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Nursing 202 > The Complete Health Assesment > Flashcards

The Complete Health Assesment Flashcards

1
Q

Subjective data-Health History

A

biographical data
reason for seeking care
history of present illness
past medical history
allergies
family history, social history
current meds
review of systems
functional assessment or activities of daily living

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2
Q

Functional assessment (ADL, IADL)

A

are you retired
stairs?
driving
food (prep, delivery, nutrition)
community of support (family, community care, Meals on Wheels)
Getting up from the chair, off the exam table
devices

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3
Q

Objective Exam for adults

A

general appearance
measurements
skin
head and face
eye
ear
nose
mouth and throat
neck
chest
upper extremities
breasts
heart
\neck vessels
abdomen
inguinal area
lower extremities
MSK
Neuro
genitalia
rectum

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4
Q

Seated-in gown, what do you assess

A

skin
vital signs
head and face
eye
ear
nose
mouth and throat
neck
chest
heart
upper extremities
breasts

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5
Q

Patient sits up-what do yuo assess

A

neuro and msk

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6
Q

Patient stands up, what do you assess?

A

lower extremities
msk

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7
Q

Supine (laying down), what do you assess

A

breasts, neck vessels, heart, abdomen, inguinal area, lower extremities

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8
Q

Objective data for newborns and infants

A

position-supine
reorder the sequence based on sleep and wakefulness
vital signs
measurement (weight, length and head circumference plotted on growth curves)
General appearance (body symmetry, strong cry)
chest and heart (apical rate, abdominal movement with respirations (retraction)
abdomen-umbilicus and skin turgor
Head and face-moulding of cranium, fontanels
eyes-pupillary, blink, corneal light reflexes
ears-startle reflex
nose/mouth/throat-nasal flaring, salivation, rooting and sucking reflexes
neck-head lag, tonic neck reflex
upper extremities-absence of scarf signs, palm creases, grasp reflex
lower extremities-ROM,syndactaly(fused fingers/toes), ortolani manoevre
Genitalia
Neuro-Doll’s eye reflex, stepping and placing reflexes
Spine/rectum-trunk incurvation reflex, symmetry of gluteal folds, patent anal opening
Final-auditory canals with otoscope

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9
Q

Objective Data for young children

A

Considerations-desire for independence, fear of new environment, fear of invasive procedures, dislike of restraint
health history
general appearance-NPDDS
Soocial interactions, speech
Measure height and weight
Chest and heart-apical pulls, thrills, tactile fremitius

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10
Q

Objective data for young children

A

genitals-palpate scrotum for testis
lower extremities-orolani manoevre
head and neck-fontanelles and cranium, head circumference

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11
Q

Documentation and critical thinking

A

record data as soon as possible after exam
consider legal responsibility in documentation
balance between recording too much and too little data
succinctness-short clear phrases
avoid redundent descriptions
use simple line drawings

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12
Q

The hospital setting

A

need for consistent, specialized, focused, examination at least every 8 hours
utility of measurement depends on consistency in procedure from nurse to nurse
documentation and communication (SOAP and SBAR
initial assessment vs ongoing frequent assessments

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13
Q

SOAP charting

A

fascilitates clinical reasoning
Subjective
Objective
Assesment
Plan

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14
Q

SBAR Technique

A

fascilitates communication
Situation
Background
Assessment
Recommendation

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15
Q

Subjective and objective data in the hospital

A

health hisotry-refer from pervious shift report and assess for pain
general appearance-personal hygiene
Measurement-vital signs, pulse oximetry, pain level rating at rest and with activity, following analgesia

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16
Q

Analgesia

A

inability to feel pain

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17
Q

Assist patient to bed

A

check general appearance
measurement
neuro
respiratory system

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18
Q

Subjective and objective neuro

A

eyes open to me
motor response is strong and equal
verbal response appropriate, clear speech
pupil response
muscle strength in upper and lower extremities
facial droop
sensation
ability to swallow

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19
Q

Subjective data and objective data-respiratory system

A

check 02 delivery method
note FiO2
respiratory effort
SOB on rest, exertion
asuculatet bresth sounds
check cough
spirometer use

20
Q

Subjective and objective assessment-cardiac

A

rythym at apex, apical and radial pulse
heart sounds in all auscultory zones
capillary refill
palpate pedal pulses
use doppler if needed
skin-assess temperature, colour, turgor, integrity, condition of dressings, Brdaen Risk Assesment

21
Q

Objective and subjective data of abdomen

A

bowel sounds, palpation in all four quadrants
nausea or vommiting
drainage tubes-placement, colour, consistency, and odour amount
stoma
tolerating diet

22
Q

Objective and Subjective GI system

A

regular voiding-amount, colour
indwelling catherter in place
bladder scan as protocol if decreased urinary output

23
Q

Critical Findings

A

systolic BP
Temp
Heart Rate
Respiratory rate
O2 saturation
Urine output
Postoperative nausea (not relieved by meds)
surgical pain not controlled with analgesia
bleeding
altered level of conscious, confusion
sudden, restlessness, anxiety

24
Q

SBAR Framework

A

Situation, background, assesement, recommendation
tool to organize verbal communication
focuses on immediate problem and keeps message concise

25
Q

Measurement

A

Height
Weight
BMI

26
Q

Vital signs

A

radial pulse
respirations
blood pressure
temperature
oxygen saturation
pain assessment

27
Q

Order of examination

A

Head to toe assessment
systems assessment

28
Q

Head and face

A

inspect scalp, hair, and cranium
inspect face, expression, symmetry

29
Q

Eyes

A

inspect external eye structures, conjunctivae, sclerae, corneae irides
test pupils size and response to light and accomodation

30
Q

Ears

A

inspect extrnal ear position and alignment, skin condition and auditory meatus
move aurcile and push tragus for tenderness
using an otoscope, inspect the canal and tympanic membrane, colour, position, landmarks and integrity

31
Q

Nose

A

symmetry and lesions

32
Q

mouth and throat

A

buccal mucosa, teeth, gums, floor of mouth, palate, uvula
tonsils if present
uvula mobility and gag reflex
stcick tongue out

33
Q

neck

A

symmetry, lumps and pulsations

34
Q

neck vessels

A

jugular venous pulse

35
Q

Upper extremities

A

inspect skin, symmetry, temp, pulses
ROM and muscle strength of hands-wrists, fingers, arms, shoulders and elicit the reflexes

36
Q

chest and thoracic area

A

inspect and auscultate

37
Q

anterior chest

A

respirations and skin and auscultate breath sounds

38
Q

heart

A

inspect and palpate the precordium for pulsations and lift
auscultate with diaphragm
auscultate apical rate and rythym
auscultate with bell at locations

39
Q

abdomen

A

inspect contour, symmetry, skin, characteristics, umbilicus, pulsations
auscultate bowel sounds
ausultate for vascular signs over the aorta and renal arteries
percuss all quadrants
plapate-in all quadrants
(IAPP)

40
Q

Lower extremities

A

inspect the symmetry, skin characteristics, hair distribution, varicose veins
palpate pulses: popiteal, posterior tibial, dorsalis pedia
palpate for temp and edema
separate toe and inspect
test ROM and muscle strength (hips, knees, ankles, feet
Test reflexes

41
Q

Standing MSK

A

GAit (tandem walking-toe to toe)
assess rombergs sign

42
Q

Romberg’s signs

A

sense of balance-stand and close eyes

43
Q

While standing-the back

A

Check spine as person touches their toes
asses range of motion of the spine as person hyperextends, rotates and bends laterally
assess the spinous process as the person bends forwards

44
Q

Neurologic

A

test sensation
test rapid alternating movements-upper extremity function
test lower extremity function by asking each person to run each heel down the oppoiste shin

45
Q

Neurologic

A

test sensation
test rapid alternating movements-upper extremity function
test lower extremity function by asking each person to run each heel down the opposite shin

Nursing 202 (15 decks)

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