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Module 1 (Intro To Basics) > Health Assessment > Flashcards

Health Assessment Flashcards

(125 cards)

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1
Q

List the Procedure and Order of Health Assessment exactly!!

A

Intro, wash hands, gloves
- Full name, DOB, current date, current location, and event
- Hair
- Eyes, Ears, Nose, Mouth, and Throat
- Smile, tongue mvmt, raise eyebrows
- Carotid pulse
- Neck ROM (side-to-side, back, and forward)
- Shrug shoulders
- Pinch the clavicle for turgor
Inspect, Palpate, Auscultate
- Heart sounds (4- APTM) for 2 cycles
- Anterior lung sounds (7) LEFT - RIGHT
Only ab: AUSCULTATE BEFORE PALPATING
- Abdomen (4-20 secs starting at RLQ clockwise)
=Ask about bowel and urinary output
- Posterior lung sounds (10 sounds Left to right)
BUE
- out to the side, up, circles, touchdown
- wrist circles
- hand grasps
- radial pulses both
- clubbing
- capillary refill
BLE
-lift, knee bend, side
- ankle circles, flexion and extension
- toe wiggle
- palpate pedal pulses
- capillary refill
Inspect perineal area if needed
Hand hygiene and document

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2
Q

Purpose of Physical Assessment

A

baseline data
supplement, confirm, or refute previous data
confirm or identify nursing diagnosis
clinical judgements
evaluate physiological outcomes of care

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3
Q

Subjective data

A

verbal description from pt (statement)

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4
Q

Objective data

A

observable by a nurse (fact, measurable)

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5
Q

Primary source of data

A

Patient (not always reliable)

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6
Q

Secondary source of data

A

Family, friends, medical records, and previous physicians

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7
Q

Considerations for Assessment

A

cultural sensitivity
infection control
environment
equipment

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8
Q

Data collecting can be done through what methods

A

interviews
health history
physical exams
diagnostic and lab results

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9
Q

Laboratory diagnostic tests

A

ABGs
CBC
Sputum

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10
Q

Radiological studies tests

A

Xrays
CT
V/Q
Pet Scans

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11
Q

The following are all different types of physical assessments what do they have in common?
-Comprehensive
-Focused
-System specific
-Ongoing

A

Head to Toe

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12
Q

During an examination, what process do you follow except for the abdomen?

A

Inspect, palpate, auscultate

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13
Q

After the nurse is done with their assessment, planning, and evaluation means the nurse is ?

A

Accountable for documenting and checking up on the outcome

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14
Q

All senses are tested during an examination except for?

A

taste

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15
Q

The back of the hand or dorsum is used to check what on a patient?

A

Temperature

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16
Q

Light palpations are about ___ cm deep.
Deep palpations are about ___ cm deep

A

1
4

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17
Q

When are deep palpations used in physical assessment?

A

abdomen

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18
Q

T/F:
Auscultating needs to happen directly on the skin.

A

True

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19
Q

The bell of the stethoscope is used for what sounds and when is it used?

A

Low sounds
vascular and heart sounds

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20
Q

The diaphragm of a stethoscope is used for what sounds and when is it used?

A

High sounds
bowel and abnormal lung sounds

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21
Q

What are some special considerations for young and elderly patients?

A

recognize limitations (adjust positions, more time, and more space)

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22
Q

What are the signs of abuse? Mandatory

A

inconsistency between injury and statement
bruises, burns, lacerations, and bites
Xrays show fractures in various stages of healing (especially not reported)
behavior issues, insomnia, anxiety, isolation

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23
Q

What do you need when you notice signs of abuse?

A

Consent
-Ask about them, but they might lie

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24
Q

Level of Consciousness is the 1st clue of what?

A

deteriorating condition

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25
What are the 5 levels of consciousness?
1) Alert 2) Lethargic 3) Obtunded 4) Stuporous/Semi-comatose 5) Comatose
26
Alert (1)
attentive, follow commands If asleep, they awaken promptly and attentive
27
Lethargic (2)
drowsy but awakens, slow response
28
Obtunded (3)
difficult to arouse, needs constant stimuli
29
Stuporous / Semi-comatose (4)
arouses only with vigorous/noxious stimuli, may only withdraw from pain
30
Comatose (5)
no response to verbal or noxious stimuli, no movement except for deep tendon reflex
31
How is cognitive awareness tested?
Orientation of person, place, time, and event Cranial nerves tested (sensory, motor, or both)
32
How many cranial nerves are there?
12
33
What is ICU sycosis?
days blend together (time is messed up)
34
What are cranial nerves tested when examining pupil responses (size, shape)? -Dilation of pupils with a penlight -Penlight off near and far sidedness
CN 3,4,6
35
What cranial nerves are tested when smiling with teeth and wrinkling forehead or raising eyebrows?
CN 7
36
What cranial nerves are tested when moving the tongue up, out, and side to side?
CN 12
37
How do you test the cardinal gaze?
tip of a penlight to and from the face H movement with eyes only
38
What cranial nerves are tested when shrugging against resistance?
CN 11
39
What motions tests the cranial motor functions?
hand grasp and toe wiggle flexion and extension with resistance bilaterally with upper and lower extremities
40
What are the areas of the lungs from medial to lateral?
Bronchial (over trachea) Bronchovesicular (closer to sternum) Vesicular (peripheral lobes)
41
Crackles or rales Sounds Common location Common cause
Rice krispies high pitch base of lungs fluid
42
Rhonchi Sounds Common location Common cause
rumbling core sounds trachea mucous plug (usually clear with cough)
43
Wheezes Sounds Common location Common cause
high pitch musical note all lung fields during exhalation narrowing of airways due to asthma, COPD
44
Pleural Friction Rub Sounds Common location Common cause
stethoscope rubbing on clothes any location where there is no fluid in the lung sac lung is rubbing on tissue
45
Bradypnea
slow breathing
46
Tachypnea
rapid breathing
47
apnea
no breathing
48
Hyperpnea
breathing deeper and faster
49
Kussmaul's
deep and labored associated with DKA
50
Cheyne-stokes breathing
cyclical episodes of hyperpnea and apnea
51
For lung auscultation, what side do you start on for both anterior and posterior?
left side
52
On the posterior lung sounds, what expiration and inspiration do you tell them to take a deep breath?
7,8,9,10
53
What lung has an extra lobe?
right
54
What does clubbing look like?
when putting your fingers together, there is a wide-angle and no gap under fingernails
55
When do people have clubbing in their nails?
low O2 for long periods of time (altitude sickness, asthma)
56
What is the route of deoxygenated to oxygenated blood through the heart?
Superior and inferior vena cava - right atrium - bicuspid valve - right ventricle - pulmonary valve - pulmonary artery - lungs lungs - pulmonary veins - left atrium - tricuspid valve - left ventricle - aortic valve - aorta
57
LUB sound is
systole (S1) associated with the closing of the mitral and tricuspid valve
58
DUB sound is
diastole (S2) associated with closing of aortic and pulmonary valves
59
SA node is known as the
pacemaker
60
What is the order and location of the 4 heart valves?
Aortic: right 2nd intercostal space next to the sternum Pulmonic: left 2nd intercostal space next to the sternum Tricuspid: left lateral sternal border, 5th intercostal space Mitral: apex, midclavicular line at 5th intercostal
61
What pulse site do you not palpate at the same time?
carotid
62
Pulses that are analyzed during the physical assessment
Carotid Radial Apical Dorsalis pedis
63
What number of pulse point is normal?
2+
64
What does a pulse point of 0 mean?
absent
65
What does a pulse point of 1+ mean?
diminished
66
What does a pulse point of 3+ mean?
full and increasing
67
What does a pulse point of 4+ mean?
bounding
68
What is a doppler device?
handheld device with ultrasound gel used for pedal pulses
69
How long normally does it take for a capillary refill?
2-3 seconds (bleaching to red)
70
Dependent edema
gravity related swelling of feet and ankles mainly on older adults when standing
71
Pitting edema
Severe swelling in the feet up to 4-8 mm of depth with no bounce back after 5 minutes venous insufficiency, kidney disease, or heart failure excess fluid in tissues throughout the body
72
Neck ROM
side to side chin to chest head backward rotation in circles
73
BUE ROM
arms out straight up touchdown wrist circles
74
BLE ROM
knee to chest hip flexion out ankle circles
75
What to inspect on the skin when doing inspection?
skin breakdown hydration temp color texture rashes lesions cracking
76
Pallor
pale or ash gray
77
erythema
redness of vasodilation
78
jaundice
yellow, impaired liver
79
cyanosis
bluish, decreased circulation of oxygen to the blood
80
How do you test turgor on a pt?
pinch the clavicle -elasticity of skin related to hydration
81
Healthy skin temperature on inspection
warm and consistent with room temperature
82
Healthy skin moisture on inspection
diaphoresis or hydrated
83
Healthy skin texture on inspection
hydrated with hair
84
Abnormal skin texture on inspection
shiny with no hair = impaired peripheral circulation
85
What are some factors affecting skin?
dampness dehydration nutrition circulation disease jaundice lifestyle
86
Normal skin changes in elderly people
collagen and elastic fibers decrease hormones decrease vascularity decreases leading to hypertension and atherosclerosis disease hair follicles and melanocytes decrease (uneven and gray hair) nails become thick skin growth of warts and liver spots
87
Pitting edema response rate when pressed against
1+ 2mm trace rapid 2+ 4mm mild 10-18 secs 3+ 6mm moderate 1-2 minutes 4+ 8mm severe 2-5 minutes
88
What bony prominences are highest for skin breakdown?
hips, heels, coccyx, shoulders
89
Nails should look like
transparent smooth rounded convex hygenic
90
Terminal hair is located where
scalp, axillae, pubic, and beard
91
Vellus hair is located where
soft tiny hairs covering the body except on palms and soles
92
Alopecia
partial or complete absence of hair on the body (baldness)
93
Hirsutism
abnormal growth of hair on the face or body especially for women
94
Where does mastication begin?
myophayrnx esophagus stomach
95
Elimination
excretion of waste products from kidneys and intestines
96
Defecation
process of eliminiation of waste
97
Feces
semisolid mass of fiber, undigested food, and inorganic matter
98
Incontinence
inability to control urine or feces
99
Void
to urinate
100
Micturate
to urinate
101
Dysuria
painful or difficult urination
102
Hematuria
blood in the urine
103
Nocturia
frequent night urination
104
Polyuria
large amounts of urine
105
Urinary frequency
voiding at frequent intervals
106
Urinary urgency
the need to void all at once
107
Proteinuria
presence of large protein in urine
108
Dribbling
leakage of urine despite voluntary control of urination
109
Rentention
accumulation of urine in the bladder without the ability to completely empty
110
Residual
urine remaining post void greater than 100 mL
111
Structures of the Gastrointestinal Tract
upper gastric intestinal tract small intestine large intestine rectum and anus
112
Small intestine -shaped -how long -3 segments
folded, twisted, and coiled tube from stomach to LG intestine 20 feet long duodenum, jejunum, and ileum
113
Large intestine - COLON -shaped -how long -7 segments
flat 5-6 ft long cecum, ascending, transverse, descending, sigmoid colon, rectum, anus
114
Where are most of the digestion and absorption happen?
small intestine
115
Chyme travels via
peristalsis
116
Kidney functions
filter and regulate remove waste from blood to form urine primary regulators of fluid and acid-base balance
117
Ureter
transport urine from kidneys to bladder usually sterile obstructions cause peristaltic waves severe pain = renal colic
118
Bladder
reservoir for urine until the urge develops In women, located anterior walls of the uterus and vagina In men, anterior wall of rectum
119
urethra
urine travels from bladder and exits through urethral meatus
120
What size is a kidney related to?
size of fists
121
What is a functional unit of a kidney?
nephron
122
Normal bladder volume = can extend to =
500mL 1000mL
123
In women, the urethra is ____ leads to a number of UTIs.
short (1 1/2 to 2 1/2 inches)
124
In men, the urethra is ____ and serves in both GU and the reproductive system, prostatic, membraneous, and penile
long (8 inches)
125
Name some of the parts of the kidney.
glomerulus, bowman's capsule, PCT, loop of Henle, DT, collecting duct

Module 1 (Intro To Basics) (32 decks)

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