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U of R SCHOOL OF NURSING > CLASS 1 - COMPREHENSIVE HEALTH ASSESSMENT > Flashcards

CLASS 1 - COMPREHENSIVE HEALTH ASSESSMENT Flashcards

(83 cards)

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1
Q

NONVERBAL COMMUNICATION

A
  • Listening w/ the eyes

- Tells if the patient is upset, agitated, maintaining eye contact

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2
Q

VERBAL COMMUNICATION

A
  • Asking open-ended or close-ended questions
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3
Q

OPEN-ENDED QUESTIONS

A
  • “Tell me about why you’re here today”
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4
Q

CLOSE-ENDED QUESTIONS

A
  • “Tell me where you’re hurting”
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5
Q

SUBJECTIVE DATA

A
  • What the patient tells you through open-ended and close-ended questions
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6
Q

EXAMPLES OF SUBJECTIVE DATA

A
  • Health History
  • Symptoms (pain, nausea)
  • Feelings (happy, sad, nervous)
  • Perceptions (beliefs, desires)
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7
Q

OBJECTIVE DATA

A
  • What the nurse assesses
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8
Q

EXAMPLES OF OBJECTIVE DATA

A
  • Observations
  • Vital signs (blood pressure, pulse, respirations)
  • Physical exam findings
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9
Q

ANTHROPOMETRIC MEASURES

A
  • Height/Weight

- BMI

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10
Q

UNDERWEIGHT BMI VALUE

A
  • < 18.5
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11
Q

NORMAL BMI VALUE

A
  • 18.5 - 24.9
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12
Q

OVERWEIGHT BMI VALUE

A
  • 25.0 - 29.9
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13
Q

OBESE BMI VALUE

A
  • > 30.0
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14
Q

VITAL SIGNS

A
  • Temperature
  • Pulse
  • Respiration
  • Blood Pressure
  • Pulse Oximetry
  • Pain
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15
Q

AVERAGE ORAL TEMPERATURE

A
  • 37 degrees C or 98.6 degrees F
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16
Q

AVERAGE RECTAL TEMPERATURE

A
  • 0.5 degrees C or 1 degrees F > oral temperature
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17
Q

AVERAGE AXILLARY TEMPERATURE

A
  • 0.5 degrees C or 1 degrees F < oral temperature
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18
Q

AVERAGE TYMPANIC TEMPERATURE

A
  • 0.8 degrees C or 1.4 degrees F > oral temperature
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19
Q

AVERAGE TEMPORAL TEMPERATURE

A
  • Close to core body temperature
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20
Q

PLACEMENT FOR ORAL TEMPERATURE

A
  • Posterior sublingual pockets (hot spots)
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21
Q

FACTORS OF INACCURATE ORAL TEMPERATURE

A
  • Hot and cold foods
  • Unable to close mouth
  • Smoking cigarettes
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22
Q

PLACEMENT FOR TYMPANIC TEMPERATURE

A
  • Beginning of the ear canal and aim the infrared beam at the tympanic membrane
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23
Q

FACTORS OF INACCURATE TYMPANIC TEMPERATURE

A
  • Cerumen

- Hearing aides

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24
Q

PLACEMENT FOR TEMPORAL TEMPERATURE

A
  • Sliding probe across the forehead and down behind the ear
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25
DOCUMENTING TEMPERATURE
- Example: 98.2 degrees F oral/rectal/temporal
26
PULSE LOCATIONS
- Radial (wrist) - Brachial (inside elbow) - Carotid (side of neck) - Pedal (top of foot) - Apical (chest)
27
MOST ACCURATE PULSE LOCATION
- Apical because you're listening to the actual beat of the heart
28
NORMAL PULSE RANGE
- 60 - 100 beats/minute
29
PULSE EXAM TECHNIQUE
- Palpate for pulse | - Count beats for 30 seconds, multiple x 2
30
BRADYCARDIA
- Less than 50 beats/minute
31
TACHYCARDIA
- Greater than 95 - 100 beats/minute
32
PULSE INTENSITY CATEGORIES
- 3+ - Full, bounding - 2+ - Normal - +1 - Weak, thready - 0 - Absent
33
DOCUMENTING PULSE
- Example: 80 BPM apical/radial/carotid
34
T/F : IF BREATHING OR PULSE IS IRREGULAR YOU HAVE TO DO THE TEST FOR 60 SECONDS?
- True
35
NORMAL RESPIRATORY RATE
- 14 - 20 breaths/minute
36
RESPIRATORY RATE EXAM TECHNIQUE
- NEVER tell a patient you are counting respirations - After 30 seconds of counting normal pulse, continue with 30 seconds of watching respirations (as if you were still counting the pulse)
37
RESPIRATORY RHYTHM CATEGORIES
- Regular | - Labored
38
RESPIRATORY DEPTH CATEGORIES
- Shallow | - Gasping
39
OXYGEN SATURATION DEFINITION
- Using a pulse oximeter to assess arterial oxygen saturation - Measures the % of hemoglobin attached to oxygen
40
NORMAL OXYGEN SATURATION
- SpO2 of 97 - 99% | - SpO2 of > 93% is clinically acceptable
41
FACTORS OF INACCURATE OXYGEN SATURATION
- Nail polish - Cold hands - If SpO2 is on the low side, have the patient take a couple deep breaths
42
DOCUMENTING OXYGEN SATURATION
- Example: 92% room air | - Example: 92% on 4 L of oxygen nasal cannula (if on oxygen need to report how much)
43
PAIN RATING SCALE
- Pain is subjective - 0 - 10 rating scale - Pain score > 3 means the patient needs intervention and re-assessment
44
DOCUMENTING PAIN RATING SCALE
- Example: Pain scale 3/10 on left ankle
45
BLOOD PRESSURE EXAMINATION TECHNIQUE
- Palpation for brachial artery - Rest patient arm with your own at mid-chest level - Center at brachial artery 2.5 cm above antecubital crease - Inflate cuff - Palpate radial pulse and inflators until pulse disappears - Inflate 20-30 mmHg further - Place stethoscope over brachial artery - Deflate cuff by 2-3 mmHg/second - First sound = systolic - Second sound = diastolic
46
FACTORS OF INACCURATE BLOOD PRESSURE
- Too large of a cuff doesn't put enough pressure on the artery --> low BP - Too small of a cuff puts too much pressure on the artery --> high BP - Releasing the bladder too slowly causes venous congestion --> high diastolic
47
NORMAL BLOOD PRESSURE VALUE
- < 120 / < 80 mmHg
48
PREHYPERTENSION BLOOD PRESSURE VALUE
- 120 - 139 / 80 - 89 mmHg
49
HYPERTENSION (STAGE 1) BLOOD PRESSURE VALUE
- 140 - 150 / 90 - 99 mmHg
50
HYPERTENSION (STAGE 2) BLOOD PRESSURE VALUE
- > 160 / > 100 mmHg
51
HYPERTENSION CRISIS BLOOD PRESSURE VALUE
- > 180 / > 110 mmHg | - Emergency care needed!
52
ORDER OF EXAMINATION
- Inspection (includes impression and all subcategories) - Palpation - Percussion - Auscultation
53
INSPECTION ASSESSMENT
- Process of observation - Careful scrutiny of the individual as a whole then of each body system - Good lighting - Adequate exposure
54
ORDER OF IMPRESSION
- Overall state of health - Physical appearance - Body structure - Behavior - Distress
55
OVERALL STATE OF HEALTH ASSESSMENT
- Does the person stand promptly to meet you? - Does the person look sick? - Does the person fully extend their arm to shake your hand? - Are the palms dry or clammy?
56
FACTORS OF PHYSICAL APPEARANCE ASSESSMENT
- Stated vs. apparent age - Body fat, stature - Level of consciousness - Motor activity - Body and breath odors - Facial expressions
57
STATED VS. APPARENT AGE ASSESSMENT
- The person appears his or her stated age?
58
BODY FAT, STATURE ASSESSMENT
- The height appears within normal range for age, genetic heritage - The weight appears within the normal range for height and body build - Body fat distribution is even
59
LEVEL OF CONSCIOUSNESS ASSESSMENT
- The person is alert and oriented to person, place, time, and situation - Responds appropriately to your questions - A & O x 3
60
MOTOR ACTIVITY ASSESSMENT
- The person has smoothness of motion, no tremors, coordinated gait
61
BODY AND BREATH ODOR ASSESSMENT
- The person appears clean and groomed appropriately (if culturally appropriate) for his/her age or occupation, and socioeconomic group
62
FACIAL EXPRESSION ASSESSMENT
- The person maintains eye contact (if culturally appropriate) - Expressions are appropriate to the situation (thoughtful, serious, smiling)
63
FACTORS OF BODY STRUCTURE ASSESSMENT
- Posture/Position - Range of Motion - Gait - Stature/Symmetry - Nutrition
64
POSTURE/POSITION ASSESSMENT
- The person stands comfortably erect as appropriate for age
65
RANGE OF MOTION ASSESSMENT
- Full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated.
66
GAIT ASSESSMENT
- Feet approximately shoulder width apart - Foot placement accurate - Walk is smooth and even - Person can maintain balance without assistance - Symmetric arm swing present
67
STATURE/SYMMETRY ASSESSMENT
- The height appears within normal range for age, genetic heritage - Body parts look equal bilaterally and are irrelative proportion to each other
68
NUTRITION ASSESSMENT
- The weight appears within normal range for height and body build - Body fat distribution is even
69
FACTORS OF BEHAVIOR ASSESSMENT
- Dress/grooming - Mood/manner - Speech - Facial expressions
70
DRESS/GROOMING ASSESSMENT
- Clothing is appropriate for the climate - Looks clean and fits the body - Appropriate to the person's culture and age-group - Culturally determined dress should not be labeled as inappropriate by Western standards
71
MOOD/MANNER ASSESSMENT
- The person is comfortable and cooperative with the examiner and interacts pleasantly
72
SPEECH ASSESSMENT
- Articulation is clear and understandable - Stream of talking is fluent, with even pace - Conveys ideas clearly
73
FACIAL EXPRESSION ASSESSMENT
- The person maintains eye contact (if culturally appropriate) - Expressions are appropriate to the situation (thoughtful, serious, smiling)
74
FACTORS OF DISTRESS ASSESSMENT
- Physiological - Pain - Emotional
75
PHYSIOLOGICAL ASSESSMENT
- The person has no apparent distress
76
PAIN ASSESSMENT
- Is the person short of breath, grimacing, guarding a certain area of the body?
77
EMOTIONAL ASSESSMENT
- What kind of emotions is the person showing? Pleasant, relaxed, angry, distressed - Flat affect: no smiling, monotone - can be hard to read
78
FACTORS OF PALPATION ASSESSMENT
- Fingertips - Ball of hand - Dorsa of hands and fingers - Base of fingers
79
FINGERTIP PALPATION ASSESSMENT
- Best for fine tactile discrimination - Skin texture - Swelling - Pulsation - Determining lumps - Crepitation - Organ size
80
BALL OF HAND PALPATION ASSESSMENT
- Vibration | - Can also be felt with ulnar surface of hand
81
DORSA OF HANDS AND FINGERS ASSESSMENT
- Best for determining temperature
82
PERCUSSION ASSESSMENT
- Tapping the person's skin with short, sharp strokes to assess underlying structures - Produces vibration and subsequent sound waves in body - Determine location and size of organ - Signaling density (air, fluid, or solid)
83
AUSCULTATION ASSESSMENT
- Listening to sounds produced by the body (heart, blood vessels, bowels) - Stethoscope used to block out sounds and concentrate on the sound

U of R SCHOOL OF NURSING (12 decks)

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