Health Assessment HESI Study Guide/ RATED A

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Health Assessment HESI Study Guide Nursing Process ADPIE • Assess • Diagnose • Outcome identification • Planning • Implementation • Evaluation • History Taking and Documentat... ions Subjective – What patient says about their history Collect Medical History Collecting data, 4 types • Complete Health data base • Episodic or problem-centered database • Follow up database • Emergency Data base • Assess Pulse in Geriatric Patients May be irregular 50-90 bpm is normal • Male Bladder Evaluation • Note frequency, urgency and noctuira • Polyuria – excessive • Oliguria – diminished quantity • Dysuria – hurts when peeing • BPH- common finding that can cause urine stream issue (blockage) • Gout – Big Toe • Accumulation of sodium crystals • Uric acid crystals and joint destruction of the base of the joint of the big toe. • Gout is most common in men; in women, it usually occurs after menopause. • Obesity and a diet high in purines is among the risk factors for gout. o Organ meats, sardines, mussels • Inflammation and redness resulting from acute gouty arthritis on the big toe. o Pain, redness, swelling, and heat • Uric acid crystals in the finger joints result in painful inflammation and stiffness. • Diagnosis: o Fluid is withdrawn from the inflamed joint and analyzed for uric acid crystals. o Fluid obtained from crystal deposits in a patient with gout. • Stay well-hydrated and reduce alcohol consumption to prevent gout attacks. • Additional prevention methods include weight reduction and dietary changes. • 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. • Inspection of Limbic Symmetry o Inspect and palpate neck (cont.) o Should be symmetric o Head position is centered in midline, and accessory neck muscles should be symmetrical o Head should be held erect and still o Thyroid gland should not be enlarged ▪ •Can be difficult to palpate, check for enlargement, consistency, symmetry, and presence of nodules • Mobility (tremor) • Aging adult • Temporal arteries may look twisted and prominent • In 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 • 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 • Smooth, even gait reflects equal leg lengths and functional hip motion • Posture and bed rest • Posture worsen with bed rest. • CV assessment for older adult • May feel dyspnea on exertion (difficulty breathing) • Common – gradual rise in systolic blood pressure • Diastolic pressure remains the same • Some older adult experience orthostatic hypotension – sudden drop in blood pressure when rising to sit or stand • Aging adult (cont.) o There should be no hemodynamic changes with aging • 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 o This is due to stiffening of large arteries, which, in turn is due to calcification of vessel walls (arteriosclerosis) o Creates increase in pulse wave velocity because less compliant arteries cannot store volume ejected • Overall size of heart does not increase with age, but left ventricular wall thickness increases • No change in resting heart rate occurs with aging • Cardiac output at rest is not changed with aging • Decreased ability of heart to augment cardiac output with exercise o Shown by decreased maximum heart rate with exercise and diminished sympathetic response • 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 • Chronic exercise conditioning will modify many of aging changes in cardiovascular function • Sensory assessment for older adult • Cataracts is common in the aging adult o This can affect visual acuity • Perform same examination as described in adult section • Central acuity may decrease, particularly after 70 years of age; peripheral vision may be diminished [Show More]

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