HEALTH ASSESSMENT HESI V.2
1. Low BMI
Body mass index (BMI) is a practical marker of optimal healthy weight for height and an
indicator of obesity or malnutrition. Evidence supports the use of BMI in obesity risk
a
...
HEALTH ASSESSMENT HESI V.2
1. Low BMI
Body mass index (BMI) is a practical marker of optimal healthy weight for height and an
indicator of obesity or malnutrition. Evidence supports the use of BMI in obesity risk
assessment because it provides a more accurate measure of total body fat compared with the
measure of body weight alone.
A healthy BMI is a level of 19 or greater to less than 25.
<18.5 Underweight
18.5 – 24.9 Normal weight
25 – 29.9 Overweight
30 – 39.9 Obesity
>40 Extreme Obesity
2. History taking document
3. History taking geriatrics
Allow for more time
4. Ataxia Asses
Ataxia—Uncoordinated or unsteady gait
A positive Romberg sign occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication),
loss of proprioception, and loss of vestibular function.
Cerebellar Ataxia: Staggering, wide-based gait; difficulty with turns; uncoordinated movement
with positive Romberg sign. Alcohol or barbiturate effect on cerebellum; cerebellar tumor;
multiple sclerosis
5. Melena
Black stools may be tarry due to occult blood (melena) from GI bleeding or non-tarry from iron
medications.
Black tarry stool with distinct malodor indicates upper GI bleeding with blood partially
digested. (Must lose more than 50 mL from upper GI tract to be considered melena.)
6. Rectal Findings
The rectal temperature measures 0.4° to 0.5° C (0.7° to 1° F) higher.
Rectal temperatures are the most accurate route, and the result is as close to core
temperature as possible without using more invasive measures reserved for the operating
room and critical care environments.
Although the rectal temperature provides the closest approximation to core temperature, it is
more invasive than other measures; therefore you must weigh the risks and benefits.
In children the temporal artery route misses fever in as many as 30% of children 6 to 36
months old; therefore it may be advantageous to use rectal temperature in children with a
suspected fever or infection.
The rectal temperature is the preferred route when the other routes are not practical (e.g., for
the comatose or confused person; people in shock; or those who cannot close the mouth
because of breathing or oxygen tubes, wired mandible, or other facial dysfunction).
Wear gloves and insert a lubricated rectal probe cover on an electronic thermometer only 2 to
3 cm (1 in) into the adult rectum, directed toward the umbilicus. (For a glass thermometer,
leave in place for minutes.) Do not let go of the temperature probe while it is inserted into the
rectum. Disadvantages to the rectal route are patient discomfort and the invasive nature of
the procedure.
The rectum, which is 12 cm long, is the distal portion of the large intestine. It extends from the
sigmoid colon, at the level of the 3rd sacral vertebra, and ends at the anal canal. Just above
the anal canal the rectum dilates and turns posteriorly, forming the rectal ampulla. The rectal
interior has 3 semilunar transverse folds called the valves of Houston. These cross one-half the
circumference of the rectal lumen. Their function is unclear, but they may serve to hold feces
as the flatus passes. The lowest is within reach of palpation, usually on the person's left side,
and must not be mistaken for an intrarectal mass.
7. Posture Assess – Bed rest
8. Sleep Assessment
9. Anus Hemorrhoids
Hemorrhoids: These painless, flabby papules are caused by a varicose vein.
An external hemorrhoid starts below the anorectal junction and is covered by anal skin.
When thrombosed, it contains clotted blood and becomes a painful, swollen, shiny blue mass
that itches and bleeds with defecation.
When it resolves, it leaves a painless, flabby skin sac around the anal orifice.
An internal hemorrhoid starts above the anorectal junction and is covered by mucous
membrane. When the person performs a Valsalva maneuver, it may appear as a red mucosal
mass.
All hemorrhoids result from increased portal venous pressure: as occurs with straining at stool,
chronic constipation, pregnancy, obesity, chronic liver disease, or the low-fiber diet common in
Western society.
10. Pulse Geriatric
The normal range of heart rate is 50 to 95 beats/min, but the rhythm may be slightly irregular.
The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition
does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial
wall needs a faster upstroke of blood, so the pulse is actually easier to palpate.
11. HF Older Adult
CVD is the leading cause of death in those ages 65 years and older. Stage 1 hypertension
(systolic >140 mm Hg and/or diastolic >90 mm Hg) and heart failure also increase with age.
Certainly, lifestyle habits (smoking, chronic alcohol use, obesity, lack of exercise, diet) play a
significant role in the acquisition of heart disease.
12. Hip Dysfunction
Pain with motion. Flexion flattens the lumbar spine; if this reveals a flexion deformity in the
opposite hip, it is a positive Thomas test. Limited internal rotation of hip is an early and
reliable sign of hip disease. Limitation of abduction of the hip while supine is the most
common motion dysfunction found in hip disease.
13. Ears Older Adult
In the aging person, cilia lining the ear canal become coarse and stiff. This may cause cerumen
to accumulate and oxidize, which greatly reduces hearing. The cerumen itself is drier because
of atrophy of the apocrine glands.
A life history of frequent ear infections also may result in scarring on the drum.
Impacted cerumen is common in aging adults (up to 57%) and other at-risk groups (e.g.,
institutionalized and mentally disabled), who may underreport the associated hearing loss.
Cerumen impaction also blocks conduction in those wearing hearing aids. Cerumen should be
removed when it leads to conductive hearing loss or interferes with full assessment of the ear.
Ceruminolytics are wax-softening agents that expedite removal with electric or manual
irrigators. After removal, over half of those with impaction passed the whispered voice test.
A person living or working in a noise-polluted area has a greater risk for sensorineural hearing
loss.
Presbycusis is a type of hearing loss that occurs with 60% of those older than 65 years, even in
people living in a quiet environment. It is a gradual sensorineural loss caused by nerve
degeneration in the inner ear that slowly progresses after the fifth decade. The person first
notices a high-frequency tone loss; it is harder to hear consonants than vowels. Much speech
information is lost, and words sound garbled. The ability to localize sound is impaired also.
This communication dysfunction is accentuated when unfavorable background noise is present
(e.g., with music, with dishes clattering, or at a large, noisy party).
14. Crying Cultural Spiritual Interview
A beginning examiner usually feels horrified when the client starts to cry, but crying is a big
relief to a person. Health problems come with powerful emotions, and it takes a good deal of
energy to keep worries about illness, death, or loss bottled up. When you say something that
“makes the person cry,” do not think you have hurt the person. You have just broached a topic
that is important. Do not go on to a new topic.
It is important that you allow the person to cry and express his or her feelings fully before you
move on. Have tissues available and wait until the crying subsides to talk. Reassure the crying
client that he or she does not need to be embarrassed and that you are there to listen.
Sometimes your client looks as if he or she is on the verge of tears but is trying hard to
suppress them. Again, instead of moving on to something new, acknowledge the expression by
saying, “You look sad.” Don't worry that you will open an uncontrollable floodgate.” The
person may cry but will be relieved, and you will have gained insight to a serious concern. Use
of appropriate therapeutic touch can help show empathy while a person is crying.
15. S1 and S2
Identify S1 and S2. This is important because S1 is the start of systole and thus serves as the
reference point for the timing of all other cardiac sounds. You must learn to distinguish systole
from diastole before you can attach meaning to all other sounds. Usually you can identify S1
instantly because you hear a pair of sounds close together (lub-dup) and S1 is the first of the
pair. This guideline works, except in the cases of the tachydysrhythmias (rates >100
beats/min). Then the diastolic filling time is shortened, and the beats are too close together to
distinguish.
Other guidelines to distinguish S1 from S2 are:
• S1 is louder than S2 at the apex; S2 is louder than S1 at the base.
• S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the
apex; the sound you hear as you feel each pulse is S1
• S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG
monitor.
Listen to S1 and S2 Separately. Note whether each heart sound is normal, accentuated,
diminished, or split. Inch your diaphragm across the chest as you do this.
First Heart Sound (S1). Caused by closure of the AV valves, S1 signals the beginning of systole.
You can hear it over the entire precordium, although it is loudest at the apex. (Sometimes the
two sounds are equally loud at the apex because S1 is lower pitched than S2.)
You can hear S1 with the d
[Show More]
 - Over 500 Questions – Nightingale College.png)
