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Assessment Flashcards

0
Q

Reg capillary refill?

A

Under two secs

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1
Q

Nevus assess? ABCDE

A

asym, border irregularity, color variation, diameter >6mm, elevation enlargement

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2
Q

When does clubbing of nails occur?

A

Oxygenation probs

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3
Q

Assess LOC?

A

Times 3 person place time

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4
Q

Micro/macrocephalic?

A

Small/big head

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5
Q

Stuporous

A

Lack of critical cog function

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6
Q

Comatose

A

Coma

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7
Q

Sclera?

A

White of eye

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8
Q

Conjunctiva?

A

Inside of eyelid

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9
Q

Caries

A

Tooth decay

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10
Q

Furrowed

A

Groove

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11
Q

Mydriasis

A

Dilation

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12
Q

Fixed and constricted

A

Miosis

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13
Q

Bulging

A

Exopthalmus

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14
Q

Strabismus?

A

Cross eyed

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15
Q

Ptosis

A

Dropping of upper lid

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16
Q

Ectropian

A

Lower lid is loose and rolling out

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17
Q

Entropion

A

Lower lids roll in

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18
Q

What are eyes PERRLA

A

Pupils equal round reactive to light accommodation

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19
Q

Lymphadenopathy?

A

Enlargement due to infection or inflammation

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20
Q

Scoliosis

A

S haped

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21
Q

Kyphosis

A

Outward curve

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22
Q

Lordosis

A

Increased lumbar curvature

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23
Q

Tachyon era

A

More than 24

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24
Q

Bradypnea

25
Q

Melena

A

Black tarry stool

26
Q

Ataxia

A

Uncoordinated movements

27
Q

Pulse assessment

A

Rate rhythm quality sym

28
Q

Pain

A

Location
Character
Intensity
Duration

29
Q

LOC ASSESSMENT

A

alertness orientation mood affect thought content coherence memory

30
Q

Speech assessment

31
Q

Hair assessment

A

Texture distribution

32
Q

Facial expressions

33
Q

Cough assess

A

Type frequency secretions

34
Q

Nose

A

Latency secretion smell

35
Q

Resperations?

A

Rate rhythm depth exertion

36
Q

Breasts

A

Sym, nipples discharge

37
Q

Stool

A

Frequency consistency color

38
Q

Voiding pattern

A

Frequency force

39
Q

Norm temp range?

40
Q

What changes temperature?

A

Age, activity, hydration, state of health

41
Q

Reg heart rate?

42
Q

Blood pressure regular?

A

120/80 or less pulse pressure 30-50

43
Q

Resp rate?

A

12-20 deep and reg

44
Q

Newborn/ unconscious pt temp?

45
Q

Weak feeble and thready heart rate?

A

Pulse of low volume

46
Q

What does palpation look for?

A

Resistance, resilience,roughness, texture, temp, mobility

47
Q

What part of hand for
Temp
Vibration
Everything else for palpation

A

Dorsal
Palm
Tips

48
Q

What does percussion detect?

A

Size
Boarders
Consistency of orgs

49
Q

Characteristics of auscultation?

A

Frequency
Loudness
Quality
Duration

50
Q

General survey?

A 
Review of primary health probs
VS, height, weight, behaviour, appearance
Notes
Illness, hygiene skin and body image
Emotional state, developmental status
51
Q

Why complete a head to toe assessment?

A

Identify norm
Baseline for comparison
Evaluate response for med or nursing intervention

52
Q

When can you complete a head to toe in acute care?

A

Admission, morning care

53
Q

When can you complete an assessment in lt care?

A

Upon admission or status change

54
Q

Head to toe in community?

A

With referral and PRN

55
Q

What do you auscultation for?

A

Heart rate breathing sounds

56
Q

What are all the systems?

A 
Neurological
Respiratory
Cardiovascular
GI
Genito urinary and reproductive
Musculoskeletal 
Integumentary and lymphatic
57
Q

What does a general survey include?

A

Physical appearance
Body structures
Mobility

58
Q

In a GS what would you observe about motility?

59
Q

In GS what would you observe about there appearance?

A

Age, sexually development
LOC
SKIN color
Facial featurese

60
Q

In GS what would you observe about their body structure?

A

Stature nutrition symm posture position body build

Obv deformities

61
Q

What is the measurement of pain?

A

Subjective

Scale of 1-10 or descriptor scale

106 (7 decks)

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