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
... [Show More] 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. [Show Less]