wall thickness increases

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†An adaptive mechanism to accommodate vascular stiffening mentioned earlier

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•No change in resting heart rate occurs with aging

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•Cardiac output at rest is not changed with aging

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•Decreased ability of heart to augment cardiac output with exercise

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•Shown by decreased maximum heart rate with exercise and diminished sympathetic response

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•Noncardiac factors also cause a decrease in maximum work performance with aging: decrease in skeletal muscle performance, increase in muscle fatigue, increased sense of dyspnea

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•Chronic exercise conditioning will modify many of aging changes in cardiovascular function

10. Sensory assessment for older adult •

Cataracts is common

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˜Aging adult

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ØVisual acuity

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•Perform same examination as described in adult section

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•Central acuity may decrease, particularly after 70 years of age; peripheral vision may be diminished

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ØOcular structures

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•Eyebrows may show loss of outer one third to one half of hair because of decrease in hair follicles; remaining brow hair is coarse

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•As result of atrophy of elastic tissues, skin around eyes may show wrinkles or crow’s feet; upper lid may be so elongated as to rest on lashes, resulting in pseudoptosis

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•Eyes may appear sunken from atrophy of orbital fat; orbital fat may herniate, causing bulging at lower lids and inner third of upper lids

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•Lacrimal apparatus may decrease tear production, causing eyes to look dry and lusterless and person to report a burning sensation

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•Pingueculae commonly show on sclera

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†These yellowish elevated nodules are due to thickening of bulbar conjunctiva from prolonged exposure to sun, wind, and dust; they appear at 3 and 9 o’clock positions

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•Cornea may look cloudy with age

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•Arcus senilis commonly seen around cornea

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†Gray-white arc or circle around limbus due to deposition of lipid material

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†As more lipid accumulates, cornea may look thickened and raised, but arcus has no effect on vision

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•Xanthelasma: soft, raised yellow plaques occurring on lids at inner canthus

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†They commonly occur around fifth decade of life and more frequently in women, occur with both high and normal levels of cholesterol, and have no pathologic significance

HEARING ˜Aging adults ØIn aging persons, cilia lining ear canal become coarse and stiff •May cause cerumen to accumulate and oxidize, which greatly reduces hearing

•Cerumen is drier with aging because of atrophy of apocrine glands •Impacted cerumen is a common but reversible cause of hearing loss in older people ØPresbycusis: type of hearing loss that occurs with aging, even in people living in quiet environment •Gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve •Onset usually occurs in 50s and slowly progresses •First notice a high-frequency tone loss •Ability to localize sound is impaired also •Accentuated when unfavorable background noise is present •Auditory reaction time increases after age 70; takes longer to process sensory input and to respond to it

11. Hip Dysfunction Geriatrics •

˜Aging adult

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ØPostural changes include decrease in height, more apparent in eighth and ninth decades

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ØKyphosis common, with backward head tilt to compensate

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ØContour changes include a decrease of fat in body periphery; fat deposition over abdomen and hips

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ØBony prominences become more marked

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ØROM testing proceeds as described earlier

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•ROM and muscle strength much as younger adult, provided no musculoskeletal illnesses or arthritic present

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ØFunctional Assessment

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•For those with advanced aging changes, arthritic changes, or musculoskeletal disability, perform functional assessment for ADLs

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•Applies ROM and muscle strength assessments to accomplishment of specific activities

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•Goal to determine adequate and safe performance of functions essential for independent home life

12. History Taking Geriatrics

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Minimize distractions

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Speak clearly

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Find main complaint

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Get all medications, frequency and dose

13. CV assessment (PMI – Point Maximum Impulse) •

PMI – point of maximum impulse – Apex of the heart

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ØDuring contraction, apex beats against chest wall, producing an apical impulse

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•Palpable in most people, normally at fifth intercostal space, 7 to 9 cm from midsternal line

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•Heart rotated so that its right side is anterior and its left side is mostly posterior

14. Cardiac Sounds: s1 and s2 •

S1: Intercostal space @APEX = systolic pressure

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S2: base of heart = Diastolic Pressure

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ØNormal heart sounds: first heart sound (S1)

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•Occurs with closure of AV valves and thus signals beginning of systole

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•Mitral component of first sound (M1) slightly precedes tricuspid component (T1)

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†Usually hear these two components fused as one sound

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†Can hear S1 over all precordium, but loudest at apex

˜Infants ØRapid rates make it more challenging to evaluate heart sounds •Expect heart sounds to be louder in infants than in adults because of infant’s thinner chest wall. •Also, S2 has a higher pitch and is sharper than S1 •Splitting of S2 just after height of inspiration is common, not at birth, but beginning a few hours after birth

•Murmurs in immediate newborn period do not necessarily indicate congenital heart disease •Murmurs are relatively common in first 2 to 3 days because of fetal shunt closure

15. Percussing for cardiac •

ØPercussion

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•Used to outline heart’s borders, but its use has often been displaced by chest x-ray or echocardiogram

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•Much more accurate in detecting heart enlargement

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•When right ventricle enlarges, it does so in anteroposterior diameter, which is better seen on x-ray film

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•Also, percussion is of limited usefulness with female breast tissue or in an obese person or a person with a muscular chest wall

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•Normally, left border of cardiac dullness at midclavicular line in fifth interspace and slopes in toward sternum as you progress upward, so that by second interspace border of dullness coincides with the left sternal border

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•Right border of dullness normally matches sternal border

16. Carotid Bruit •

˜Neck vessels (cont.)

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ØAuscultate carotid artery

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•For persons middle-aged or older, or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for presence of a bruit

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†This is a blowing, swishing sound indicating blood flow turbulence; normally none is present

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Located next to adam’s apple. (left side) above clavicle.

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Can suggest changed/reduced blood flow due to plaque build up

17. (2) Endocrine Hypothyroidism, Thinning Hair •

Underactive (aging women)doesn’t produce enough thyroid hormone, may need synthetic hormonr

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Can cause hair loss

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Most common cause: Hashimoto Disease – auto immune disease

18. GI – 7 Topics a. Descriptive Terminology b. Melena – Dark Stool Melena is black, tarry feces caused by the digestion of blood in the gastrointestinal tract, and it is common in newborns. GI bleeding or Iron medications c. Abdominal Assessment, •

State the rationale for performing auscultation of the abdomen before palpation or percussion

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Palpation and percussion can increase peristalsis, which would give a false interpretation of bowel sounds d. assess umbilicus •

Midline and inverted

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No discoloration, inflammation or hernia

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Everted = mass/hernia

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Blue = cullens sign, abdnormal bleeding = can predict acute pancreatitis

e. Borborygmi – Rumbling Gurgling Normal sound in the stomach loud, gurgling bowel sounds signaling increased motility or hyperperistalisis, occurs with early bowel obstruction, gasteroenteritis, diarrhea

f. Palpating the gall bladder •

Shouldn’t be palpable

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Tender/enlarged = acute cholecytis

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Non tender/enlarged = gall stones

• g. Rectal Findings •

Abnormal = itching, pain, burning, hemmorhoids –fissure, fistula

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Normal = smooth when palpate, no nodules inside, tight even sphincter

19. (5) Integumentary – Skin a. Mole Change ABCDE Asymmetry Border Color Diameter Elevation

b. Hirsutism = abnormal condition Hirsutism (HUR-soot-iz-um) is a condition of unwanted, male-pattern hair growth in women. Hirsutism results in excessive amounts of stiff and pigmented hair on body areas where men typically grow hair — face, chest and back.

c. Assessing skin for cyanosis -

blue in color = not enough oxygen to tissue = decreased perfusion

d. Facial assessment •

No slouching of one side

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Bruising, lesion, abnormal moles

e. Muscoskeletal Assessment •

Able to feel light touches

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Normal ROM

20. Neurological (5) a. DTR assessment – Deep Tendon Reflex use to detect neurologic response Deep Tendon Reflex – elicit using percussion hammer Neurologic Assessment : ØTest cerebellar function of lower extremities by asking person to run each heel down opposite shin ØElicit deep tendon reflexes: biceps, triceps, brachioradialis, patellar, and Achilles ØNormally these are 1+ to 2+ and are equal bilaterally

b. Mental Status •

A – Appearance (posture, movement, dress)

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B – Behavior (Conscious, Expression, Speech)

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C – Cognition (Orientation, Attention Span, Memory, learning)

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T – Thought Process (perception, anxiety, depression)

c. Neurostatus Stupororous- Neuro stuporous: stuporous = sleep like state: not conscious - low state of conciousness , sleep like d. Rhomberg Signs

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To test equilibrium, ask the patient to stand with arms at the sides, feet and knees close together, and eyes open. Check for swaying, and then ask him or her to close his or her eyes and maintain position.

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The examiner should be close enough to prevent falling if the patient cannot stay erect. If he or she sways with the eyes closed but not when the eyes are open (the Romberg sign), the problem is probably proprioceptive (awareness of body position).

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If the patient sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin.

e. PERRLA = Pupils Equal Round Reacting to Light and Accommodation

21. Cyanosis of dark skin •

Cyanosis is a bluish mottled color that signifies decreased perfusion; the tissues do not have enough oxygenated blood. Be aware that cyanosis can be a nonspecific sign. Do not confuse cyanosis with the common and normal bluish tone on the lips of dark skinned persons of the Mediterranean origin.

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Cyanosis is difficult to observe in darkly pigmented persons. ➔ gray or whitish

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Given that most conditions causing cyanosis also cause decreased oxygenation of the brain, other clinical signs such as changes in the level of consciousness and signs of respiratory distress will be evident

22. Bone Density •

˜Two newer techniques to measure body composition

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ØBioelectrical impedance analysis (BIA)

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ØDual-energy x-ray absorptiometry (DEXA)

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•Both BIA and DEXA measure fat and lean body mass

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•In addition, DEXA measures bone mineral density

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˜Aging adult

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ØBone remodeling is cyclic process of resorption and deposition; after age 40 resorption occurs more rapidly than deposition

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•Net effect is loss of bone density, or osteoporosis

Bone density (or bone mineral density) is a medical term normally referring to the amount of mineral matter per square centimeter of bones. Bone density (or BMD) is used in clinical medicine as an indirect indicator of osteoporosis and fracture risk.

This medical bone density is not the true physical "density" of the bone, which would be computed as mass per volume. It is measured by a procedure called densitometry, often performed in the radiology or nuclear medicine departments of hospitals or clinics. The measurement is painless and non-invasive and involves low radiation exposure. Measurements are most commonly made over the lumbar spine and over the upper part of the hip. The forearm may be scanned if the hip and lumbar spine are not accessible.

There is a statistical association between poor bone density and higher probability of fracture. Fractures of the legs and pelvis due to falls are a significant public health problem, especially in elderly women, leading to much medical cost, inability to live independently, and even risk of death. Bone density measurements are used to screen people for osteoporosis risk and to identify those who might benefit from measures to improve bone strength.

23. (4) neurological

a. MRI head Magnetic resonance imaging (MRI) is a noninvasive medical test that helps physicians diagnose and treat medical conditions.

MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. The images can then be examined on a computer monitor, transmitted e...