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Nursing Health Assessment > HA Final > Flashcards

HA Final Flashcards

1
Q

Expected outcomes or goals should be in SMART format:

A

Specific, Measurable, Achievable, Relevant, Time-bound

EG: “Pt will move from bed to chair at least three times per day”
“patient will rate pain as tolerable by end of shift”

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2
Q

Episodic/focused:
Complete:
Follow-up:
Emergency:

A

Episodic/focused: obtain for a specific problem or condition i.e. sore throat, dysuria, surgery
The subjective data you obtain is directly related to the episode

Complete: first encounter with patient
Complete health history and full physical exam to determine baselines

Follow-up: status of identified acute or chronic problems i.e. new medication, post-surgery

Emergency: collect crucial subjective data while simultaneously assessing ABCs

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3
Q

Cultural Competence:
Hispanic
Asian
Questions to ask in cultural assessment

A

Hot/Cold – Hispanic
Yin/Yang - Asian

Questions to ask in cultural assessment
What are your religious or spiritual preferences?
What cultural practices are important to you?
What are your health goals?

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4
Q

A patient reports smoking 1 pack of cigarettes per day for 30 years. The nurse reports this as:

A

30 pack years

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5
Q

Test to indicate chronic alcohol abuse:

A

Elevated GGT (gamma glutamyl transferase) levels.

Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol.

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6
Q

Measurements:

  • growth chart
  • kg to lbs
  • Head and chest circumference
  • BMI categories
A

Document on CDC growth charts; should be growing along curve
<5th and >95th percentiles are considered risky

1 kg = 2.2 lbs

Head circ about 2cm greater than chest; will even out around 6 mo-2 years

BMI categories 
Underweight 		<18.5
Normal 		18.5-24.9
Overweight 		25-29.9.
Obese 		30-39.9
Extreme/morbid obesity 	40+
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7
Q 
Temperature:
normal range F and C
fever levels
hyperthermia
hypothermia
A

Normal Range: 35.8- 37.3 (96.4 – 99.1)

> 38 (100.5) considered a fever
Hyperthermia >41.1 (106): infection, exposure, hyperthyroidism/thyroid storm
Hypothermia <35 (95): shock, exposure

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8
Q

Pulse deficit

A

(common with heart failure, arrhythmias, PAD) =

Difference between apical and radial

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9
Q 
Abnormal LOC: 
Delirious
somnolent
Stuporous
Comatose
A 
Delirious = restless, confused
Lethargic/drowsy/somnolent = drowsy; common post-op
Stuporous/Semi-coma = vigorous stimulation needed; sedation, drug overdose
Comatose = no response
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10
Q

test for Anxiety:

test for Depression:

A

Anxiety: GAD-7

Depression: PHQ-9

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11
Q

BMI <18.5 = Underweight: Check…

BMI >24.9 = Overweight : Check…

A

prealbumin
Nursing Diagnosis = Nutrition Imbalance; Less than Body Requirements

triglycerides and cholesterol
Nursing Diagnosis = Nutrition Imbalance: Greater than Body Requirements

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12
Q 
Protein
Vitamin C
Vitamin A
Thiamine
Calcium and Vitamin D
A

Protein
Dull, dry hair
Muscle wasting

Vitamin C
Splinter hemorrhages (nails)
Bleeding gums
Joint pain

Vitamin A
Eye changes: dryness, plaques

Thiamine
Often associated with alcoholics
Neuro changes including hyporeflexia and neuropathy

Calcium and Vitamin D
Muscle pain, weak bones, rickets

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13
Q

skin Color:
ecchymosis
erythema

A

ecchymosis: pooling of blood under the skin poss unrelated to trauma
erythema: superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

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14
Q

senile purpura-

A

increased vascular fragility so minor trauma may produce dark red discolored areas

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15
Q

Physiological jaundice

A

common after 3rd or 4th day of life (at birth is abnormal)

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16
Q

Lanugo-

A

fine hair

17
Q 
Atopic dermatitis- 
Pediculosis capitis
Chronic renal failure: 
Lyme Disease:
Types of Alopecia:
A

Atopic dermatitis- very dry skin, erythematous rash, possible edema
Pediculosis capitis (head lice)
Chronic renal failure: pruritus; also ammonia breath, fatigue, muscle cramps, irritability, oliguria
Lyme Disease: bull’s eye rash
Types of Alopecia: toxic, areata, traumatic

18
Q

Carcinomas:
Basal =
Squamous =
Melanoma =

A 
Basal = slow growing
Squamous = fast growing, scaly
Melanoma = ABCDE
19
Q

Braden Scale uses a scores from less than or equal to 9 to 23.

what s being tested?

A 
The lower the number, the higher the risk for developing an acquired ulcer/injury.
19-23 = no risk
15-18 = mild risk
13-14 = moderate risk
less than 9 = severe risk

sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

20
Q 
Test Eye Muscles:
Corneal light reflex 
Cover-uncover test 
Diagnostic Positions Test
Nystagmus
A
  • Corneal light reflex should be symmetric
  • Cover-uncover test done if light is not in same spot in both eyes
  • Diagnostic Positions Test/6 cardinal positions- CNs III, IV, and VI- oculomotor, trigeminal, abducens
  • Nystagmus is indicative of disease of cerebellum or brainstem
21
Q

Arcus Senilis:

A

lipid material causes grey/white arc around the cornea (normal)

22
Q 
Fixed & dilated pupil = 
Pupillary dilation: 
Pinpoint: 
Nystagmus: 
Ptosis:
A

Fixed & dilated pupil = increased ICP
Pupillary dilation: amphetamines, cocaine–stimulants
Pinpoint: opiates—depressants. Then withdrawal and opposite happens—dilate. Flu-like symptoms
Nystagmus: neuro damage
Ptosis (upper eyelid droops over the eye): CN III or VII

23
Q

Retinal detachment

A
  • emergency

Sudden onset of spots or flashing, curtain or veil like loss of vision in one quadrant of eye

24
Q

Papilledema-

A

optic disc swelling that is caused by increased ICP.

25
Q

Otitis Media

A

(middle ear infection)
Subjective: ear pain
Objective: bulging, immobile, red ear drum, no cone of light

26
Q

Epistaxis

A

(bloody nose)

27
Q

Xerostomia =

A

dry mouth (lips will lock white, cracked)

28
Q

Fruity breath =

A

DKA

29
Q

Thyroid assessment:

A

First inspect
Then palpate: usually not palpable, posterior approach is preferred, ask pt to swallow
Auscultate for bruit if enlarged
may be enlarged in pregnancy

30
Q

Tactile Fremitus: “blue moon”
Decreased fremitus:
Increased fremitus:

A

Tactile Fremitus: “99” or “blue moon”
Decreased fremitus: emphysema, pneumothorax, pleural effusion
Increased fremitus: areas of consolidation (pneumonia)

31
Q

Tracheal (bronchial)-
Bronchovesicular-
Vesicular-

A

Tracheal (bronchial)- supraclavicular, near trachea
Bronchovesicular- major airways; next to sternum, between scapulae
Vesicular- alveoli and smaller bronchioles; remainder of lungs

32
Q

Vocal fremitus:

A

sounds will be clearer with pathology that increases lung density i.e. pneumonia

33
Q

Crackles (rales):
Wheezes:
Rhonchi:
Stridor:

A

Crackles (rales): PNA, HF, pulm edema, CF; pulm fibrosis; may be fine (high-pitched, popping) or coarse (low-pitched, bubbling); often heard upon inspiration

Wheezes: high pitched, musical, inspiratory or expiratory
Aspiration, foreign body, asthma, chronic bronchitis, bronchiolitis

Rhonchi: low-pitched wheeze; snoring, rattling sound; coughing or suctioning may clear or change sounds; common with bronchitis

Stridor: Upper Airway obstruction i.e. Croup or anaphylaxis; inability to speak, wheezing, dyspnea, anxiety, cyanosis; loud, high pitched; inspiration; Life-threatening

34
Q

Systole/diastole

A

Diastole- mitral/tricuspid open & aortic/pulmonic closed ( A/P closing = S2)

Systolic- contraction!, M/T close = S1 sound beginning

35
Q

APETM

s1 and s2

A

S1 (apex) & S2 (base) - rate and rhythm
Physiologic split S2- inspiration can cause pulmonic to close later than aortic (heard 2nd ICS)

S3 (ventricular gallop; heard just after s2) - rapid ventricle filling; cardinal sign of heart failure; can be normal young adults and children, pregnant women

S4 (atrial Gallop; heard in late diastolic): listen L lateral position - slow ventricle filling; hypertension, elderly, aortic stenosis, CAD

Pericardial friction rub- “scratchy rubbing quality”, rubbing, grating, leather

36
Q 
Deep Vein Thrombosis (DVT)
who is most at risk
s/s
measurement
test
A

Elderly and those on bed rest most at risk
Unilateral pain, redness, swelling
Asymmetry >1cm considered abnormal
Homan’s sign = calf pain with dorsiflexion

37
Q

Hyperreflexia –
Hyporeflexia –
DTRs:
Superficial:

A

Hyperreflexia – UMN i.e. CVA, MS, ALS
Hyporeflexia – LMS i.e. spinal cord transection, herniated disk
DTRs: Biceps, triceps, quads (patellar), brachioradialis, achilles
Always use reinforcement if you can’t elicit a DTR

Superficial: Cremasteric, abdominal, plantar reflex

38
Q

when infant reflexes disappear

Babinski:

A

Primative: infants
Palmar Grasp, Moro, Rooting should disappear by 4 months
Babinski: disappears by 2 years
Absence of persistence of reflexes can indicate CNS damage

Nursing Health Assessment (16 decks)

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