Clinical Assessment and Nursing Fundamentals: A Comprehensive Review

Posted on Dec 11, 2024 in Physical Education

HEENOT (Head, Eyes, Ears, Nose, Oral, Throat)

Skin and Lesions

Types of Lesions: Macule, papule, pustule, vesicle, cyst, nodule.

Pressure Ulcer Stages

  • Stage I: Non-blanchable erythema of intact skin.
  • Stage II: Partial-thickness skin loss.
  • Stage III: Full-thickness skin loss; underlying fascia.
  • Stage IV: Full-thickness skin loss with extensive destruction.
  • Unstageable: Base covered by slough or eschar.

Skin Color Changes: Erythema (red), cyanosis (blue), jaundice (yellow), pallor (white).

ABCDEs of Melanoma: Asymmetry, Border, Color, Diameter >6 mm, Evolving.

Headaches

  • Migraine: Throbbing, unilateral, prodrome, relieved by rest.
  • Cluster: Stabbing, around one eye or cheek.
  • Tension: Band-like pain across the head.

Cranial Nerves

  • Detailed testing for CN I–XII (e.g., CN I: Smell test, CN II: Visual acuity, CN VII: Facial symmetry).

Braden Scale

  • Risk factors for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, friction/shear.

Musculoskeletal System

Movements and Joints

Movements: Flexion, extension, hyperextension, abduction, adduction, dorsiflexion, plantar flexion, supination, pronation.

Joint Types: Gliding joints (e.g., wrists and ankles).

Spinal Abnormalities

  • Scoliosis: Lateral spinal curvature.
  • Kyphosis: Outward thoracic curvature (hunchback).
  • Lordosis: Exaggerated lumbar inward curve (often seen in pregnancy).

Rheumatoid Arthritis

  • Boutonniere deformity, ulnar deviation, swan-neck deformity.
  • Warm but not swollen joints.

Osteoarthritis

  • Fusiform swelling, Heberden’s nodes, morning stiffness.
  • No warmth in joints.

Muscle Strength Grading

  • Scored 0–5 based on range of motion and resistance.

Crepitus

  • Grating sensation caused by bone/cartilage friction.

Abdominal System

Organ Quadrants

  • RUQ: Liver, gallbladder, duodenum, head of pancreas.
  • LUQ: Stomach, spleen, left kidney, pancreas body.
  • RLQ: Cecum, appendix, small intestine.
  • LLQ: Descending colon, sigmoid colon.

Assessment Order: Inspection, auscultation, palpation.

Special Signs

  • Murphy’s Sign: Pain on liver palpation (cholecystitis).
  • Rovsing’s Sign: RLQ pain with LLQ palpation (appendicitis).
  • Psoas Test: RLQ pain on thigh extension (appendicitis).

Cardiac System

Heart Sounds

  • S1 (“lub”): AV valves closing.
  • S2 (“dub”): Semilunar valves closing.
  • S3: Abnormal, indicates ventricular failure.
  • S4: Abnormal, caused by stiff ventricles (e.g., in hypertension).

Auscultation Points

  • Aortic Area: S2 louder, 2nd ICS right sternal border.
  • Pulmonic Area: S2 louder, 2nd ICS left sternal border.
  • Erb’s Point: S1 and S2 equal, 3rd ICS left sternal border.
  • Tricuspid Area: S1 louder, 5th ICS left sternal border.
  • Mitral Area: S1 louder, 5th ICS midclavicular line.

Peripheral Vascular

  • Arterial Insufficiency: Absent pulses, ischemia, shiny skin.
  • Venous Insufficiency: Brawny skin changes, edema, varicosities.
  • DVT: Sharp pain, redness, swelling; risk for pulmonary embolism.

Respiratory System

Upper and Lower Airway

  • Upper: Nose, pharynx, larynx.
  • Lower: Trachea, bronchi, bronchioles, lungs, alveoli.

Adventitious Breath Sounds

  • Rales/Crackles: Clicking, bubbling during inspiration.
  • Rhonchi: Snoring sound from airway secretions.
  • Wheezes: High-pitched, narrowed airway.
  • Stridor: Emergency upper airway sound (e.g., anaphylaxis).

Neurologic System

Cranial Nerve Testing

  • CN I: Smell test.
  • CN VII: Facial movements.
  • CN VIII: Hearing (e.g., whisper test, Weber, Rinne).
  • CN IX & X: Gag reflex, “ahh” test.
  • CN XI: Shoulder shrug.
  • CN XII: Tongue protrusion.

Pain Assessment

  • Pain history and behavioral/physiological responses.

General Nursing and Health Assessment Concepts

Nursing Process

  • Steps: Assessment, Diagnosis, Planning, Implementation, Evaluation.
  • Use in forming nursing diagnoses and care plans.

Health History and Interview Techniques

  • Biographic Data: Name, date of birth, gender identity, etc.
  • Psychosocial History: Financial background, social/emotional concerns.
  • Interview Techniques: Active listening, clarification, focus, summarize.
  • Barriers to Communication: Anxiety, medical jargon, false reassurance.

Standard Precautions

  • Hand hygiene, PPE use, and infection control for all.
  • PPE Donning: Gown, mask, goggles, gloves.
  • PPE Doffing: Gloves, goggles, gown, mask.

Vital Signs Across the Lifespan

Temperature

  • Infants: 97–100°F.
  • Adults: 98.6–99.6°F.
  • Older Adults: 96.9–98.3°F.

Pulse

  • Newborn: 100–160 bpm.
  • Adults: 60–100 bpm.
  • Athletes: 40–60 bpm.

Respiratory Rate

  • Infants: 25–40 breaths/min.
  • Adults: 12–20 breaths/min.

Blood Pressure

  • Newborns: 50–70 systolic.
  • Adults: 90–120 systolic; <80 diastolic.