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Health Assessment > RLE: prelim > Flashcards

RLE: prelim Flashcards

(90 cards)

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1
Q

INTERVIEW PROCESS AND HEALTH HISTORY CHECKLIST PHASES (4)

A

pre-introductory
introductory
working
evaluation/closing phase

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2
Q

COLDSPA

A

character
onset
location
duration
severity
pattern
associated factors

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3
Q

PQRST

A
  • pallative/provoking/precipitating factors
  • wuality
  • radiation/region
  • severity
  • temporal factors/timing
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4
Q

working phase

A
  • demographic data
  • chief complaint
  • HPI
  • past health history
  • family health history
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5
Q

COLDSPA: (How does it feel, look, smell, sound, etc.?)

A

Character

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6
Q

COLDSPA: (When did it begin; is it better, worse, or the same since it began?)

A

Onset

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7
Q

COLDSPA: (Where is it? Does it radiate?)

A

Location

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8
Q

COLDSPA: (How long does it last? Does it recur?)

A

Duration

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9
Q

COLDSPA: (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever experienced]?)

A

Severity

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10
Q

COLDSPA: (What makes it better? What makes it worse?)

A

Pattern

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11
Q

COLDSPA: (What other symptoms do you have with it? Will you be able to continue doing your work or other activities [leisure or exercise]?

A

Associated factors

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12
Q

PQRST: (What makes it better? What makes it worse? (.e.g. argument, exercise, resting)

A

Palliative / Provoking / Precipitating Factors

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13
Q

PQRST: (Describe what exactly is it like? e.g. pressure, dull, aching, tight, squeeze)

A

Quality

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14
Q

PQRST: (Where is the pain? Does it spread anywhere?)

A

Radiation/Region

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15
Q

PQRST: (How severe is it? On a scale of 1 to 10, how would you rate? (mild, moderate, severe)

A

Severity

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16
Q

PQRST: (When did this begin? Does the intensity of the pain change with time? Have you had this before?)

A

Temporal Factors / Timing

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17
Q

During assessment of the head, the nurse inspects and palpates simultaneously and auscultates. The nurse examines the skull, face, eyes, nose, sinuses, mouth, and pharynx.

A

assessing skull and face

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18
Q

normal findings: Inspect the skull for size, shape, and symmetry.

A

Rounded (normocephalic and
symmetric, with frontal, parietal, and occipital prominences);

smooth skull contour

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19
Q

abnormal findings: Inspect the skull for size, shape, and symmet

A

Lack of symmetry, increased skull
size with more prominent nose and
forehead;

longer mandible (may
indicate excessive growth hormone
or increased bone thickness)

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20
Q

normal findings: Palpate the skull for nodules or masses and depressions.

A

Smooth, uniform consistency;

absence of nodules/ masses or
depression

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21
Q

abnormal findings: Palpate the skull for nodules or masses and depressions.

A

Sebaceous cysts;

local deformities from trauma;

masses;

nodules

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22
Q

To indicate an inherited or chronic disorder with typical facies such as Grave’s disease, hyperthyroidism with myxedema, cushing syndrome or acromegaly.

A

Inspect the facial features.

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23
Q

normal findings: Inspect the facial features.

A

Symmetric or slightly asymmetric
facial features;

palpebral fissures equal in size,

symmetric nasolabial folds

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24
Q

abnormal findings: Inspect the facial features.

A

Increased facial hair;

low hair line;

thinning of eyebrows;

asymmetric features;

exophthalmos;

myxedema facies;

moon face

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25
abnormal findings: Inspect the eyes for edema and hollowness.
Periorbital edema; sunken eyes
26
abnormal findings: Note symmetry of facial movements.
Asymmetric facial movements (e.g., eye cannot close completely); dropping of lower eyelid and mouth; involuntary facial movements (i.e., tics and tremors)
27
Inspect skin color (best assessed under natural light and on areas not exposed to the sun). RATIONALE
Some medications can cause photosensitivity reactions after being exposed to the sun. Some clients may exhibit allergic skin reaction to specific drugs.
28
Some medications can cause photosensitivity reactions after being exposed to the sun. It often appears [time] after taking the medication and leaves after [???]
24 hours; discontinuing the medication
29
Normal skin color:
Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive
30
abnormal skin color:
Pallor, cyanosis, jaundice, erythema
31
Inspect uniformity of skin color RATIONALE
As light hits the skin's surface, it is either reflected diffusely back, scattered, or absorbed by particles within the skin.
32
??? is the result of reflected and absorbed light from unpigmented skin, mixed with colors of various constitutive pigments, such as ???
Skin color ; melanin’s, hemoglobin’s, and carotenes
33
normal uniformity of skin color:
Generally, uniform except in areas exposed to the sun; areas of lighter pigmentation (Palms, lips, nail beds) in dark-skinned People
34
abnormal uniformity of skin color:
Areas of either hyperpigmentation or hypopigmentation
35
occurs when something disrupts the usual balance of fluids in your cells.
Edema
36
result of edema
an abnormal amount of fluid accumulates in your tissues (interstitial space). Gravity pulls the fluid down into your legs and feet.
37
[???] edema is common in older adults and pregnant women, but it can occur at any age
Peripheral
38
skin lesion: Touching a patient conveys ??? and ??? (where appropriate) that the patient's rash is ???.
empathy and reassurance; the patient's rash is not contagious
39
an important but underestimated examination modality. ... For localized lesions, palpation identifies tenderness, consistency, induration, depth and fixation.
Palpation
40
normal: Inspect, palpate, and describe skin lesions
Freckles, some birthmarks that have not changed since childhood, and some long-standing vascular birthmarks (strawberry or port-wine hemangiomas), some flat and raised nevi; no abrasions or other lesions
41
nevi
moles
42
abnormal: Inspect, palpate, and describe skin lesions
Various interruptions in skin integrity; irregular, multicolored, or raised nevi, some pigmented birthmarks such as melanocytic nevi, and some vascular birthmarks such as cavernous hemangiomas. Even these deviations from normal may not be dangerous or require treatment. Assessment by an advanced-level practitioner is required.
43
normal/abnormal? strawberry or port-wine hemangiomas
normal
44
normal/abnormal? melanocytic nevi & cavernous hemangiomas
abnormal
45
normal skin moisture:
Moisture in skinfolds and the axillae (varies with environmental temperature and humidity, body temperature, and activity)
46
abnormal skin moisture:
Excessive moisture (e.g., in hyperthermia); excessive dryness (e.g., in dehydration)
47
Palpate skin temperature. Compare the two feet and the two hands, using the ?
backs of your fingers
48
Palpate skin temperature. Compare the two feet and the two hands RATIONALE
Changes in sensation or temperature may indicate vascular or neurologic problems such as peripheral neuropathy related to diabetes mellitus or arterial occlusive disease.
49
Decreased sensation may put the client at risk for ???
developing pressure ulcers
50
normal skin temperature:
Uniform; within normal range
51
skin turgor
fullness or elasticity of skin
52
Note skin turgor (fullness or elasticity) by ???
lifting and pinching the skin on an extremity or on the sternum
53
When you pinch the skin on your arm, for example, it should spring back into place with [duration]
a second or two
54
Having [???] means it takes longer for your skin to return to its usual position. It's often used as a way to check for [???]
poor skin turgor ; dehydration
55
abnormal skin turgor
Skin stays pinched or tented or moves back slowly (e.g., in dehydration).
56
WTD: Skin stays pinched or tented or moves back slowly (e.g., in dehydration).
Count in seconds how long the skin remains tented
57
Examination of the hair includes assessment of [4]
evenness, thickness, texture, and oiliness
58
Inspect the evenness of growth over the scalp. NORMAL
evenly distributed hair
59
Inspect the evenness of growth over the scalp. RATIONALE
Scalp should be free from dandruff, lesion or parasites.
60
Inspect the evenness of growth over the scalp. ABNORMAL
Patches of hair loss (i.e., alopecia
61
Inspect hair thickness or thinness. NORMAL
thick hair
62
Inspect hair thickness or thinness. ABNORMAL
very thin hair
63
very thin hair (e.g., in???)
hypothyroidism
64
Inspect hair texture and oiliness. NORMAL
Silky, resilient hair
65
Inspect hair texture and oiliness. RATIONALE
Hair should be smooth not oily or dry
66
Inspect hair texture and oiliness. ABNORMAL
Brittle hair (e.g., hypothyroidism); excessively oily or dry hair
67
Note presence of infections or infestations by ???
parting the hair in several areas, checking behind the ears and along the hairline at the neck.
68
Note presence of infections or infestations NORMAL
No infection or infestation
69
Note presence of infections or infestations RATIONALE
Many of these conditions show the presence of Staphylococcus aureus [SA] and response to antibiotic therapy
70
Note presence of infections or infestations ABNORMAL
Normal Flaking, sores, lice, nits (lice eggs), and ringworm
71
Inspect amount of body hair. RATIONALE
To determine the quantity, quality and distribution of hair.
72
Inspect amount of body hair. ABNORMAL
Hirsutism (excessive hairiness) in women; naturally absent or sparse leg hair
73
what does naturally absent or sparse leg hair indicate?
poor circulation
74
Perform blanch test of capillary refill.
Press the nails between your thumb and index finger: look for blanching and return of pink color to nail bed. Perform on at least one nail on each hand and foot.
75
Inspect fingernail plate shape to determine its curvature and angle. NORMAL
Convex curvature; angle of nail plate about 160°
76
Inspect fingernail plate shape to determine its curvature and angle. RATIONALE
Determined by the form of the underlying bone. A few layers of dead, compacted cells make the nail strong and rigid, yet somewhat flexible.
77
Inspect fingernail plate shape to determine its curvature and angle. ABNORMAL
Spoon nail; clubbing (180° or greater)
78
Inspect fingernail and toenail texture. NORMAL
Smooth texture
79
Inspect fingernail and toenail texture. RATIONALE
To determine the quality of blood circulation
80
Inspect fingernail and toenail texture. ABNORMAL
Excessive thickness or thinness or presence of grooves or furrows; Beau’s lines discolored or detached nail
81
Inspect fingernail and toenail bed color NORMAL
Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks
82
Inspect fingernail and toenail bed color RATIONALE
Color changes in nails may indicate a local or systemic problem.
83
Inspect fingernail and toenail bed color ABNORMAL
Bluish or purplish tint (may reflect cyanosis); pallor (may reflect poor arterial circulation)
84
Inspect tissues surrounding nails. NORMAL
Intact epidermis
85
Inspect tissues surrounding nails. RATIONALE
The paronychium is the soft tissue border around the nail, and paronychia is an infection in this area.
86
Inspect tissues surrounding nails. ABNORMAL
Hangnails; paronychia (inflammation)
87
Perform blanch test of capillary refill. NORMAL
Prompt return of pink or usual color (Generally, less than 2 seconds)
88
Perform blanch test of capillary refill. RATIONALE
is performed on the nail beds as an indicator of tissue perfusion and dehydration
89
Perform blanch test of capillary refill. ABNORMAL
Delayed return of pink or usual color (May indicate circulatory impairment)
90
the amount of blood flow to tissue
tissue perfusion

Health Assessment (19 decks)

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