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Module 1 > Health Assesment > Flashcards

Health Assesment Flashcards

(138 cards)

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1
Q

Before you begin

A

Age group considerations
Organization of the assessment is a must if you go from dirty to clean always clean stethascope and wash hands

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2
Q

Neuro specific health assessment components

A

Level of consciousness and orientation
Pupil response and cardinal age
Smile and show teeth, raise eyebrows
Tongue to roof of the mouth out side to side
Shoulder strength with resistance
HGTW
FLEXION AND EXTENSION BUE AND BLE

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3
Q

Level of consciousness

A

Single most important part of the assessment
Clue to see of deteriorating condition
Alert, lethargic, obtunded, stuporous/ semi-comatose, comatose
Name and date of birth, where are you, and what brought you to the hospital

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4
Q

Alert

A

Attentive, follows commands, if asleep wakes promptly remains attentive

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5
Q

Lethargic

A

Drowsy slow to respond

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6
Q

Obtunded

A

Difficult to arouse needs constant stimulation

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7
Q

Stuporous/semicomatouse

A

Arouses only to vigorous stimuli like pain

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8
Q

Comatose

A

No response to verbal or nonverbal or noxious stimuli no movement except deep tendon reflex

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9
Q

Cranial nerves

A

12 pairs
Sensory motor or both
Not all of the cranial nerves are always tested
Listed in order of testing not numerical value

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10
Q

Testing cranial nerves iii IV AND VI

A

Pupil response with pen light to see pupils dialate
Use tip of pen and have patient follow with their eyes and with an H motion

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11
Q

Testing cranial nerve VII

A

Ask patient to smile and show teeth
Wrinkle forehead

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12
Q

Testing cranial number 12 `

A

Put tongue on the roof of mouth
Stick tongue out and move it from side to side

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13
Q

Testing cranial nerve XI

A

Place hands on shoulders and ask patient to shrug them up and down

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14
Q

Testing motor function

A

Hand grasp and toe wiggle
FLEXION and extension with resistance
All done bilaterally BUE BLE
Done to make sure everything is working properly

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15
Q

Respiratory components of assessment

A

Anterior and posterior lung sounds
Clubbing

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16
Q

Auscultation of the lungs

A

Vesicular
Bronchovesicular
Bronchial

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17
Q

Vesicular

A

Periphery of the lungs Soft and breezy sounds

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18
Q

Bronchovesicular

A

Closer to the sternum is like a blowing sounds

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19
Q

Bronchial

A

Over the trachea largest and loud and high pitched

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20
Q

Abnormal or adventitious sounds

A

Crackles or rales
Rhonchi
Wheezes
Pleural friction rub

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21
Q

Crackles or rales

A

Can be fine or coursed
Call them crackles because they sound like rice crisps
They are caused by fluid
Can be cleared with a cough

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22
Q

Rhonchi

A

Due to large secretions in the air way sounds like flapping
Can be cleared with a cough so the airway will be cleared

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23
Q

Wheezes

A

High pitched musical sounds so we can hear them over all of the lungs commonly heard in the exhale but in severe cases can be heard inhale
Can be caused by respiratory illness

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24
Q

Pleural friction rub

A

Sounds like stehascope rubbing against cloth
Why we use stethascope on skin
No fluid and something could be rubbing against tissue
It is very painful

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25
Abnormal respiratory patterns
Bradypnea Tachypnea Apnea Hyperpnea Kussmauls Cheyne strokes
26
Bradypnea
Slow breathing
27
Tachypnea
Breathing fast
28
Hyperpnea
Breathing more deeply and faster than usual
29
Kussmaul breathing
Fast and deep breaths that occur in response to metabolic acidosis
30
Cheyne-strokes
Breathing disorder characterized by cyclical episodes of apnea and hyperventilation
31
Pattern of auscultation
1 starting on the left
32
Clubbing of the nails
Can occur when the blood is consistently low oxygen in the blood. Also people who live in places with high elevations this can happen
33
Cardiac specific health assessment components
Heart sounds Carotid pulses Radial pulses Pedal pulses Capillary refill Assess for Edema
34
Heart sounds
LUB S1 DUB S2
35
LUB
Systole or s1 and is the sounds associated with the mitral and tricuspid valves
36
DUB
S2 or diastole and is the sounds associated with the aortic and the pulmonic valves closing
37
Pauses between heart sounds
There are natural pauses between s1 and s2 but the pauses between s2 and s1 is longer
38
Location of heart sounds
Aortic Pulmonic Tricuspid Mitral
39
Aortic
Right base and the second intercostal space to the right of the eternal border
40
Pulmonic
Left bases and second intercostal space to the left of the eternal border
41
Tricuspid
Left lateral sternal border and fifth intercostal space to the left of the sternal border
42
Mitral
Apex and midclavicular line at the fifth intercostal space
43
Pulses
Carotid Brachial Radial Ulnar Apical Femoral Popliteal Dorsalis pedis
44
Assessment of pulses
Carotid Radial Apical Dorsalis pedis
45
Carotid
One at a time bilaterally
46
Radial
Bilaterally at the same time
47
Apical
With a stethoscope for two beats
48
Dorsalis pedis
Bilaterally at the same time
49
Pulse points
0,1+,2+,3+,4+
50
0 pulse point
Absent non palpable
51
1+ pulse point
Diminished palpable very weak
52
2+ pulse point
Strong normal
53
3+ pulse point
Full increased
54
4+
Bounding can feel it very strongly
55
Doppler
Hand held device Most often used for pedal pulses If we can not feel it by hand If we use the Doppler make sure to document it every time
56
Assessment of extremities
Capillary refill Edema
57
Edema
Swelling in the extremities Dependent and pitting edema
58
Dependent edema
Most often on feet and ankles older adults and standing
59
Pitting edema
Venous insufficiency or heart failure fluid tissues
60
Musculoskeletal specific health assessment components
Neck ROM BUE ROM BLE ROM HGTW FLEXION AND EXTENSION BUE AND BLE
61
RANGE OF MOTION ROM
Neck Shoulders,upper arms and elbows Upper arms and elbows Wrist Hips Knees Ankles
62
NECK ROM
Move neck side to side Chin to chest Extension back
63
Shoulders upper arms and elbows
Arms out to the side Straight up Touch down
64
Wrist
Wrist circles
65
Hips knees and ankles
Bilateral hip FLEXION out Bend knees Ankle circles
66
Strength
Hand grip Toe wiggle FLEXION and extension of BBUE/BLE
67
Integumentary specific health assessment
Hair and scalp Inspect ears Inspect nose Mouth and throat Inspect and palpate neck Assess skin turbot Inspect skin on back and bony prominences Inspect skin of BUE AND BLE Nails
68
Assessment of skin
Inspect head to toe for Hydration The pasture Color Texture Rashes Lesions Cracking
69
Changes in skin color
Pallor Erythema Jaundice Cyanosis
70
Pallor
Pale or ashen gray
71
Erythema
Redness r/t vasodilation
72
Jaundice
Yellow impaired liver
73
Cyanosis
Bluish, decreased circulation of oxygenation of blood
74
Skin characteristics
Temp should be warm consistent with room temp Moisture from diapers is or dry from dehydration Texture can be dry and course (elbows/knees) or shiny with no hair (impaired peripheral circulation) Turgor tests elasticity of the skin related to hydration
75
Factors of effecting skin
Dampness Dehydration Nutrition circulation Disease Jaundice Lifestyle
76
Normal skin changes in older adults
Epidermis Subcutaneous tissue Collagen and elastin fibers Hormones Vascularity Hair follicles Melanocytes Nails Skin growths
77
Epidermis
As we get older it becomes thinner translucent and older adults are more prone to skin tearing
78
Subcutaneous tissue
This becomes thinner as well which is decreased protection which is why older adults get cold faster
79
Collagen and elastin fibers
When we start losing collagen we get wrinkles and skin doesn’t return the way when it was pulled
80
Hormones
Lack of hormones can lead to dry and thinning of the hair
81
Vascularity
As we get older some of the smaller microcapillaries on the skin decrease on cooler areas on the skin
82
Hair follicles
Slower growing over time
83
Melanocytes
Gives our skin pigmentation so it decreases over time which causes pigment to become uneven and causes hair to turn gray
84
Nails
Nails become thicker and softer or thick and hard
85
Skin growths
Wartz or liver and age spots which should limit sun exposure
86
Pitting edema
Caused by kidney failure Leads to excess fluid collection in tissues
87
Four point scale 1+
2mm to trace (rapid response)
88
Four point scale 2+
4mm to mild 10-18 seconds
89
Four point scale 3+
6mm to moderate 1-2 minutes
90
Four point scale 4+
8mm to severe 2-5 minutes
91
Assessment of bony prominence
Hips heels coccyx shoulders Assess for skin integrity Non blanching red spots
92
Assessment of nails
Shape contour cleanliness Nearly manicured Should be transparent, smooth, rounded, convex, hygienic
93
Assessment of hair
Terminal hair Vellum hair Quantity - alopecia hirutism Distribution Texture Color Parasites
94
Terminal hair
Scalp, axillae, pubic, and beard
95
Vellum hair
Soft tiny hairs covering body except on palms and soles (what makes humans to be considered mammals)
96
Alopecia
Abnormal hair loss
97
Hiritusm
Abnormal growth of hair on a persons face and body especially if a woman
98
Assessment of ears
Symmetry, drainage, shape, hearing defects, lesions, redness, tenderness or odor Could odor or if it is green it can indicate of a possible infection
99
Assessment of the nose
Inspect nose for position, symmetry, color, swelling, deformities, discharge, flaring, latency and sinus tenderness
100
Assessment of oral cavity and throat
Lips oral mucosa Teeth Gums/tongue Breath order Throat: lumps Ulcers Edema White spots Redness Swallowing
101
Assessment of neck
Contour and symmetry, Midline trachea Jugular vein Palpate the neck for enlarged lymph nodes
102
Elimination
Excretion of waste products from kidneys and intestines
103
Defamation
Process of elimination of waste
104
Feces
Semisolid mass of five, undirected food, inorganic matter
105
Urinary elimination vocab
Incontinence Void Micturate Dysuria Hematuria Nocturnal Polyuria Urinary frequency Urinary urgency Protienuria Dribbling Retention Residual
106
Incontinence
Inability to control urine or feces
107
Void
To urinate
108
Micturate
To urinate
109
Dysuria
Painful or difficult urination
110
Hematuria
Blood in the urine
111
Nocturia
Frequent night urination
112
Polyuria
Large amounts of urine
113
Urinary frequency
114
Urinary frequency
Voiding at frequent intervals Holding it till a later time
115
Urinary urgency
The need to void all at once “I have to go and i have to go now”
116
Protienuria
Protienuria in the urine
117
Dribbling
Leakage of urine despite voluntary control of urination
118
Retention
Accumulation of urine in bladder without the ability to completely empty
119
Residual
Urine remaking post void >100ml Anything that what we would consider that is left in the bladder and it is known through a bladder scan
120
Structures of the gastrointestinal tract
Upper gastrointestinal tract Small intestine Large intestine Rectum and anus Mouth pharynx Stomach
121
Small intestine
Folded, twisted and coupled tube from stomach to large intestine 1” in diameter and 20’ long Most digestion and absorption takes place here Chyme travels via peristalsis 3 segments duodenum, jejunum and ileum
122
Chyme
Food mixed with stomach acids it is chyme once it leaves the stomach
123
Large intestine
Aka colon 2.4” diameter and 5-6’ long 7 segments cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum and anus
124
Organs of urinary elimination
Kidneys Ureters Bladder Urethra
125
Kidneys
Filter and regulate Remove waste from blood to form urine
126
Ureters
Transport urine from kidneys to bladder Enter the bladder posteriorly and obliquely into the bladder to prevent reflux
127
Bladder
Resvoir for urine until urge develops
128
Urethra
Urine travels from bladder and exits through urethral meatus
129
Kidneys
Bilateral posterior flanks Size of fists Primary regulators of fluid and acid base balance
130
Kidneys
Nephron- functional unit of the kidney Glomerulus Bowman’s capsule Proximal consulates tubule Loop of henle Distal tubule Collecting duct
131
Ureters
Tubule structures that enter the bladder Urine traveling through the Exeter’s is typically sterile Ureters enter bladder obliquely and posterior lay to prevent reflux Obstructions cause peristaltic waves severe pain often referred to as renal colic
132
Bladder
Hollow, distensible,muscular organ In men- bladder lies against anterior walls of rectum In women- bladder rest against anterior walls of uterus and vagina When bladder is full it extends above symphysis pubis
133
Normal bladder
500 ml but can extend to 1000 ml
134
Urethra
Turbulent flow washes urethra free of bacteria Descends through pelvic floor muscles can prevent flow of urine In someone- urethra is short(1 1/2 to 2 1/2 in) leads to prevalence of infection In men urethra is long (8 in) serves in both GU and reproductive system three sections- prostatic membranous, and penil
135
Assessment of the abdomen
Look listen and feel When you listen listen for digestion for 5-20 seconds When you feel ask if any pain or tenderness and feel for masses Ask “have you had a bowl movement today? How are your bowl movements and what are your urinary patterns?”
136
Assessment of urethral meatus and perineal area
Inspect urethral or if ace for erythema, discharge swelling or odor Signs of infection, inflammation or trauma Perineal areas -color, condition, presence of urine or stool
137
GI/GU components
Examination of abdomen- look listen and feel Ask questions and habits Examination of urethral meatus and perineal area
138
Head to toe assessment
Created to move from head to toe Be methodical Be aware of clean to dirt and dirty to clean

Module 1 (18 decks)

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