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Health Assesment > Midterm > Flashcards

Midterm Flashcards

(74 cards)

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1
Q

What are the dour different types of databases/assessments

A

Complete
Focused
Follow-up
Emergency

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2
Q

What is a complete assessment

A

baseline, provides first diagnoses

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3
Q

what is a focused assessment

A

short-term problem, acute illness

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4
Q

what is a follow-up assessment

A

evaluate previously identified problems (may be acute or chronic disease processes follow up)

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5
Q

what is an emergency assessment

A

developed concurrently with life saving measures

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6
Q

what is the purpose of assessment in the nursing process

A

we assess a patient to first find pain and figure out what is wrong

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7
Q

define the purpose and components of the health history

A 
biographic data
reason for seeking care
history of present illness
past health including family history (Genogram, medication, reconciliation)
review of systems
functional assessment (ADL's)
health perception
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8
Q

describe methods for establishing rapport

A

you build rapport best by letting the patient discuss the concern early and by actively listening, throughout the interview

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9
Q

describe how to ensure comfort

A 
appropriate touch 
moderate rate of speech 
moderate tone of voice 
appropriate eye contact and smiling 
leaning slightly towards the person 
open posture
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10
Q

describe how to define expectations

A

doing a summary at the end of the interview shows what you guys have established

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11
Q

describe the principles of effective communication that apply to the working phase of the interview

A

the data gathering phase
use open-ended and closed question s
also use objective and subjective data

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12
Q

discuss the transcultural considerations of assessment

A 
culturally sensitive
culturally appropriate
culturally competent 
culturally uniqueness
cultural characteristics
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13
Q

the four steps of examination:

A

inspection
palpation
percussion
auscultation

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14
Q

inspection

A

90% of information collected through observation

the use of your eyes

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15
Q

palpation

A

using your sense of touch to assess

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16
Q

percussion

A

tapping to assess tissue density

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17
Q

auscultation

A

listening to body’s sounds
stethoscope has to be on skin
use diaphragm for high pitched sounds (breath, bowel, normal heart sounds)
use bell for low-pitched sounds (hold lightly against the skin, helps to hear extra heart sounds)

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18
Q

24 hour diet recall

A

stating all the food that you have eaten in the last 24 hours

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19
Q

food diary

A

a place to write down all of your intake of food for a period of time

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20
Q

BMI

A

body mass index

BMI>30 = obesity

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21
Q

health history questions important to skin, hair, and nails

A

skin history (allergies and birthmarks)
pigmentation change (localized or generalized)
mole change (appearance, sores that don’t heal)
excessive dryness or moisture (seasonal and constant)
pruritus (mild, intense, onset)
excessive brusing
rash/lesion (onset, location, quality, PQRST)
medication (prescription or over-the-counter)
nail changes (shape, color, brittleness, bite/chew nails)
environmental/occupational
self care

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22
Q

objective data (skin)

A

color, temperature, moisture, texture, thickness, edema, turgor, lesions

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23
Q

objective data (hair)

A

color, texture, distribution, lesions

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24
Q

objective data (nails)

A

skin (shape and contour)
consistency (grooves, thickened)
color
capillary refill (<2 sec)

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25
inspection of posterior chest
shape and configuration of chest walls (spine in straight line, symmetric scapulae and thorax, A:T = 1:2, ribs at 45 degree angle) breathing position skin color and condition
26
inspection of anterior chest
shape and configuration (costal angle <90 degrees) facial expression (related) level of consciousness (alert and cooperative) quality of respirations (effortless)
27
palpation of posterior chest
symmetric expansion: thorax at T9 T10 tactile fremitus: say "99 or blue moon", base lies on diaphragm chest wall: tenderness, temperature, moisture, lumps, lesions
28
palpation of anterior chest
symmetric chest expansion: thumbs along costal margins, pointing to diploid tactile fremitus: say "99 or blue moon", avoid breast tissue chest wal: asses turgor intravascular; tenderness, lumps, temperature, moisture
29
percussion of posterior chest
lung fields: avoid scapulae and ribs, apex at C7 or 2-4 cm above clavicle, base lies on diaphragm resonance (hyper resonance: too much air, low pitch; hyporessoance: abnormal density)
30
auscultation of the posterior chest
``` breath sounds: bronchial, bronchovesicular, vesicular voice sounds: (soft, muffled) crackles (popping) atelectatic crackles wheezes decreased/absent ```
31
what do decreased or absent breath sounds mean
loss of elasticity or brachial tree obstruction
32
what do increased breath sounds mean
consolidation/compression
33
atelectatic crackles
popping sounds that discontinue after breathing or coughing
34
wheezes
connected sound, musical sounding
35
bronchial breath sounds
trachea, larynx | short inspiration and long expiration
36
bronchovesicular breath sounds
bronchi | even inspiration and expirations
37
vesicular breath sounds
peripheral lung fields | long inspiration short expiration
38
palpation of anterior chest
one full breath per spot breath sounds: avoid breast tissue pulmonary function status (pulse oximetry > 90%)
39
developmental changes in the lungs of the aging adult
``` thorax less mobile chest expansion decreased increased A:T diameter kyphosis decreased lung capacity easily fatigued ```
40
s1
systole | mitral, tricuspid (AV) valves close
41
where is S1 loudest
at apex
42
s2
diastole | pulmonic (semilunar) valves close
43
where is S2 loudest
base
44
s3
after s2, early diastole
45
when is s3 abnormal
after 35 years old
46
s4
before S1, late diastole
47
who can S4 occur in
elderly without cardiac disease
48
pericardial friction rub
1st week after MI, pericarditis
49
capillary refill
should return to color in <2 sec
50
thrills
feeling a "purr" like vibration | palpate, murmur
51
heaves
lifting
52
murmurs
unusual sound between heartbeats | sometimes hear a whoosing and swishing sound
53
bruits
turbulent blood flow (blockage)
54
neck vessel assessment
observe and palpate: carotid artery | auscultate: bruit, 3 different places
55
inspection of precordium
heave and lift, ventricular hypertrophy, located at sternal border or apex
56
auscultation of precordium
``` (APE To Man) Aortic valve Pulmonic valve Erbs area Tricuspid valve Mitral valve ```
57
palpation of precordium
cap refill; <2 sec radial and brachial pulses (2+ bilaterally) thrills edema
58
describe the changes that occur in the cardiovascular system during the aging process
``` increase SBP increase L ventricular wall thickness decrease ability to compensate with activity increase dysrhythmias orthostatic hypotension calf veins enlarged ```
59
where do you palpate for epitrochlear lymph nodes
palpate between bicep and tricep muscles (where you take BP)
60
where do you palpate for inguinal lymph nodes
palpate near panty lines
61
describe expected changes in the GI system in aging adult
``` increase fat deposits abdomen muscles relax salvation decreases delayed esophageal emptying gastric acid decreases gallstones increase constipation ```
62
scoliosis
sideways curvature of the spine
63
lordosis
excessive inward curvature of spine (belly out)
64
kyphosis
excessive curvature of the spine outwards (back out)
65
expected changes of musculoskeletal system in aging adult
``` osteoporosis kyphosis loss of muscle mass bony prominences postural changes ```
66
assessment of temporomandibular joint
- inspect: no swelling crepitus or pain - palpate: spinous processes, muscles firm, no hardness or tenderness - rom: head flexion and extension, lateral motion, protrude without deviation - muscle strength: push down on chin
67
assessment of cervical spine
- inspect: spine straight, head erect, muscles symmetric - palpate: spinous processes, muscles firm, no hardness or tenderness - rom: head flexion and extension, lateral bending and rotation - muscle strength: rotation and lateral bending with resistance
68
assessment of the shoulders
- inspect: redness, symmetry, deformity, swelling, atrophy - palpate: warmth, hardness, tenderness, crepitus - ROM; abduction and adduction, forward flexion and hypertension, internal and external rotation - muscle strength: shrug w resistance, abduct and adduct with resistance
69
assessment of elbow
- inspect: swelling, redness, deformity - palpate: tenderness and nodules - ROM: flexion and extension, pronation and supination - muscle strength: flexion and extension w resistance
70
assessment of wrist and hand
- inspect: contour, position, shape, digits - palpate: heat, tenderness, nodules - ROM: hyperextension, flexion and extension, ulnar and radial deviation, opposing digits - muscle strength: grip
71
assessment of hips
- inspect: standing and walking, symmetry, gait - palpate: no instability or tenderness, crepitus - ROM: internal and external rotation, abduction and adduction, hyperextension - muscle strength: raise and lower leg w resistance
72
assessment of the knees
- inspect: skin, deformity, swelling, symmetry - palpate: quadriceps muscles, patella - ROM: flexion, extension, hyperextension
73
assessment of ankle and foot
- inspection: standing and walking, symmetry - palpate: no tenderness - ROM: dorsiflexion and plantar flexion, eversion and inversion - muscle strength: dorsiflexion and plantar flexion w resistance
74
assessment of spine
- inspect: shoulders, scapulae, spinal curvature - palpate: spinous processes, straight - ROM: flexion and extension, hyperextension, lateral bending and rotation

Health Assesment (4 decks)

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