lOMoARcPSD|5967629
lOMoARcPSD|5967629
NUR 3029 Final EXAM Study Guide W2017
Foundations of Health Assessment (Nova Southeastern
University)
Susset H. Alcover - Health Assessment Final Exam: Study Guide
The comprehensive examination will contain 100 multiple questions. Always ask yourself: What are the normal expected assessment
findings? Abnormal assessment findings? (How would I know?) What am I going to do about it? Be prepared to describe the
assessment (findings, technique and procedure). Please include the assessment of the ‘Older Adult’ within each of the body
systems. Use the Nursing Process to guide you!
Health History, Assessment Techniques, General Survey, Pain
o Older adult *
o Communication, Safety: physical & psychological
o VS (including orthostatic changes), Pain, Functional/ADL assessment(s)
o Purpose & techniques (inspection, auscultation, percussion, palpation) (*What would you see, hear, and feel with each body
system?), Use of equipment: (stethoscope: bell & diaphragm, otoscope, ophthalmoscope)
o Health History: Parts of the health history, comprehensive vs. focused assessments
Integumentary
• Older adult (expected changes vs. abnormal changes)
• Primary/secondary lesions (names/descriptions)
Head, Neck, Lymph; Face, Nares, Nails
• Older adult
• Lymph assessment/techniques (normal/abnormal findings)
• Nares- inspection, patency, smell
• Nails, Clubbing
Eyes and Ears
• Older adult
• Eyes: CN testing, Confrontation test, pupillary constriction: direct/consensual constriction, PERRLA, Extraocular muscle
function, cover/uncover test, glaucoma, macular degeneration, cataracts, handheld eye chart testing vs. Snellen Chart,
Corneal Light Reflex, peripheral vision testing, etc…
• Ears: Hearing loss (testing), Otoscope assessment
Respiratory, Cardiac, Peripheral Vascular, and Abdomen
• Older adult
• Breath sounds/anatomical locations, A/P diameter, Adventitious breath sounds: wheezing, rhonchi, rales, crackles, etc…;
Respiratory distress signs/symptoms
• Asthma, emphysema, COPD, atelectasis, pneumonia, chest expansion, pulse oximetry
• Anatomical location of organs, Bruits (all areas), peripheral vascular disease, circulation, arterial/venous insufficiency, S1, S2,
S3, S4 heart sounds; Murmurs: (assessment/etiology/locations); Doppler use, pulse locations, heart failure
• Assessment of spleen, appendix, liver, Costovertebral testing
• Assessment of pain specific to location,
Musculoskeletal Assessment
• Abduction, adduction, flexion, extension, pronation, circumduction etc…
• Spinal curvature(s)
Neurological Assessment
• Cranial Nerves (1-12) (sensory/motor components), Neurological Assessment, Glascow Coma Scale, Unconscious
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patient, Aphasia(s): Broca’s/Wernicke’s, objective/subjective vertigo, syncope, seizures/auras, stroke,
balance/coordination assessment & testing, anatomical landmarks and structures
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HEALTH HISTORY, ASSESSMENT TECHNIQUES, GENERAL SURVEY, PAIN
o Older adult *
◆ DO NOT confuse diminished hearing or vision with confusion
◆ Other general assessments such as gait and balance, weight loss, fat deposition, spinal curvatures abnormalities
(kyphosis), wide pulse range are throughout the study guide ***
o Communication, Safety: physical & psychological
o VS (including orthostatic changes)
◆ Temperature: 35.8 – 37.3 C (96.4 – 99.1 F)
• Abnormal Findings: Thermostatic function of the hypothalamus may become scrambled during illness or CNS
disorders.
◆ Pulse rate: 50-95 beats/min
• Many medications such as medications for heart diseases, slow the heart rate
• Tachycardia occurs with fever, sepsis, pneumonia, MI, pancreatitis
◆ Respirations: 10-20 respirations/ min
◆ BP: 120/80
• SBP increases with age
• BP climbs to a high in late afternoon or early evening, and then declines to an early morning low.
◆ Orthostatic (Postural) Hypotension
• A drop in systolic pressure of > 20 mm Hg with a quick change in standing position.
• Caused by abrupt peripheral vasodilation without a compensatory increase in CO.
• Occur with prolonged bed rest, older age, hypovolemia, and some medications (antihypertensive meds)
o Pain
◆ Subjective
◆ Acute: short term exposure: surgery, trauma, or kidney stones
◆ Chronic: persistent, long term pain, 6 months or longer, it can last beyond 20 years, can be malignant or nonmalignant
exposure: tumors
◆ Pathological pain in older adults not a normal process of aging ***
◆ Pain assessment
• P = Provocative or palliative- what brings on the pain? What were you doing when you noticed it?
• Q = Quality or quantity- How does it feel? Aching, burning, dull … etc.?
• R = Region or radiation- Where is it? Does it spread anywhere?
• S = Severity scale: 1 to 10- How bad is the pain?
• T = Timing or onset- Onset: When did it first occur? Duration: How long did it last? Frequency: How often does it
occur?
• U = Understand patient’s perception of problem- What do you think it means?
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o Functional/ADL assessment(s)
o Assessment Technique
▪ INSPECTION: it is close careful scrutiny, first of the individual as a whole and then of each body system.
◆ When to use it: Assess for symmetry, color
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◆ How is it done: By observing and not touching patient
▪ PALPATION
◆ When to use it: To assess for texture, temperature/ moisture, organ location/size, swelling, vibration/pulsation,
rigidity/spasticity, crepitation, lumps/mass, tenderness/pain.
◆ How to use it:
• Light: for surface
• Deep: for size, density, tenderness
• Bimanual: to cup a body part or organ
• Fingertips: for fine tactile discrimination; skin texture, swelling, pulse, and lumps
• Grasping of finger and thumb: for position, shape, and consistency of organ or mass
• Base of fingers: vibrations
• The dorsa (backs) of hands & fingers: best for determining temperature because the skin here is thinner than on
the palms
▪ PERCUSSION
◆ When to use it: to asses for vibrations, locations and size
◆ How to use it:
• Stationary hand: place your dominant hand flat and hyperextended on patient
• Striking hand: use middle finger of dominant hand as the one to strike. With your striking hand use both index
and middle finger to strike
• Directly: striking hand to skin
• Indirectly: striking hand to dominant hand
◆ Types
• Resonant: pitch- low, Normal lung tissue
• Hyperresonant: pitch-lower, abnormal amount of air in adult, emphysema
• Tympany: pitch-drum, air filled, normal in stomach/ intestine
• Dull: pitch-high, over dense organ ex: liver/ spleen
• Flat: pitch-high, ex: muscle, bone, tumor
o Health History: Parts of the health history, comprehensive vs. focused assessments
◆ Biographic data
◆ Reason for seeking care
◆ Present health history
◆ Past History
◆ Medication reconciliation
◆ Family history
◆ Review of systems
◆ Functional assessments or ADLs
INTEGUMENTARY
o Older adult (expected changes vs. abnormal changes)
◆ Atrophy of skin and loss of skin elasticity; it folds and sags
◆ The outer layer of the epidermis thins and flattens, and wrinkling occurs allows chemicals easily into the blood, so more
