Health Assessment Exam 2
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79 terms
Terms | Definitions |
|---|---|
 Infants | palmar gras, stepping reflex, rooting reflex assess appearance, alertness, motor, sensory and pain |
| children | assess behavior such as hyperactivity, history of seizures, headache, eye pain (may indicate ADHD, meningitis, concussion assess dietary intake (caffeine, sugar), signs of abuse |
| signs of abuse | unable to show emotion or responds inappropriately to painful procedures |
| pregnancy | -importance of folic acid supplementation -deficiencies linked to neural tube defects -carpal tunnel, headaches, lower extremity cramps, numbness or tingling in thighs -hyperactive reflexes-may signal preeclampsia |
| older adults | *most are dehydrated->change in mental status -neural impulses are slower, decreased neurons -change in memory, cognitive function, intelligence, processing, requires work up -deficits can be caused by numerous factors (meds, dehydration, infection, illness, nutrition, diabetes, thyroid problems, alcohol, environmental changes, depression, psychiatric disorders) |
| older adults: common deficits | alzheimer's, dementia, diminished reflexes, alterations in hearing, vision, pupillary size and reactivity, skeletal muscles decrease in bulk, muscular atrophy, caution for asymmetrical changes or neurological symptoms *check batteries in hearing aides, stand close and in front and ask y/n questions |
| 5 major tests of nervous system | -Mental status -cranial nerves -motor/coordination -sensory -reflexes |
| mental status | definition: emotional and intellectual functioning *Appearance, Behavior, Cognitive function, Thought process |
| mental status tests | -level of consciousness -orientation -memory: core cognitive function -higher intellect -judgment |
| CN 3,4,6: pupil response importance | sensitive to increasing pressure in the brain -early warning sign of increased ICP |
| unequal pupil size | increased ICP, unilateral brain herniation or stroke |
| pinpoint pupil size | drugs, brain injury |
| dilated pupils | brain herniation (terminal event), anoxia (terminal event), drugs *pt very close to death |
| macule | flat skin lesion 1 cm or less |
| patch | flat skin lesion >1cm |
| papule | raised solid skin lesion 1cm |
| placque | raised solid skin lesion >1cm; wheal, crust, scale |
| raised solid skin lesions | nodule or tumors |
| raised fluid filled skin lesions | -vesicle -pustule -bulla |
| depressed skin lesions | -atrophy -erosion -ulcer -fissure |
| pedunculated skin lesions | -skin tags -horns |
| vascular skin lesions | -spider angioma -purpura -venous star -petechiae -telangectasia -ecchymosis -cherry angioma |
| ABCDs of skin cancer | -Asymmetry -Borders -Color -Diameter |
| infants:skin | newborns, less fat, hypothermia, smooth skin, desquamation at birth, sweat glands at 1 months |
| adolescents: skin | apocrine glands-sweating sebaceous glands-acne terminal hair |
| pregnancy: skin | -skin darkening 90% around face, nipples, areola, axillae, vulva, umbilicus -increased sweating, sebaceous gland activity -vascular spiders, hemangiomas already present can enlarge -skin thickens, fat deposits, striae |
| elders: skin | less sebaceous activity, less sweating, subcutaneous tissue loss, epidermis thins, skin flattens and sags, dermis less elastic, hair migrates, skin cancers |
| anterior neck | -sternoclidomastoid muscle -trachea -thyroid -carotid arteries -jugular veins |
| Inspection of trachea | -trachea is in the midline |
| inspection of thyroid | -is the thyroid visible? -is the thyroid symmetrical? |
| palpation of the trachea | -gently rest fingers to either side of the trachea -observe that it is symmetrically placed in a vertical line with the nose and chin |
| palpating the thyroid | -stand behind client -sit up straight and lean slightly right -push thyroid to the right with left hand -palpate the gland for size and texture -repeat on each side |
| normal finding of thyroid | -no tissue palpable -slight fullness |
| abnormal finding of thyroid | -asymmetry -nodularity -tenderness |
| Preauricular node | node in front of ear |
| post auricular node | node behind ear |
| tonsilar node | node at the angle of the jaw |
| sub mandibular node | node along the jawline |
| sub mental node | node below the chin |
| superficial cervical node | node over the sternomastoid |
| deep cervical chain | chain of nodes deep to the sternomastoid |
| posterior cervical node | node at the hollow of the back of the neck |
| occipital node | node at the base of the skull |
| supra clavicular node | node above the clavicle |
| infraclavicular node | node below the clavicle |
| central node | node deep in axilla |
| lateral node | node along inside of arm |
| anterior node | node at anterior axillary line in front of shoulder |
| posterior node | node at posterior axillary line behind shoulder |
| epitrochlear node | node 2cm above elbow |
| inguinal node | node in the crease of the groin |
| palpating lymph nodes | -do both sides together -use of pads of fingers -moderate pressure |
| normal findings of lymph nodes | -not palpable -smooth, rubbery |
| abnormal findings of lymph nodes | -fixed, stony, hard, matted |
| implications of palpable pre&post auricular nodes | -otitis externa -otitis media -foreign body in canal |
| implications of palpable tonsilar nodes | -tonsilitis -pharyngitis |
| implications of palpable submandibular nodes | -dental, oral lesions |
| implications of palpable cervical nodes | -lymphoma -HIV |
| implications of palpable posterior cervical nodes | -mononucelosis |
| implications of palpable supra/infraclavicular nodes | -breast, mediastinal mass |
| Motor/ Coordination tests | -muscle bulk, tone, strength against resistance in upper and lower extremities -coordination in upper and lower extremities bilaterally with PTP, RAM -cerebellar: gait, balance with romberg |
| sensory tests | -light touch -pain: major skin areas -position sense -vibratory sense |
| reflexes | -triceps -brachial -brachioradialis -patellar -ankle |
| CN 1 | CN for smell |
| CN 2 | CN for basic vision: use snellen chart *pt covers one eye at a time and reads smallest line *test both eyes separately and then together |
| CN 3, 4, 6 | CN's for eye movements Control: lid movement, eyeball movement, pupil response *pt follows hand movement with eyes |
| nystagmus | eyeball flutters after a while |
| strabismus | lazy eye |
| CN 5 | CN trigeminal: FACE -motor: movements of temporal and masseter muscles *clenching jaw and tugging on tongue -sensory: pain and light touch to 3 major dermatomes of the face including buccal mucosa and gums *light touch to forehead, cheeks and jaw -corneal reflex |
| CN 7 | CN facial -observing for symmetry of lower lids, corners of mouth, nasolabial folds *pt smiles, frowns and puffs cheeks |
| CN 8 | CN for hearing -whispering with blocked ear |
| CN 9&10 | CN for glossopharangeal -motor: look in mouth-uvula and soft palate rise in midline -sensory: gag reflex |
| CN 11 | CN for spinal accessory *have pt turn head and shrug shoulders against resistance |
| CN 12 | CN for hypoglossal *tongue protrudes in midline |
| inspection of the nose | -inspect for symmetry of the nasal skeleton -nares patent: ask pt to occlude one side and breathe -nasal mucosa: intact |
| palpation of the nose | -nasal skeleton |
| inspection of tonsils | -inspect for color and lesions, tonsil size and exudate |
| palpebral conjunctiva | transparent membrane lines under surfaces lids -pull down on lower lid and inspect for erythema |
| bulbar conjunctiva | overlies the sclera, clear -patient looks up, down, right and left |
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