Health Assesment and PE Flashcards

(40 cards)

1
Q

systematic method of collecting SUBJECTIVE and OBJECTIVE data to establish a patient’s overall level of functioning in order to make a professional clinical judgement

A

health assesment

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2
Q

to determine patient’s current and ongoing health status, predict risks to health, and identify health promoting activities

A

health assesment

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3
Q
  • detect during examination, lab info and test data
    -directly or indirectly observed through measurement
A

objective

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4
Q

What the patient tells you
- verified by client
- client interview

A

subjective

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5
Q

symptoms and history from Chief Complaint through Review of Systems

A

subjective

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6
Q

physical examination findings or signs

A

objective

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7
Q

clinician should have a basic knowledge of what when doing health assesments

A
  • anaphy
  • interviewing skills
  • types and operations of equipment needed for a particular examination
  • preparation of the setting, oneself and the patient for the PE
  • Performance of : inspectionm, plapation, percussion, and auscultation
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8
Q

usually done when patient has no record

A

comprehensive adult health history

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9
Q
  • age, gender, occupation, martial status, birthday and address
  • source of history
  • source of referral
  • reliability
A

identifying data and source of the history

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10
Q

one or more symptoms causing the client to seek care

A

chief complaints

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11
Q
  • complete, clear, and chronologic account of the problems prompting the patient to seek care
  • amplifies the chief complaint: describes how each symptom developed
    -includes the problem’s onset, setting and its manifestations and any treatments
A

present illness

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12
Q

includes health maintenance practices such as immunizations, screening tests, lifestyle issues and home safety

A

past health history

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13
Q

dates of onset, info about hospitalizations with dates, number and gender of sexual partners: risky sexual practices

A

medical

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14
Q

dates, indicationws and type of operation

A

surgical

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15
Q

obstetric history, menstrual history, birth control, and sexual function

A

obstetric

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16
Q

illness and time frame, diagnoses, hospitalizations and treatments

A

psychiatric

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17
Q

reviewing conditions whether present or absent in the familly

A

family history

18
Q

documents presence or absence of common symptoms related to each of the major body systems

A

review of systems

19
Q

sources of data

A

primary and secondary

20
Q

client, unless confused, too young or too ill to partricipate in an interview

21
Q

family members, caretakers, and support individuals as well as previous medical or health records and laboratory and diagnostic data

22
Q

organized, systematic process of collecting objective data about the client’s health based upon the head to toe general system

A

physical examination

23
Q

before the PE, what to do to make a patient more comfortable

A

offer patient to empty his or her bladder

24
Q

use of vision to distinguish normal from abnormal findings

25
sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts
sitting
26
most normally relaxed position for easy access to pulse sites
supine
27
for abdominal assessment because it promotes relaxation of abdominal muscles
dorsal recumbent
28
provides maximal exposure of genitalia and lacilitates insertion of vaginal speculum
lithotomy
29
flexion of hip and knee improves exposure of rectal area
sims
30
for assesing extension of hip, joint, skin and buttocks
prone
31
helps to detect murmurs
lateral recumbent
32
provides maimal exposure of rectal area
knee chest
33
involve the use of the hands to touch body parts and make sensitive assesments
palpation
34
in palpation how many quarters of the abdomen to assess
4 quarters
35
depresses the skin 1 to 2 cm
light
36
about 5 to 8 cm
deep
37
involves tapping the client's skin to assess underlying structures and to determine vibrations and sounds
percussion
38
involves listening to sounds produced by the body, such as heart, lung, or bowel sounds
auscultation
39
unaided ears
direct
40
use of stethoscope
indirect