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Nursing 1 > Health Assessment > Flashcards

Health Assessment Flashcards

(56 cards)

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1
Q

Holistic Health Assessment

A

Comprehensive evaluation of physical, mental, and emotional aspects

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2
Q

Focused Assessment

A

Specific evaluation targeting a particular health issue

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3
Q

System-specific Assessment

A

Evaluation focusing on a particular body system

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4
Q

What are types of physical exams?

A

comprehensive PE
focused PE
system-specific assessment
ongoing assessment

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5
Q

Ongoing Assessment

A

Continuous evaluation over time to monitor changes

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6
Q

Rapport

A

Establishing a positive relationship with the client

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7
Q

Order of physical exam techniques to follow

A

-inspection
-palpation
-percussion
-auscultation
-olfaction

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8
Q

What body system has an exception to the assessment order and what is the order?

A

the abdomen

-inspection
-auscultation
-percussion
-palpation

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8
Q

what happens during the inspection phase?

A

use of sight to gather data & eval each system of body

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9
Q

what happens during the palpation phase?

A

use of touch to gather data

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9
Q

what happens during the percussion phase?

A

tapping of fingers on skin using short strokes- produces vibrations

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9
Q

what happens during the auscultation phase?

A

use of hearing to gather data
direct- no equipment
indirect- equipment

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10
Q

what happens during the olfaction phase?

A

use of smell to gather data

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11
Q

What are component of the general survey?

A

personal Identity, appearance and behavior, body type, speech, mental state, hygiene, vitals, height and weight

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12
Q

What do we observe the skin for?

A

Tone
Temperature
Moisture
Texture
Turgor

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13
Q

what is ecchymosis?

A

bruising

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14
Q

what is petechiae?

A

Tiny pinpoint red or reddish-purple spots

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15
Q

what it mottling?

A

Bluish marbling

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16
Q

what are skin lesions?

A

Variation in pigment or a break in continuous tissue
- always be suspicious of malignancies
ABCDE:
Asymmetry
Border irregularity
Color variation
Diameter >0.5 cm
Elevation above the skin surface

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17
Q

What to assess the hair for?

A

inspect and palpate for
Color
Texture
Distribution
Alopecia
Hirsutism
Scalp
Pediculosis
is it free of debris?

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18
Q

What to assess the nails for

A

color, shape, texture

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19
Q

how to assess eyes

A

Inspect and palpate external eye structures
Assess vision
Examine the internal eye structures

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20
Q

what is visual acuity?

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A

A measure of the eye’s ability to detect the details of an image

Assess distant, near, peripheral, and color vision

21
Q

How to assess the neck

Study These Flashcards
A

palpate the tracheal rings, the cricoid, and the thyroid cartilage, cervical lymph nodes, thyroid

22
how to assess the lungs
Respiratory rate Rhythm Depth Symmetry Palpate: Trachea Chest Chest excursion (expandability)
23
what is rhonchi?
snoring during inspiration and expiration
24
what is friction rub?
high-pitched grating or rubbing sound that may be heard through the resp cycle. loudest over lower lateral anterior field
25
The female client admitted for an unrelated diagnosis asks the nurse to check her back because "it itches all the time in that one spot." When the nurse assesses the client's back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first? 1. Notify the HCP to check the lesion on rounds. 2. Measure the lesion and note the color. 3. Apply lotion to the lesion. 4. Instruct the client to make sure the HCP checks the lesion.
2.
26
The nurse assesses a clients capillary refill. The nurse notes that the capillary refill was > 3 seconds. Is this finding normal or abnormal?
Abnormal
27
What is the nurse assessing? Ask the patient to sit or stand about 2 feet away, facing you sitting or standing at eye level with the patient. Ask the patient to hold the head still and follow the movement of your forefinger or a penlight with the eyes. Keeping your finger or light about 1 foot from the patient's face, move it slowly through the cardinal positions: up and down, left and right, diagonally up and down to the left, diagonally up and down to the right
extra ocular muscles
28
what test as the PT maintain balance with the eyes closed?
romberg test
29
what is the first cranial nerve associated with?
olfaction
30
During the assessment the nurse notes a small lesion on the patients lower gum line. What would be an appropriate follow up question for the client? Is the area of the lesion painful? What does your diet consist of? Do you smoke or use tobacco products?
Do you smoke or use tobacco products?
31
General Survey
Initial overall assessment of the client's appearance and behavior
32
Client Education
Providing information to clients on health assessment and care
33
Body Systems
Organized approach to examining different physiological systems
34
Developmental Differences
Considering developmental variations in assessment and care
35
Direct Auscultation
Listening without using an instrument.
36
Indirect Auscultation
Listening with the help of a stethoscope
37
Olfaction
The use of smell to gather data
38
The General Survey
Overall impression of the client that begins at first contact and continues through the examination, always considering a client's cultural background
39
Erythema
Reddened area
40
Ecchymosis
Bruised (blue/green/yellow) area
41
Petechiae
Tiny pinpoint red or reddish-purple spots
42
Mottling
Bluish marbling
43
Skin Lesions
Variation in pigment or a break in continuous tissue, requiring assessment of size, shape, pattern, color...
44
Visual Acuity
A measure of the eye's ability to detect the details of an image, assessed using distant, near, peripheral, and color vision
45
Capillary refill
It measures how quickly blood returns to the capillaries after they have been compressed and then released. Normal: <3 seconds.
46
Peripheral pulses
Normal: amplitude +2, regular, strong, equal bilaterally
47
Peripheral edema
The swelling of tissues in the extremities, such as the hands, arms, legs, and feet, due to the accumulation of excess fluid in the interstitial spaces.
48
Kyphosis
Abnormal body shape with a rounded back
49
Lordosis
Abnormal body shape with exaggerated inward curvature of the spine
50
Deep tendon reflexes (DTRs)
Reflexes elicited by tapping a tendon with a reflex hammer
51
Superficial reflexes
Reflexes elicited by stimulating the skin
52
Genitourinary System
Includes reproductive and urinary systems
53
Bi-manual exam
Internal examination involving the insertion of two fingers into the vagina

Nursing 1 (20 decks)

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