Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Nursing ( Lab Values) > health and physical assessment of adults > Flashcards

health and physical assessment of adults Flashcards

(71 cards)

Start Studying
1
Q

What does SOAP stand for?

A

subjective, objective, assessment and plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How to obtain the information?

A

Health history- chief complaint, history of present illness, general state of health, social history, family history, domestic violence

Mental status exam

Cognitive level

Physical exam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What do you ask in social history?

A

drugs, tobacco, alcohol, sex practice, tattoos, piercing, traveling history, work environment to assess occupational hazard

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What do you ask in family history?

A

Disease in blood related relatives and spouse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What to ask in mental exam?

A

Appearance- grooming, hygiene, dressing, posture, body movement

Behavior

  • level of consciousness (are they alert and aware; are they interacting with the environment)
  • facial expression and body movement (eye contact; is there facial and body movement appropriate for the situation)
  • Speech ( cohesive; can they articulate and appropriate)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What to ask in cognitive level of function

A

12-2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Is health history subjective or objective

A

subjective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Is physical exam subjective or objective?

A

objective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the order of the physical exam?

A

Inspect, palpate, percussion and auscultation

except the abdominal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Difference between light and deep palaption?

A

Light is for surface problem using one hand and 2-3 finger and deep use one hand on top of the other and use all the fingers to place pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Types of percussion?

A

learn

resonance, hyper resonance, tympani, dullness, and flatness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

is vitals included in the physical exam

A

yes

also radial pulse, height and weight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How to check for cyanosis, jaundice, bleeding and inflammation in dark skin?

A

cyanosis- the conductive will be pale, the lip and tongue will be grey, the nail bed, palm and sole will be blue

jaundice - the sclera is yellow and the mucous membrane

Bleeding - discoloration and edema; compare with unaffected side

Inflammation- taut, warm and shiny

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What do you recommend for skin assessment?

A

ABCDE

Asymmetry
Border irregularity
Color variance
Diameter greater than 6 mm
Evolve in color, size or shape
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Assessment of head?

A

Inspect size, symmetry, shape, tenderness, mass

Palpate the temporal artery, the maxillary and frontal sinus

Inspect the temporomandibular joint: ask to move jaw side to side

any crepitus, tenderness or limited range of motion is problem

tests cranial nerve number 5 - trigeminal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Assess the face?

A

tenderness, edema, involuntary movement, shape, size and symmetry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Assess the neck?

A

symmetry of the accessory muscle, palpate the trachea ( should be in the middle and not deviated), the thyroid gland ( when patient swallows the gland should move up, palpate with anterior and posterior approach usually not palpable, if then auscultate for bruit)

Test cranial nerve 11 (accessory nerve)

shrug shoulder for trapezius and move chin to side against resistance for sternocleidomastoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Objective assessment of the eye?

A

assess eyebrow for symmetry, eyelid for ptsosis or drooping, eyelashes for equal distribution, exophthalmus for bulging of eye and enopthalmus for sunken eyes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are all the eye exams?

A 
snellen test
near vision
confrontation test
corneal light reflex
cover uncover
6 cardinal position/diagnostic position test
color vision
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what is the snellen test?

A

assess for distant vision/vision acuity

the client must be standing 20 feet away from the chart
can wear contact lense or glasses but not reading glasses

numerator is the person denominator is the normal eye or others

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What nerve does the snellen test assess for?

A

optic nerve (nerve 2)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the near vision test?

A

handheld device held 14 inches from the patient that includes various sizes of print or ask the patient to read the magazine

cover the eye not being used

normal result is 14/14

testes cranial nerve 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

what is the confrontation test

A

examines for peripheral vision

client covers one eye and looks straight ahead while the nruse covers the opposite eye

the nurses advances finger or small object from periphery from several direction

the client should see the object at the same time as the nurse

tests for cranial nerve 2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

what is the corneal light reflex?

A

assess for parallel alignment of the axes of the eye

each eye tested separately

nurse hold penlight 12 inches from the patient and reflect the light at the middle of the two eye; there should be a reflection (red dot) on the cornea at the same position on both eye

the patient is looking straight ahead

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is the cover uncover test
checks for slight degrees of deviated alignment; assess for strabismus (when the eye does not align with each other) the patient will cover one eye and look straight ahead the uncovered eye should have steady fixed gaze
26
what is the 6 cardinal test
tests the 6 muscle sattaching the eyeball to the orbit and serves to direct the eye in point of interest head is still and moves both eyes following a object
27
which nerves do the 6 cranial test assess for?
3, 4 and 6 trochlear, abducens and oclomotor
28
what is the color vision test
uses the ishihara chart in which a number or letter needs to be picked out of a complex and colorful picture diagnosis of red-green color blindness not blue
29
how should the pupils be
round and equal constriction upon light and dilation in darkness light being shone which causes constriction is called direct light light not being shown with constriciton is called consensual
30
How should sclera be?
sclera should be white in dark skin people they may have yellow scelera which is normal with dots
31
how should cornea be
transparent, shiny, smooth and bright cloudy can indicate accident or injury
32
opthalmoscopy or fundoscopy
patient in dark room to dilate the pupil assess for external structures and interior of the eye the instrument is held in the right hand if right eye is being tested client looks ahead the instrument is 12-15 inches away as instrument is directed at the eye a red glare is seen in the pupil; if not then it means opacity of the lens
33
how should optic disc, general background, macula and retinal vessels be
optic disc is round or oval, yellow cream orange to redish pink color the general background the light to dark brown red the retinal vessels should be visible without engorgement the ma
34
What do you assess in the ear?
size,shape, symmetry, pain, redness
35
What do you assess in the external auditory meatus?
cerumen, pus, redness, pain, swelling
36
how is sound transmitted?
bone or air conduction
37
what is conductive hearing loss
when there is a physical obstruction of sound waves
38
what is sensorineural hearing loss
defect of the cochlea or 8th cranial nerve
39
what is mix hearing loss
mix of conductive and sensori
40
what is the wisper test?
the examiner stands 1-2ft away from the client the client the other ear the examiner will cover mouth and whisper 2 syallabul wods the client will state if they herd it if the client did not that means there is fluid accumulation
41
what is the watch test
tests of client can hear high acuity sounds examiner will hold ticking watch 5 inches away from the testing ear
42
what is tuning fork test
measures hearing on the basis of bone or air conduction
43
what is a otoscopic exam
tests the ear pull pinna up and back
44
how does the normal external canal look?
pinkish intact without any lesions there can be wax and hair
45
how does the tympanic membrane look
it should in intact without any perforation or lesions should be transparent, opaque and pearly grey cone. of light reflex is 5 oclock on the right and 7 on the left if membrane is retracted or bulging then the edges of the light reflex will diffuse The otoscope is never introduced blindly into the external canal because of the
46
what is the vestibular assessment
assess for any imbalance in the air Test for fallin aka rombergs -client will close eyes and place feet together, slight sway or normal but excessive sway is positive rombergs Past pointing client sits down in front of the examiner and closes eyes and sticks both the index finger out the examiner places index finger below the client, the client raises arms and places them back down when the examiners fingers are Gaze Nystagmus Client stares 30 degrees away and examiner looks for twitching Dix-hallpike Examiner turns client head 40 degrees and lies him down and check for nystagmis for 30 seconds
47
how to check patency of the nostrils
close one nose and ask client to breath in and out through the other
48
What is the rating of the tonsils?
``` (0 is surgically removed; 1 + is tonsils hidden within pillars; 2 + is tonsils extending to the pillars, 3 + is tonsils extending beyond the pillars, 4 + is tonsils extending to the midline) ```
49
what should you recommend for dental care?
fluoride water
50
What are the adventitious lungs sounds?
``` fine crackles medium crackles coarse crackles wheezing rhonchi pleural rub ```
51
What is fine crackles?
High pitch popping noise that comes at the end of the inspiration Caused by: P, asthma, heart failure and restrictive pulmoary disease
52
medium crackles?
Medium pitch popping sounds that comes in the middle of the inspiration .Worse than fine crackles. Same condition as fine
53
Coarse crackles
Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration. Not cleared by cough. Same as above, but condition is worse or may be heard in terminally ill clients with diminished gag reflex. Also heard in pulmonary edema and pulmonary fibrosi
54
wheezing
High-pitched, musical sound similar to a squeak. Heard more commonly during expiration, but may also be heard during inspiration. Occurs in small airways. Heard in narrowed airway diseases such as asthma
55
rhonchi
Low-pitched, coarse, loud, low snoring or moaning tone. Actually sounds like snoring. Heard primarily during expiration, but may also be heard during inspiration. Coughing may clear Heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis
56
Pleural rub
A superficial, low-pitched, coarse rubbing or grating sound. Sounds like 2 surfaces rubbing together. Heard throughout inspiration and expiration. Loudest over the lower anterolateral surface. Not cleared by cough. Heard in individuals with pleurisy (inflammation of the pleural surfaces)
57
What are the voice sounds?
Done with lung disease is suspected Broncophony - ask to say ninety nine nurse should hear muffle, soft, indistinct sounds Egophony- say eeeee, nurse should hear eeeee Whispered- whisper 1 2 3 nurse should hear faint, muffled and almost inaudible
58
Auscultation of the heart?
``` Auscultate heart rate and rhythm; check for a pulse deficit (auscultate the apical heartbeat while palpating an artery) if an irregularity is noted. c. Assess S1 (“lub”) and S2 (“dub”) sounds, and listen for extra heart sounds, as well as the presence of murmurs (blowing or swooshing noise that can be faint or loud ```
59
How to check the peripheral vascular system?
``` BP Symmetry of arterial pulse Carotid pulse (one at a time) Listen for bruits Measure calf circumference and check for pretibial edema ``` Palpate superficial inguinal nodes Check arteries of the extremities
60
Check the breast
palpate with three fingers and also check the axillary nodes (should not be palpable)
61
Order of the abdomen assessment
inspect, ausculatate, percussion and palapate
62
How to auscultate abdomen
After inspection start the auscultation Listen to all 4 quadrants starting with RLQ(hypo, hyper or normoactive) Listen for 5 mins before stating absent sounds Auscultate aorta, renal arteries, femoral and iliac to listen for bruits
63
how to percuss the abdomen
predominantly tympani; dull over the liver and the spleen Measure liver and spleen and make sure no pain from the kidney
64
what is in the muskuskeletal assessment
only inspection and palpation assess active and passive ROM grade the muscle strenght
65
Assess neurological system
1. Assess cranial nerves 2. Level of consciousness, pupils, coordination, reflex and sensory function 3. Note mental and emotional status 4. record vitals
66
How to assess level of consciousness? (neuro)
Determine behavior alert, confused, delirium, unconsciounsess, stupor and coma In extreme levels use glascow coma scale light touch if appropriate
67
How to assess pupils? | neuro
size, equality, and reaction to light (brisk, slow and fixed) brisk is rapid which is normal
68
How to assess motor function ? | neuro
``` . Assess for voluntary and involuntary, strenght movements and purposeful and nonpurposeful movements. c. This component of the neurological examination may be performed during assessment of the musculoskeletal system ```
69
How to assess cerebellar function ? | neuro
rombergs test, assess as clients walks in straight line
70
How to assess coordination function ? | neuro
Assess by asking the client to perform rapid alternating movements of the hands (e.g., turning the hands over and patting the knees continuously) ``` The nurse asks the client to touch the nurse’s finger, then his or her own nose; the client keeps the eyes open and the nurse moves the finger to different spots to ensure that the client’s movements are smooth and accurate. c. Heel-to-shin test: Assist the client into a supine position, then ask the client to place the heel on the opposite knee and run it down the shin; normally the client moves the heel down the shin in a straight line. ```
71
how to assess sensory function ( neuro)?
Assess pain by applying sharp object Assess light touch Position sense- kinethesia; move tow or finger up and down and ask which one was moved Stereognosis: Tests the client’s ability to recognize objects placed in his or her hand Graphesthesia: Tests the client’s ability to identify a number traced on the client’s hand Two-point discrimination: Tests the client’s ability to discriminate 2 simultaneous pinpricks on the skin Plantar reflec- a. A cutaneous (superficial) reflex is tested with a pointed but not sharp object. b. The sole of the client’s foot is stroked from the heel, up the lateral side, and then across the ball of the foot to the medial side. c. The normal response is plantar flexion of all toes. Bruzinki and kernigs sign for meningial irritation DTR- biceps, triceps, ptella and achillies

Nursing ( Lab Values) (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions