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Fundamentals of Nursing > 26 Health Assessment > Flashcards

26 Health Assessment Flashcards

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1
Q

5 types of Health Assessment

A

1 comprehensive/initial
2 ongoing/partial
3focused
4 emergency

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2
Q

primary source of info is from…

A

the patient.

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3
Q

preparing patient for physical assessment

A
  • consider physiologic/psychologic needs
  • explain process
  • explain physical assessment will not be painful
  • explain procedure
  • ask patient to change into gown + empty bladder
  • answer patient questions directly + honestly
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4
Q

Sim’s Position

A

laying on left side w right leg and right arm raised

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5
Q

Supine

A

laying on back

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6
Q

Prone

A

laying on belly

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7
Q

Lithotomy

A

laying on back with legs open and raised

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8
Q

Dorsal Recumbent

A

laying on back with legs bent and open

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9
Q

Low Fowlers, Fowlers, High Fowlers

A

Low Fowlers 30 degree
Fowlers 45 degree
High Fowlers sitting, leaning forward

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10
Q

what is high fowler position for

A

breathing problems, feeding issues

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11
Q

General Survey

A
  • general appearance
  • vital signs
  • height, weight, waist measurement
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12
Q

auscultation sound types

A

pitch, loudness, quality, duration

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13
Q

3 places we carry our fluids

A

cells, bloodstream, inbetween

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14
Q

Pitting Edema

A

when an indentation remains after palpation

-may be measured by mm

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15
Q

objective vs subjective data

A 
objective = signs
subjective = symptoms
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16
Q

Health Assessment

A

health history + physical assessment

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17
Q

health history vs physical assessment

A

both make up a HEALTH ASSESSMENT

health hx is collection of subjective info

phys assessment is collection of objective data

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18
Q

Comprehensive Health Assessment

A

broad; incl. complete health hx + physical assessment

-conducted when patient first enters a health care setting

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19
Q

why is a comprehensive health assessment important?

A

makes up the patient’s baseline for comparing later assessments

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20
Q

Ongoing Partial Health Assessment

A

aka follow-up assmt

  • conducted at reg intervals (beginning of each patient visit)
  • focuses on ID’d health problems, to monitor +/- changes, + evaluate intervention effectiveness
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21
Q

Focused Health Assessment

A
  • conducted to assess a specific problem
  • may also address most immediate/highest priority concern for patient
    ex) woman w ab pain:focus will be on urinary, bowel, allergies, or menstrual history
22
Q

Emergency Health Assessment

A

type of rapid focused assessment

-conducted while addressing life-threatening/unstable situation

23
Q

Physical Assessment

sequence

A

1 inspection
2 palpation
3 percussion
4 auscultation

**bilateral body parts are inspected for symetry

24
Q

ecchymosis

A

collection of blood in subcutaneous tissue, causes purplish discoloration

25
Q

lesions

A

diseased or injured tissue

ex) bruise, cut, burn, scratch

26
Q

Abdomen Assessment

sequence

A

1 inspection
2 auscultation
3 percussion
4 palpation

27
Q

why is percussion + palpation sequenced towards the end?

A

they can stimulate bowel sounds

28
Q

Abdomen Auscultation

sequence

A

1 R lower Q
2 R upper Q
3 L upper Q
4 L lower Q

29
Q

PERRLA

A 
pupils are
Equal
Round
Reactive to 
Light +
Accommodations
30
Q

supine is best for…

A

VS, head, neck, lung,s heart, breasts, abdomen, extremities

31
Q

never check a patient’s pulse in these positions

A

standing or sitting can alter the patient’s pulse

32
Q

Prone is best for…

A

hip joint, posterior thorax

33
Q

Knee to chest is best for…

A

anus/rectum… but sim’s is usually more common

34
Q

sitting is best for…

A

lung expansion

35
Q

6 Cardinal Gaze

A
  • checks for 6 extraocular eye muscles are working along with cranial nerves III, IV, VI
  • wagon wheel or H technique
36
Q

Accommodation

A

+++LENS CHANGING ITS SHAPE++
act of physiologically adjusting crystalline lens elements to alter the refractive power and bring objects that are closer to the eye into sharp focus

37
Q

how to check for accommodation

A

have the patient focus on a n object close to the face and move away
-check for pupil constrict/dilate

38
Q

normal bowel sounds

A

gurgles and clicks every 5 - 34 seconds

-can be heard w diaphragm

39
Q

HYPOactive bowel sounds may indicate…

A

post-abdomen surgery or

late bowel obstruction

40
Q

HYPERactive bowel sounds may indicate…

A

diarrhea or early bowel obstruction

41
Q

absent bowel sounds may indicate…

A

peritonitis or paralytic ileus

42
Q

high pitched tinkling of rushes of high pitched sounds may indicate…

A

bowel obstruction

43
Q

diaphragm vs bell for pitch

A

high pitch = diaphragm

low = bell

44
Q

Pitting Edema

grading

A 
1+ 2mm
2+ 4mm
3+ 6mm
4+ 8mm
Brawny fluid can no longer be displaced, no more pitting, tissue palpates as hard + firm
45
Q

Snellen Chart reading

A

someone with 20/60 vision can read at 20 feet away what a person with normal vision could read at 60 feet away

46
Q

percussion checks for…

A

location, shape, size, density of tissues

47
Q

Tonsil Grading

A 
0 removed tonsils
1 hidden w/in pillars
2 extending to pillars
3 beyond pillars
4 extend to midline
48
Q

Orthostatic Hypertension

A

increase in the blood pressure upon assuming an upright posture

49
Q

Otoscope

A

medical device which is used to look into the ears

50
Q

Ophthalmoscope

A

an instrument for inspecting the retina and other parts of the eye.

51
Q

conditions that can lead to Systolic Hypertension

A 
1+ gradual stiffening of large arteries
2 anemia
3 overactive thyroid or adrenal gland
4 malfunctioning aortic valve
5 kidney disease
6 obstructive sleep apnea
52
Q

bell of stethoscope is used for

A

low pitch, hrt murmurs,

Fundamentals of Nursing (17 decks)

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