Health Assessment Exam 2 Flashcards

Question

Inspecting/Palpating the Tongue

Answer 1

Ask the patient to touch the roof of the mouth with the tongue inspect tongue: - Floor - Frenulum: thin fold tissue connects underside to the floor of the mouth - Ventral surface: inferior aspect of tongue - Wharton’s ducts: saliva tube from submandibular gland to mouth Using gauze, gently palpate the tongue for lumps Normal Findings: - Color pink and saliva present - Papillae on dorsal surface - Midline position - Ventral surface smooth, pink, moist - No lumps or nodules with palpation - Wharton’s and Stensen’s ducts visible Abnormal Findings: - Cracked, dry, red, presence of ulcers or lesions, bleeding, thick white or yellow coating - Atrophic glossitis - Hairy tongue - Leukoplakia - Squamous cell carcinoma

Answer 2

Assess for redness/inflammation Normal Findings: - Uvula rises midline symmetrically - Throat pink - Tonsils pink; may partially protrude or be absent + (presence of) gag reflex Abnormal Findings: - Asymmetrical rise of the uvula - Throat deep red, inflamed, with drainage - Throat pain - Tonsils protruding with or without drainage - Tonsilitis (Grading 1–4 scale) - Pharyngitis

Answer 3

Assess symmetry, movement, swelling of the neck ROM: range of motion Normal Findings: - Symmetrical, no swelling - No pain with ROM - Full ROM of neck Abnormal Findings: - Asymmetrical - Pain with movement - Unable to perform ROM movements - Torticollis: tilted, asymmetrical head/neck

Answer 4

Assess for tracheal shift or deviation. - Ask the patient to sit up straight and bend her or his head slightly forward. - Inspect the trachea below the thyroid isthmus. - Gently place your right index finger in the sternal notch. - Slip your finger off to each side, noting distance from the sternomastoid muscle. - Assess the symmetrical spacing on each side and note any deviation from midline. Normal Findings: - Trachea is midline - space is symmetric on each side Abnormal Findings: - Trachea is deviated from midline

Answer 5

Further assessment of an enlarged thyroid gland is necessary to check for presence of a bruit, increased, turbulent blood flow. - Patient sits up straight with neck slightly flexed. - Using the bell of the stethoscope, auscultate both lobes of the thyroid gland for a bruit (sound when blood flows through narrowed artery). - Assess for a “whooshing” sound Normal Findings: - No bruit is heard Abnormal Findings: - A bruit is heard

Answer 6

Goal: Improve oral health by increasing access to oral healthcare, including preventative services

Answer 7

Normal Findings: - Hyperpigmentation: birthmarks, sun damage, freckles, tan lines - Hypopigmentation: scars, stretch marks, vitiligo Abnormal Findings: - Pallor: face, conjuctivae, lips, buccal, mucosa (causes: anemia, shock, lack of blood flow) - Erythema: face, skin, pressure sore areas (causes: inflammation/infection, vasodilation, sun exposure, rash) - Cyanosis: best place to note in darker skin tones is mucous membranes and nail beds (causes: hypoxia, impaired venous return) - Jaundice: skin, sclera, mucous membranes (causes: liver dysfunction)

Answer 8

Abnormal Temp: hyperthermia, hypothermia Abnormal Texture: velvety skin (thyroid disease), roughness, xerosis (dryness), flakiness (dehydration) Abnormal Moisture: diaphoretic Abnormal Turgor: edema, tenting

Answer 9

Accumulation of fluid in the tissue, skin is shiny and tight Assess over a boney area (shin): - +1: trace, 2mm, rapid return - +2: mild, 4mm, 10-15 sec return - +3: moderate, 6mm, prolonged return - +4: severe, 8mm, prolonged return

Answer 10

Results from blood leaking into the dermis Petechiae: infection or trauma Ecchymosis: trauma (collection of blood in dermis >3mm in diameter); purple fading to green or yellow Purpura: infection or bleeding disorder

Answer 11

Asymmetry Border: irregular, scalloped/poorly defined Color: varied from one area to another Diameter: usually greater than 6mm when diagnosed Evolving: mole/skin lesion that looks different from the rest

Answer 12

Macule: freckles, mole, measles, scarlet fever Patch: birthmark, vitiligo, hormonal changes

Answer 13

Plaque: psoriasis, eczema Papule: wart, elevated mole, skin tag

Answer 14

Tumor: neoplasm Wheal: insect bites, allergic reaction, hives Nodule: melanoma

Answer 15

Pustule: acne, cold sore Cyst: cystic acne, sebaceous cyst Bulla: blister, medication reaction

Answer 16

Color: - Red: healthy regeneration - Yellow: presence of purulent drainage/slough - Black: presence of eschar Size: length, width, depth, undemining, tunneling Exudate: - odors, amount, consistency - Serous: clear - Sanguineous: blood - Serosanguineous: clear & bloody - Purulent: pus Surrounding Skin: intact, macerated (soft, white, wrinkled), edematous (edema), erythematous (red/flushed)

Answer 17

- Reddened area, does not blanch at pressure - Skin intact - Texture firmer/softer than surrounding tissue - Darker skin tones (blue/purple hue) - Never rub a reddened area

Answer 18

- Partial thickness loss to dermis - Skin breakdown of the epidermis/dermis - Red/pink, shiny wound bed - Appears as a blister, abrasion, very shallow crater

Answer 19

- Full thickness skin loss with damage to subcutaneous tissue - Dead tissue may be present in wound bed - Deep without exposed muscle or bone

Answer 20

- Full thickness skin loss resulting in exposed bones, tentions, muscles - Tissue necrosis/damage to muscle, bone, or underlying structures - Slough, eschar, tunneling, undermining

Answer 21

- Ulcer covered with eschar or slough - Depth unknown

Answer 22

- Discoloration but skin intact - Damage to underlying tissue - Appears as a bruse with intact skin

Answer 23

- Inspect skin daily - Wrinkle free linen - Reposition q2h, shift weight q15min - <1hr in chair - Head Of Bed (HOB) <30 - Float heels, Ambulate ROM - Lift Device - Speciality Mattress - Assess: Braden Scale - Clean skin with warm water & little friction, moisture barrier cream - Nutrient dense foods: high protein diet - Provide wound care per facility guidelines

Answer 24

Auricle: helps direct sound to the eardrum Helix: prominent outer rim of the auricle Tragus: protuberance anterior to the auditory canal Lobule: soft lobe on the bottom of auricle Malleus, Incus, Stapes: bones transmit sound waves from the eardrum to the inner ear and the eustachian tube Cochlea, Semicircular Canal: transmits sound waves through the auditory nerve to the brain Cranial Nerve 8 (Vestibulocochlear) transmits sound and information Sound Frequence: - Pitch of sound - measured in Hertz (Hz) Sound Intensity: - Volume of sound - Measured in Decibels (dB)

Answer 25

Normal Findings: - Color same as facial skin - Equal size and shape bilaterally; normal size (4 cm to 10 cm) - Symmetrical - No deformities, inflammation, nodules, or drainage - Angle of attachment < 10 degrees Abnormal Findings: - Color is blue, red, white, or pale - Asymmetrical - Lesions - Drainage - Cauliflower ear - Microtia: malformed outer ear (birth defect) - Macrotia: abnormally large ears (medical condition) - Tophi: uric acid crystals form around joints, causes inflammation and pain

Answer 26

Cranial Never 8 (Vestibulocochlear) Assess for impaired/loss of hearing - Conductive: - Sound isn't conducted through the outer ear canal to the eardrum & ossicles - Earwax buildup, fluid, ear canal rupture, obstruction, middle ear infection, otosclerosis, sinus infection - Sensorineural: - Damage to the inner ear (cochlea) or never pathways from the inner ear to the brain - Congenital rubella syndrome, cytomegalovirus (CMV), toxoplasmosis, certain meds, multiple sclerosis, inner ear disorders

Answer 27

Assess unilateral hearing loss Use 512 Hz tuning fork Normal Findings: - Sound quality is heard equally in both ears Abnormal Findings: - Sound is perceived louder in the good ear & softer in the bad ear (Sensorineural hearing loss) - Sound is perceived louder in the bad ear (Conductive hearing loss)

Answer 28

Assess hearing by bone conduction vs air conduction Use 512 Hz tuning fork - Place fork on mastoid bone 1 inch from the ear Normal Findings: - Positive Rinne: Air conduction is 2x bone conduction Abnormal Findings: - Negative Findings: Bone conduction is longer than air conduction

Answer 29

Normal Findings: - External ear canal patent - No inflammation or drainage - Small amount of pale yellow, moist wax - Tympanic membrane intact, pearly gray color; translucent; contour slightly conical - Bony landmarks visible - Cone of light present Abnormal Findings: - Excessive ear wax - Otitis externa: redness/swelling of external ear canal - Otitis media: infection of middle ear - Serous otitis media: middle ear fluid without acute infection - Otomycosis: fungal infection in the ear canal - Scarred/perforated tympanic membrane

Answer 30

- Prevent sensory & communication disorder & improve quality of life for people - Wear ear protection - Get hearing test regularly

Answer 31

CN 1: Olfactory - recognize smell CN 2: Optic - visual acquity, Snellan Test CN 3: Oculomotor - PERRLA CN 4: Trochlear - up & down eye movement CN 5: Trigeminal - facial sensation CN 6: Abducens - side to side eye movement CN 7: Facial - smile, frown, raise eyebrows CN 8: Vestibulocochlear - cover ear & whisper or snap, assess patients gait CN 9: Glossopharyngeal - gagging & swallowing, have patient say "ah" and yawn

Answer 32

Assess the external eye structures Abnormal Findings: - Asymmetrical/protruding - Drainage - Cornea is not smooth - Unequal pupils - Lacrima ducts red/inflamed - Palpebral fissures unequal - Abnormal spasms - Belpharitis: inflammed eyelids - Cataract: clouded lens - Conjuctivitis: inflammed conjuctiva - Corneal abrasion - Ectopion: lower eyelid turns outward - Entropion: eyelids roll inward - Exophthalmos: bulging eyeball from sockets - Hordeolum: infection of oil gland in eyelid - Icterus: jaundice - Pterygium: fleshy growth develops in the conjuctiva and can extend to the cornea - Ptosis: upper eyelid droops

Answer 33

Measure & assess visual acuity using Snellen Chart Abnormal Findings: - Higher denominator = poorer distant acuity - Myopia: nearsightedness - Hyperopia: farsightedness - Presbyopia: gradual loss of the ability to focus on nearby objects - Legal blindness: vision 20/200

Answer 34

Assess the ability to distinguish colors using Ishihara Plate Abnormal Findings: - Patient incorrectly identifies the colors/doesn't see the colors

Answer 35

Assess using Amsler Grid - Checks everyday eyesight - Can help diagnose & monitor conditions that distort the surface of the macula - Focus on the dot in the middle, ask if any lines are distorted, broken, blurred, missing, mark the areas not seen

Answer 36

Assess peripheral vision, overall field of vision, blind spots Move fingers at the following angles: - Temporal: 90 Degrees - Nasal: 60 Degrees - Superiorly: 50 Degrees - Inferiorly: 70 Degrees Abnormal Findings: - Scotoma: blind spot in one/both eyes - Hemianopia: loss of vision/blindness in half the visual field

Answer 37

Assess the functioning of the ocular muscles Have patient follow pen/finger with eyes from 12-14 inches away in an "H" & "star" pattern Abnormal Findings: - Patient is unable to follow the movement in each of the six cardinal directions - Diplopia: double vision - Nystagmus: uncontrolled eye movement

Answer 38

Assess pupillary light reflex & integrity of optic pathways Abnormal Findings: - Anisocoria: one pupil bigger than the other - Mydriasis: dilated pupil - Miosis: excessive pupil constriction - Horner's Syndrome: rare neurological syndrome, drooping upper eyelid, constricted pupil, bloodshot eye, lack of sweating

Answer 39

- Cone-shaped, air-filled structure - Acid-base balance maintains blood pH through the release of carbon dioxide from the lungs during each respiratory cycle - Pleura is a serous membrane - Parietal Pleura: produces pleural fluid between the two pleurae to keep the area lubricated for easy movement - Visceral Pleura: secretes a serous fluid that also lubricates the pleural cavity to help keep the lungs expanded

Answer 40

- Blood test that takes a sample from the artery to measure the levels of oxygen and carbon dioxide - Checks the balance of acids and bases in your blood - Test can help interpret conditions that affect your respiratory, circulatory and metaboli processes

Answer 41

- Using a needle to take fluid out from around your lungs (pleural space) - Some medical conditions/diseases cause fluid to leak into the pleural space (pleural effusion), making it hard to breathe

Answer 42

- Uses a bronchoscope through the nose or mouth to look directly at the airways in the lungs - Can see the larynx (voice box), trachea, bronchi (large airway to the lungs), bronchioles (smaller branches of the bronchi) Rigid Bronchoscope: - remove large amount of secretions/blood, foreigh objects, lesions (diseased tissue) - control bleeding - do procedures such as stents Flexible Bronchoscope: - can move to the bronchioles - used to place breathing tube - suction out secretions, take tissue samples, put medicine in lungs

Answer 43

uncomfortable awareness of the act of breathing

Answer 44

Difficulty breathing while lying down

Answer 45

shortness of breath when the patient is asleep in bed

Answer 46

Normal Findings: - AP-transverse ratio is approximately 1:2 - Conical shape - Symmetrical - Skin color uniform - Respiratory rate 12 to 20 breaths per minute Abnormal Findings: - AP-transverse ration is approximately 1:1 - Pectus excavatum: sternum/ribs curve inward - Pectus carinatum: sternum/ribs protrude outward - Muscle retractions - Abnormal respirations - Abnormal skin color - Clubbing of nail plates (COPD symptom)

Answer 47

Normal Findings: - Skin dry - Surface smooth and uniform - Warm skin - No tenderness Abnormal Findings: - Excessive moisture - Irregular surface - Temperature cool or clammy - Tenderness - Crepitus: light crackling or popping feeling under the skin caused by leakage of air into the subcutaneous tissue

Answer 48

Crackles: - Produced by air passing over retained airway secretions - Usually heard at the end of inspiration but may be heard on inspiration or expiration - May be cleared by coughing - Fine crackles are soft, high-pitched sounds; sounds like crunching, or a fine rubbing sound - Coarse crackles are louder, low-pitched lung sounds (sounds like ripping open Velcro) Rhonchi: - Louder, deeper, lower-pitched wheezes occurring in the upper bronchi - May be related to obstruction of the larger airways - Commonly heard during exhalation - Sounds like snoring. Wheezes: - Caused by narrowed passageways in the trachea-bronchial tree by secretions, inflammation, obstruction, or a foreign body - High-pitched, whistling or musical sound Pleural Friction Rub: - Caused by inflammation of the parietal and visceral pleurae that normally slide without friction - Deep loud, harsh, leathery sound - Heard during inspiration and expiration Stridor: - Caused by inflammation of the parietal and visceral pleurae that normally slide without friction - Deep loud, harsh, leathery sound - Heard during inspiration and expiration

Answer 49

Assess lung functioning & forced expiratory volume of air in the lungs - Have patient take a deep breath, place PFM in mouth with tongue under the mouth peice - Have patient close lips tightly and blow hard/fast as possible - Take few normal deep breaths and repeat process 2x - Record highest number Normal Findings: - Green Zone: 80-100% highest peak flow Abnormal Findings: - Yellow Zone: 50-80% personal best - Red Zone: <50% personal best

Answer 50

- Stop smoking - Avoid exposure to environmental pollutants - Prevent infection - Get vaccinated - Exercise

Health Assessment Exam 2 Flashcards

(74 cards)