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HESI Health Assessment Fortis 2024/2025 already graded A+
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HESI Health Assessment Fortis 2024/2025 already graded A+
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HESI Health Assessment FortisPrioritize the nursing actions - ANSABC rule:
Airway
Breathing
Circulation
two point discrimination: Fingers - ANS2-3 mm
two point discrimination: Palm - ANS10 mm
two point discrimination: Forearm - ANS35 mm
Two point discrimination: Upper arm - ANS39
Cranial Nerves - ANS12 pairs of nerves that carry messages to and from the brain
Nerve I - ANSOlfactory
Nerve II - ANSOptic
Nerve III - ANSOculomotor
Nerve IV - ANSTrochlear
Nerve V - ANSTrigeminal
Nerve VI - ANSAbducens
Nerve VII - ANSFacial
Nerve VIII - ANSAcoustic
Nerve IX - ANSGlossopharyngeal
Nerve X - ANSVagus
Nerve XI - ANSspinal accessory
Nerve XII - ANSHypoglossal
Hips ROM Osteoarthritis - ANSPain increases at night, movement increases pain
Reasons for enlarged spleen - ANStraumatic injury
acute infection (mono)
, referred chest pain, back, mid/upper R section of abd.
Hemorrhoids - ANSpainless, flabby pa-pules, are cause by varicose veins. Thrombosed,
contains clotted blood and becomes painful, swollen, shiny blue mass that itches and bleeds
with deification. Occur with straining stool, chronic constipation, pregnancy, obesity, chronic
liver disease, low fiber diet.
ascites assessment - ANSpathologic increase in fluid in peritoneal cavity- percuss for
dullness and resonance, shifting dullness, fluid wave
breast exam - ANSearly detection is important. Every woman should preform exam monthly,
as soon as menstrual bleeding has ceased or if postmenopausal same date every month.
S1 - ANSthe first heart sound, heard when the atrioventricular (mitral and tricuspid) valves
close, beginning of systole, loudest at APEX
S2 - ANSsecond heart sound,heard when the semilunar valves close, signals the end of
systole, loudest at the BASE
chronic ear infection inspection - ANSuse an otoscope, for adults pull up and back, for
children pull down. Eardrum is yellow amber color, scarring and denting may be present.
Cardiovascular - ANSpalpate cold feet, check pulses in both feet. May indicate arterial
deficiency or oxygen deficit. deep muscle pain in calf, lower leg or foot; intermittent
claudication feels like cramps, numbness, and tingling.
Chronic ear infection inspection - ANSinspect with otoscope. Pull up and back for adults,
down for children. Eardrum is yellow amber color, scarring may be present
Seizure documentation - ANS*Course and duration-when a seizure starts, do you have any
warning signs? What type of sign?
*Motor activity-Where in your body doe the seizures begin? Do they travel through your
body? On one side or both? Does your muscle tone seem tense or limp
Any associated sign-color change in face or lips, loss of consciousness (for how long),
automatism, incontinence
Postictal phase-After seizure do you sleep, have any confusion? Do you have a weakness,
headache, or muscle aches?
Precipitating factors-Does anything seem to bring on the seizure? activity, discontinuing
meds, fatigue, stress?
Do you take any medications?
Coping strategies-How ahve the seizure affected daily life, occupation?
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