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Health Assessment > Test #2 > Flashcards

Test #2 Flashcards

(47 cards)

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1
Q

Neurological Assessment: Critical Findings

A

Sudden decline in alertness
Sudden change in speech or new on set of speech difficulties
Signs of stroke or transient ischemic attack
Sudden onset of severe headache
Signs of raised intracranial pressure
Sudden onset of weakness, numbness, eye movement problems and/or double vision
Seizures
Lethargy that persists beyond appropriate times and circumstances

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2
Q

olfactory nerve

A
  • not routinely tested, only when there is report of loss of smell, head trauma, abnormal mental status, or when intracranial lesion is suspected
  • with eyes closed have patient identify an aromatic substance - one nostril at a time
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3
Q

optic nerve

A
  • snellen eye chart (far away)
  • jaeger card (up close)
  • confrontation test
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4
Q

Cranial nerves 3,4,6

A
  • check pupil size, regularity, and equality
  • direct and consensual light reactions
  • accommodation
  • extra ocular movements
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5
Q

trigeminal nerve

A
  • test sensory function using cotton wisp
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6
Q

facial nerve

A
  • make 3 facial movements (note symmetry)
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7
Q

vestibulocochlear nerve

A
  • whispered voice test
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8
Q

glossopharyngeal & vagus nerve

A
  • depress the tongue and note pharyngeal movement as the patient says “ahhhh”
  • gag reflex
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9
Q

accessory nerve

A
  • Assessing size, strength, ROM, and resistance of the sternocleidomastoid and trapezius
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10
Q

hypoglossal nerve

A
  • Inspect the muscle of the tongue for symmetry at rest and with movement
  • Clear lingual speech
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11
Q

balance tests

A
  • gait
  • tandem walking
  • Romberg test
  • shallow knee bend
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12
Q

coordination skilled movement

A
  • rapid alternating movement
  • finger to finger
  • finger to nose
  • heel to shin
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13
Q

Spinothalamic tract

A

Pain (sharp dull)
Temperature
Light touch (yes or now) (cotton ball wisp)

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14
Q

Posterior column tract

A
  • Vibration (tuning fork)
  • Position (kinesthesia) (patients eye closed, passive ROM)
  • Tactile discrimination (fine touch)
    - Stereognosis (put something in their hand and see if they can identify it)
    - Graphesthesia (patients eyes closed, write a letter or number in their hand)
    - 2 point discrimination (distance between sensations, closer together 2 points of contact feel like 1)
    - Extinction (touch on both sides on body)
    - Point location
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15
Q

neurological recheck

A 
Level of consciousness (person, place, time)
Motor function
Pupillary response
Vital signs 
Glasgow coma scale (GCS)
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16
Q

Mental Health Assessment - Components

Only In Europe People Compete

A 
Observation
Interview
Examination
Physical assessment 
Collaboration
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17
Q

Indication for Comprehensive Mental Health Nursing Assessment

A

Behaviour changes
Brain lesions (trauma, tumor, stroke)
Aphasia (caused by brain damage)
Symptoms of psychiatric mental illness

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18
Q

mental health status examination - domains

A

appearance
behaviour
cognition
thought

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19
Q

mental health domains

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A

appearance - posture, body movements, dress, grooming and hygiene
behaviour - level of consciousness, facial expressions, speech, mood and affect
cognitive functions - orientation, attention span, immediate memory, recent memory, remote memory, new learning
thought - is their thought process linear, content, perceptions, do they understand why they are in the hospital

20
Q

supplemental mental status examination

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A

MoCA - quick, good for detecting mild cognitive impairment, dementia
Mini-Cog - 3 word registration, clock drawing
Mini mental status examination - used to test cognitive function in the elderly, more severe conditions

21
Q

breath sounds

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A

Bronchial breath sounds - (expiration > inspiration)
Bronchovesicular breath sounds - characteristics (inspiration = expiration)
Vesicular breath sounds - characteristics (inspiration > expiration)

22
Q

respiration patterns

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A 
Sigh 
Tachypnea 
Bradypnea 
Hyperventilation
Hypoventilation 
Cheyne-stokes respiration 
Biot’s respiration
Chronic obstructive breathing
23
Q

adventitious lung sounds

Study These Flashcards
A

Discontinuous

  • Crackles - fine
  • Crackles - course
  • Atelectatic crackles
  • Pleural friction rub

Continuous

  • Wheeze - high pitched (sibilant)
  • Wheeze - low pitched (sonorous rhonchi)
  • Stridor
24
Q

Lymphatics

Study These Flashcards
A 
Preauricular 
Posterior auricular (mastoid)
Occipital 
Submental 
Submandibular
Tonsillar 
Superficial cervical 
Deep cervical 
Posterior cervical
Supraclavicular
25
lymphatic system: objective data
``` Head - inspect and palpate the skull Size and shape (normocephalic = normal size & shape) Temporal area Head - inspect the face Facial structures inspect and palpate - symmetry - range of motion - lymph nodes thyroid gland ```
26
extra ocular muscle function
- corneal light reflex - tells about muscle weakness - light points to the side that is weaker
27
use of ophthalmoscope
Contains set of lenses - unit of strength is diopter - Positive diopters (black) focus on near objects - Negative diopters (red) focus on objects farther away
28
Ocular funds - Inspection
Retinal Vessels - Number - Colour - Artery-vein ratio - Calibre - Arteriovenous crossing - Tortuosity - Pulsations Red reflex Optic Disc - Colour - Shape - Margins - Cup-disc ratio (⅓:1)
29
types of hearing loss
- conductive - sensorineural - mixed
30
auditory system levels
- peripheral - brain stem - cerebral cortex
31
subjective data: Ears
``` Earaches Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo Self-care behaviours ```
32
objective data: ears
External ear - inspect and palpate - Size and shape - Skin condition - Tenderness - External auditory meatus External Canal - Colour - Swelling - Lesions/foreign bodies - Discharge (colour, odour) Tympanic Membrane - Colour and characteristics - Position - Integrity of membrane - Should be cupping inward (if its popping out there is to much pressure in the middle ear)
33
Testing hearing acuity
- conversational speech - whispered voice test - tuning fork tests (weber, rinne)
34
Subjective data: nose
``` Discharge Frequent colds (upper respiratory infections) Sinus pain Trauma Epistaxis (nosebleeds) Allergies Altered sense of smell ```
35
subjective data: mouth and throat
``` Sores and lesions Sore throat Bleeding gums Toothache Hoarseness Dysphagia (difficulty swallowing) Altered taste Smoking, alcohol consumption Self care behaviours ```
36
physical exam: nose
inspect and palpate - external nose - nasal cavity - palpate frontal and maxillary sinuses
37
physical exam: mouth
inspect - Lips - Teeth and gums - Ask if they have trouble chewing - Tongue - Buccal mucosa - Palate and uvula
38
physical exam: throat
inspect - tonsils (1-4) - posterior pharyngeal wall
39
nutritional status
The degree of balance between nutrients intake and nutrient requirements
40
optimal nutritional status
Consumption of nutrients in amounts that support daily growth and any increased metabolic demands
41
undernutrition
Depletion of nutritional reserves or adequate intake to meet daily requirements
42
over nutrition
Consumption of nutrients in excess of requirements
43
nutrition screening
Malnutrition screening tool Comprehensive nutritional assessment 24 hour food recall (everything that was eaten in the last 24 hours) Food frequency questionnaire Food diaries Direct observation Canada’s food guide and dietary reference intakes
44
subjective data: nutrition
Eating patterns Usual weight/recent changes Changes in appetite, taste, smell, chewing, swallowing Recent surgery, trauma, burns, infection Chronic conditions Nausea, vomiting, diarrhea, constipation Food allergies Medication and/or nutritional supplements Self management behaviours/access to healthy foods Alcohol or illegal drug use Exercise and activity patterns Family history Psychological problems Physical impairments that limit ability to independently consume foods or liquids
45
derived weight measures
current weight/usual weight x 100 ``` 85-95% = mild malnutrition 75-84% = moderate malnutrition <75% = severe malnutrition ```
46
Keys to a healthy diet
Eat a variety of foods from all food groups Consume recommended amounts Limit intake of saturated fats, trans fat, added sugars, starch, cholesterol, salt, and alcohol Match caloric intake with calories expended Engage in 30-60 minutes of moderate physical activity most days Follow food preparation guidelines for handling, preparing, and storing foods
47
objective data: nutrition
Derived weight measurement Body weight as percent of ideal body weight Percent usual body weight Recent weight change

Health Assessment (3 decks)

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