HA Final Exam (1)

• General Health Status or General Survey


  The first part of the physical examination begins the moment the nurse meets the client. It uses observational skills while interviewing and interacting with the client leading to an overall picture of the client’s health status.
• General Health Status or General Survey

  • Physical Appearance
  • Level of Consciousness
  • Skin Conditions and Color
  • Body Mass Index
  • Body Structure – Stature
  • Body Structure – Nutrition
  • Body Structure – Symmetry
  • Body Structure – Posture
  • Body Structure – Position
  • Body Built
  • Body Structure – Gait
  • Mobility – Range of Motion
  • Mental Status
  • Facial Features
  • Behavior – Mood and Affect
  • Behavior – Speech
  • Behavior – Dress
  • Behavior – Hygiene
  • Cognitive Functions - Orientation
  • Cognitive Functions – Attention Span
  • Thought Process and Perceptions
• PHYSICAL APPEARANCE

  • AGE
  • Height and Weight
• Age (Normal)


  The person appears his or her stated age
• Age (Abnormal)


  Appears older than states age as with chronic illness
• Height and Weight

  • It is an assessment of overall health, hydration status, and nutrition
  • Prior:
  • Assist patient in changing into gowns
  • Obtain usual height and weight (e.g. before hospitalization)
  • Compute the BMI to determine nutritional status
• Level of Consciousness

  • The most sensitive indicator of the changes in neurologic status of the client
  • The center for wakefulness is the ascending reticular activating system (ARAS)/ reticular formation
• ascending reticular activating system (ARAS)


  It functions to arouse the cerebral cortex, to awaken the brain to a conscious level, and to prepare the cortex to receive the rostrally projecting impulses from any sensory modality.
• Levels of consciousness (Level 1)


  conscious, cognitive, coherent (3C’s)
• Levels of consciousness (Level 2)


  confused, drowsy, lethargic, obtunded, somnolent
• Levels of consciousness (Level 3)


  stuporous; respond only to noxious, strong, or intense stimuli; e.g. sternal pressure, trapezius pinch, pressure at the base of the nail or supraorbital area; very strong light or very loud sound.
• Levels of consciousness (Level 4)


  Comatose
• Light Coma – (+) all forms of painful stimulation

  Deep Coma – (–) to painful stimulation
• Glasgow Coma Scale (GCS)


  assessment tool for LOC which comes in 3 areas: eye-opening, motor response, and verbal response
• GCS Scoring

  14 – 15: perfectly normal

  13 – 10: lethargic

  8 – 9: stuporous

  7 and below: comatose
• Alert

  • Awake
  • Readily aroused
  • Fully aware of the internal and external environment
  • Conducts meaningful interpersonal conversation
• Lethargic

  • Drifts off to sleep when not stimulated
  • Aroused when name is called but looks drowsy
  • Responds to question but thinking seems to be slow
• Obtunded

  • Sleeps most of the time
  • Difficult to arouse
  • Needs a loud shout or vigorous shake
  • Speech mumbled
• Stupor or Semi Coma

  • Spontaneously unconscious
  • Responds only to spontaneous vigorous shake
  • Can only groan, mumble or move restlessly
  • Reflex activity still persists
• Comatose

  • Completely unconscious
  • No response to pain
  • Some reflex activity but no purposeful activity
• Level of Consciousness (Normal)


  The person is alert and oriented, attends to questions, and responds

  appropriately
• Level of Consciousness (Abnormal)

  • Lethargic
  • Obtunded
  • Stupor
  • Coma
• Skin Conditions and Color (Normal)


  The color tone is even, pigmentation varying with genetic background, skin is intact with no obvious lesions
• Skin Conditions and Color (Abnormal)

  • Pallor
  • Cyanosis
  • Jaundice
  • Erythema
  • Vitiligo
  • Edema
• Pallor


  A paleness or a loss of color from the normal skin tone
• Cyanosis


  It is a bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood.
• Jaundice


  It is a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes.
• Erythema


  It is redness of the skin caused by injury or another inflammation-causing condition.
• Vitiligo


  It is a chronic (long-lasting) autoimmune disorder that causes patches of skin to lose pigment or color.
• Edema


  It is swelling caused by too much fluid trapped in the body's tissues.
• Body Mass Index


  Practical measure for estimating total body fat; calculated as weight in

  kilograms and divided by the square height in meters
• Body Mass Index (Normal)


  18.5 to 24.9
• Body Mass Index (Abnormal)

  • ˂ 18.5 = underweight
  • 25.0 to 29.9 = overweight
  • ˃ 30 = obesity
• Body Structure - Stature (Normal)


  The height appears within the normal range for age, and genetic heritage.
• Body Structure - Stature (Abnormal)


  Excessively short or tall
• Body Structure - Nutrition (Normal)


  The weight appears within the normal range for height and body build;

  body fat distribution is even.
• Body Structure - Nutrition (Abnormal)

  • Cachectic
  • Obesity with even fat distribution
  • Centripetal obesity – fat concentrated in specific body parts.
• Body Structure - Symmetry (Normal)


  Body parts look equal bilaterally and are relative in proportion to each

  other.
• Body Structure - Symmetry (Abnormal)

  • Unilateral atrophy of hypertrophy.
  • Asymmetric location of body part.
• Body Structure - Posture (Normal)


  Stands comfortably erect as appropriate for age.