Health Assessment
- Grinding the teeth; a sign of stress or of slight
• Leukoplakia
- thick white patches of cells; precancerous
condition.
• History of Present Health Concern
o Noses and Sinuses
- Do you experience nosebleeds? Describe
the amount of bleeding you have and how
often it occurs. What color is the blood?
- Do you have pain over your sinuses (cavities
around nasal passages)?
- Do you experience frequent clear or mucous
drainage from your nose?
- Can you breathe through both of your
nostrils? Do you have a stuffy nose at times
during the day or night?
- Have you experienced a change in your
ability to smell or taste
o Tongue and Mouth
- Do you experience tongue or mouth sores or
lesions? If so, explore the symptoms using
COLDSPA.
- Characteristics: Describe the size and
texture of the lesions.
- Onset: When did they first occur? Do you
notice these more when you are under stress
or taking certain medications? Did they occur
after any injury to your mouth?
- Locations: Describe exactly where these
lesions are located in your mouth.
- Duration: How long have you had these
lesions? Have you ever had these before and
did they go away?
- Severity: Do these lesions keep you from
eating, talking, or swallowing?
- Palliative/relieving factors: What aggravates
these lesions or makes them go away? What
over-the-counter remedies and past
prescriptions have you used?
- Associated Factors: Do you have any other
symptoms with these lesions such as stress,
pain, bleeding? Describe.
- Do you experience redness, swelling,
bleeding, or pain of the gums or mouth? How
long has this been happening? Do you have
any toothache? Have you lost any
permanent teeth?
o Throat
- Do you have difficulty swallowing or painful
swallowing? How long have you had this?
- Do you have a sore throat? How long have
you had it? Describe. How often do you get
sore throats?
- Do you experience hoarseness? For how
long?
• Bruxism
malocclusion.
• Pharyngitis
- A bright red throat with white or yellow
exudate
• Air-filled cavities
- decrease the weight of the skull and act as
resonance chambers during speech.
• Abnormal findings on extraocular muscle
o Esotropia
- inward turn of the eye
o Tropia
- specific type of misalignment
o exotropia
- outward turn of the eye
o Strabismus
- constant malalignment of the eyes.
o Phoria
- term used to describe misalignment that
occurs only when fusion reflex is blocked.
o Nystagmus
- an oscillating (shaking) movement of the
eye—may be associated with an inner ear
disorder, multiple sclerosis, brain lesions, or
narcotics use.
• Night blindness
- associated with optic atrophy, glaucoma, and
vitamin A deficiency.
• Risk factors for cataracts as:
- Increasing age (often start developing at 30
years of age, but are most prevalent by 75
years of age)
- Diabetes (especially with early-onset
cataracts)
- Drinking excessive amounts of alcohol
- Excessive exposure to sunlight
- Exposure to ionizing radiation, such as that
used in X-rays and cancer radiation therapy
- Family history of cataracts
- High blood pressure
- Obesity (especially with early-onset
cataracts)
- Previous eye injury or inflammation
- Previous eye surgery
- Prolonged use of corticosteroid medications
(ingestion or applied to skin)
- Smoking
• Gaze or Position test
- Cardinal fields; which assess eye muscle
strength and cranial nerve function.
• ACT FAST
o F – face; face drooping
o A – arm weakness
o S – Speech difficulties
o T – Time loss is brain loss
• Pressure Ulcer Stage
o Stage 1
- Intact skin with nonblanchable redness of a
localized area usually over a bony
prominence. Darkly pigmented skin may not
have visible blanching; its color may differ
from the surrounding area. The area may be
painful, firm, soft, warmer, or cooler as
compared to adjacent tissue. Stage I may be
difficult to detect in individuals with dark skin
tones.
o Stage 2
- Partial thickness loss of dermis presenting as
a shallow open ulcer with a red-pink wound
bed, without slough. May also present as an
intact or open/ruptured, serum-filled blister.
Presents as a shiny or dry shallow ulcer
without slough or bruising; bruising indicates
suspected deep tissue injury. This stage
should not be used to describe skin tears,
tape burns, perineal dermatitis, maceration,
or excoriation.
o Stage 3
- Full-thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon, or muscle is
not exposed. Slough may be present but
does not obscure the depth of tissue loss.
May include undermining and tunneling. The
depth of a stage III pressure ulcer varies by
anatomic location. The bridge of the nose,
ear, occiput, and malleolus do not have
subcutaneous tissue, and stage III ulcers can
be shallow. In contrast, areas of significant
adiposity can develop extremely deep stage
III pressure ulcers. Bone/tendon is not visible
or directly palpable.
o Stage 4
- Full-thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be
present on some parts of the wound bed.
Often includes undermining and tunneling.
The depth of a stage IV pressure ulcer varies
by anatomic location (see stage III). Stage IV
ulcers can extend into muscle and/or
supporting structures (e.g., fascia, tendon, or
joint capsule), making osteomyelitis
possible. Exposed bone/tendon is visible or
directly palpable.
o Unstageable
- Full-thickness tissue loss in which the base
of the ulcer is covered by slough (yellow, tan,
gray, green, or brown) and/or eschar (tan,
brown, or black) in the wound bed. Until
enough slough and/or eschar is removed to
expose the base of the wound, the true
depth, and therefore stage, cannot be
determined. Stable (dry, adherent, intact
without erythema or fluctuance) eschar on
the heels serves as “the body’s natural
(biological) cover” and should not be
removed.
• Difference between keloid and scars
o Keloids
- excess scar tissue; result from trauma or
surgery and is more common in African
Americans and Asians
o Scar
- Skin mark left after healing of wound or
lesion that represents replacement by
connective tissue of the injured tissue.
• Difference between fissures and
excoriation
o Fissures
- Linear crack in the skin that may extend to
the dermis and may be painful. Examples
include chapped lips or hands and athlete’s
foot. Interdigital tinea pedis with fissures and
maceration is pictured below.
o Excoriation
- may be from scratching an area infected by
fungi or pinworms.
• Abnormal findings for skin coloration:
o Pallor
- (loss of color) is seen in arterial insufficiency,
decreased blood supply, and anemia. Pallid
tones vary from pale to ashen without
underlying pink.
o Cyanosis
- may cause white skin to appear blue-tinged,
especially in the perioral, nail bed, and
conjunctival areas. Dark skin may appear
blue, dull, and lifeless in the same areas.
o Jaundice
- in light- and dark-skinned people is
characterized by yellow skin tones, from pale
to pumpkin, particularly in the sclera, oral
mucosa, palms, and soles.
o Acanthosis nigricans
- roughening and darkening of skin in localized
areas, especially the posterior neck
o Erythema
- (skin redness and warmth) is seen in
inflammation, allergic reactions, or trauma.
• Major arteries of the arm
o brachial artery
- major artery; can be palpated medial to the
biceps tendon in and above the bend of the
elbow.
o radial artery
- divides near the elbow; extending down the
thumb side of the arm; can be palpated on
the lateral aspect of the wrist.
o ulnar pulse
- located on the medial aspect of the wrist, is a
deeper pulse that may not be easily
palpated.
• Major Arteries of the Leg
o femoral artery
- major supplier of blood to the legs; can be
palpated just under the inguinal ligament
o popliteal artery
- can be palpated behind the knee; divides
below the knee into anterior and posterior
branches.
o dorsalis pedis artery
- anterior branch descends down the top of
the foot; can be palpated on the great-toe
side of the top of the foot.
o posterior tibial artery
- posterior branch, can be palpated behind
the medial malleolus of the ankle
• Peripheral vascular system: Lifestyle
and Health Practices
- Do you (or did you in the past) smoke or
use any other form of tobacco? How much
and for how long? If you use tobacco
currently, are you willing to quit?
- Do you exercise regularly?
- For female clients: Do you take oral or
transdermal (patch) contraceptives?
- Are you experiencing any stress in your life
at this time?
- How have problems with your circulation
(i.e., peripheral vascular system) affected
your ability to function?
- Do leg ulcers or varicose veins affect how
you feel about yourself?
- Do you regularly take medications
prescribed by your physician to improve
your circulation?
- Do you wear support hose to treat varicose
veins?
• Risk factors for (Deep bone thrombosis)
DVT:
- injury to a vein (fracture, surgery, muscle
injury);
- prolonged bedrest or sitting;
- limited movement (as with a cast);
- increased estrogen (pregnancy, birth control
pills, hormone replacement therapy);
- chronic medical conditions (heart, lung,
cancer, inflammatory bowel disease);
- previous DVT or pulmonary embolism (PE);
- family history of DVT or PE, especially over
60 years of age; obesity; or inherited clotting
disorder
• Traditional Areas of Auscultation
o Aortic area: Second ICS at the right sternal
border-the base of the heart
o Pulmonic area: Second or third ICS at the
left sternal border- the base of the heart
o Erb point: Third ICS at the left sternal
border
o Mitral (apical): Fifth ICS near the left MCL
the apex of the heart
o Tricuspid area: Fourth or fifth ICS at the
left lower sternal border
• tripod position
- Client leans forward and uses arms to
support weight and lift chest to increase
breathing capacity
- Emphysema and COPD
• 75% of clients with asthma have
gastroesophageal reflux disease (GERD) or
are more susceptible to GERD
• The bronchi and trachea represent “dead
space” in the respiratory system, where air
is transported but no gas exchange takes
place.
• Resonance
- percussion tone elicited over normal lung
tissue; elicits flat tones over the scapula.
• Three types of normal breath sounds may
be auscultated: bronchial,
bronchovesicular, and vesicular.
• The client does not use accessory
(trapezius/shoulder) muscles to assist
breathing.
• How many quadrants does the breast have?
- 4 quadrants (upper inner, upper outer
(most targeted by breast cancer), lower
inner, and lower outer)
• Peau d’orange
- Resulting from edema, an orange peel
appearance of the breast is associated with
cancer
• S3 – ventricular gallop
• S4 – atrial gallop
• Types of headaches
• Ear pain
o Otorrhea
- Drainage (otorrhea) usually indicates
infection. Purulent, bloody drainage
suggests an infection of the external ear
(external otitis).
o Otalgia
- Earache (otalgia) can occur with ear
infections, cerumen blockage, sinus
infections, or teeth and gum problems. Pain
caused by “swimmer’s ear” differs from pain
felt in middle ear infections.
o Tinnitus
- Ringing in the ears (tinnitus) may be
associated with excessive earwax buildup,
high blood pressure, or certain ototoxic
medications (such as streptomycin,
gentamicin, kanamycin, neomycin,
ethacrynic acid, furosemide, indomethacin,
or aspirin), loud noises, or other causes.
o Vertigo (true spinning motion)
- may be associated with an inner-ear
problem. It is termed subjective vertigo
when clients feel that they are spinning
around and objective vertigo when clients
feel that the room is spinning around them.
It is important to distinguish vertigo from
dizziness.
o Benign paroxysmal positional vertigo
(BPPV)
- Can occur at any age, but often occurs in
persons aged 50 years and is more
common in women

• Rinne test
- compares air and bone conduction sounds
(AC and BC). Strike a tuning fork and place
the base of the fork on the client’s mastoid
process

• Stensen and Wharton ducts

- Two ducts of salivary glands

• Torus palatinus
- bony protuberance in the midline of the hard
palate

• Tension Headache
- Dull, tight, diffuse

• Cluster Headache
- Stabbing pain; may be accompanied by
tearing, eyelid drooping, reddened eye, or
runny nose