Assessment Flashcards
1
Q
What is included in a Health/Medical History?
A
Biographical info Chief Complaint/ Reason for Seeking Care History of present illness Perception of health status Expectations for care Past medical history Family/social history Medications Complementary therapies Review of systems Functional abilities
2
Q
What are Gordon’s 11 Functional Health Patterns?
A
Health Perception and Management Values and Beliefs Cognitive and Perceptual Nutrition and Metabolic Activity and Exercise Elimination Sleep and Rest Role and Relationship Coping and Stress Self-Perception and Self-Management Sexuality and Reproduction
3
Q
Why do a Nursing Physical Assessment?
A
- It gathers data about patient and focuses on functional abilities and responses to illness/stressors.
- Identify nursing diagnoses and collaborative problems
- Monitor the status of an identified problem
- Screen for health problems
- Evaluate Nursing Care
4
Q
What are the steps in the Nursing Process?
A
Assessment, Diagnosis, Planning, Implementing, Evaluating.
5
Q
Types of Physical Assessments?
A
Comprehensive
Focused
Ongoing
Emergency
6
Q
What do you do when preparing for an assessment?
A
Develop Rapport Explain Procedure Respect Cultural Differences Proper Positioning and Draping Promote Comfort Provide Privacy Limit Noise Enable Visualization
7
Q
Integrate Assessment during routine Nursing Care when doing …
A
…vitals, bathing, ROM, ADL’s.
8
Q
What are the 4 categories of Assessment?
A
Inspection, Palpation, Percussion, and Auscultation.
9
Q
What are some Assessment Parameters for older adults?
A
Basic ADL’s:
-bathing, dressing, grooming, eating, continence, transferring
Instrumental ADL’s:
-meal prep, shopping, med administration, housework, transportation, accounting, mobility, ambulation, pivoting
10
Q
What are the aspects of the General Survey?
A
Appearance/behavior/affect Body type/posture Speech Grooming/hygiene Vital signs Height/weight/BMI
11
Q
What are the Systems of a Head to Toe Assessment?
A
Neurological, Skin, HEENT, Cardiovascular(CV)/Peripheral Vascular(PV), Respiratory, Gastrointestinal(GI), Genitourinary(GU), Musculoskeletal.
12
Q
Basic Neuro Assessment Responsibilities?
A
LOC, Orientation, Emotional/Behavioral, PERRLA(pupils equal round reactive to light & accommodation), Grips/Pushes/Pulls.
13
Q
Complete Neuro Assessment
A
Cerebral Function (mental status), Cranial Nerves, Reflexes, Sensory a Function, Motor and Cerebellar Function.
14
Q
Determining Orientation?
A
Person
Place
Date
15
Q
Levels of Consciousness
A
Alert: vigilantly attentive, keen
Lethargic: drowsy, sluggish, half asleep
Obtunded: mentally dulled, responds slowly, decreased interest
Stuporous: near unconsciousness, reduced ability to respond
Coma: unconscious, unresponsive
16
Q
Glascow Coma Scale’s 3 parameters and scores.
A
Parameters: -eye opening -verbal response -motor response High Score: 15 (fully alert and oriented) Score of 7 or less reflects Coma
17
Q
Mental Status/Cognitive Function
A
Behavior, mood/affect, speech, memory, thought processes, judgement/insight.
18
Q
Assessment of Sensory Function
A
Patient keeps eyes closed as you apply various stimuli, have patient indicate when they feel sensation. Vary the location and approach, usually test upper and lower extremities and trunk.
19
Q
Motor/Cerebellar Function
A
Movement/coordination
Muscle Tone
Posture
Equilibrium
20
Q
Neuro Related Data
A
Headache, head injury, dizziness/vertigo, seizures, tremors, uncoordinated, numbness or tingling, weakness, difficulty swallowing, difficulty speaking, significant history, environmental/occupational hazards.
21
Q
Abnormal Neuro Findings
A
Cerebral function, cranial nerves, reflexes, sensory function, motor and cerebellar function(gait/grips/pushes/pulls).
22
Q
What is the importance of Skin?
A
It is a membrane barrier, responds to changes, gives clues about our general state of health, largest body organ.
23
Q
What are the structures of the Skin?
A
Epidermis, dermis, hypodermis. Hair and nails.
24
Q
Why do a Skin Assessment?
A
- Can tell us about local problems and systemic problems
- Gives data about patient’s health, hygiene, nutritional habits.
25
Performing Skin Assessment
Inspect and Palpate
| Note: color, temperature, moisture, texture, vascularity, lesions, distinguishing marks, turgor, edema.
26
Abnormal Skin Findings
Pallor
Jaundice
Cyanosis
Erythema
27
Define Pallor
Due to inadequate blood supply, anemia, blood loss, the patient looks pale.
28
Define Jaundice
Due to an increase of liver enzymes, anemics can be jaundice, yellow of color.
29
Define Cyanosis
Due to a lack of oxygen the gums, lips, and nails will be a blue color.
30
Define Erythema
Various reasons from allergic reaction, sunburn, rash, it is a redness of the skin usually to the face and neck.
31
Skin Assessment: Excessive Moisture can be from...
Hyperthermia
Anxiety
Overactive Thyroid
32
Skin Assessment: Dry Skin can be from...
Dehydration
| Hypothyroidism
33
Factors affecting Skin Texture
Exposure, age, endocrine disorders, and impaired circulation
34
Check Skin for Bleeding/Bruising, it can be indicative of what systemic problems?
Cardiovascular
Hematologic
Liver
35
What is Eccymosis?
Extravasation (leakage) of blood into the skin or mucous membranes, purple discoloration.
36
What is Petechiae?
Small hemorrhagic spots caused by capillary bleeding, common in blood clotting disorders.
37
What are some normal variations of skin lesions?
Moles, freckles, birthmarks, skin tags, striae(stretch marks).
38
What are some abnormal skin lesions?
Primary- result of disease or irritation
| Secondary- develop from primary lesions as a result of continued illness, exposure, or infection.
39
What do you note when assessing skin lesions?
- Assess size, shape, pattern, color, distribution, texture, exudate (oozing), pain, itching.
- Describe lesions in terms of: type, size, elevation, coloring, presence of drainage, itching.
40
Define Contusion
A bruise, caused by blunt force trauma, injury where skin is discolored, but not broken.
41
Define Rash
Change in skin which affects its color, appearance, or texture. Maybe localized or may affect all skin, usually itchy, may blister.
42
Define Abrasion
A scrape, superficial damage to skin, generally not deeper than the epidermis. Often occurs when exposed skin comes into moving contact with a rough surface.
43
What factors determine turgor?
Dehydration, edema, age, hydration
44
Define Edema
Swelling caused by excessive amount of fluid in tissues. Pitting Edema and non-pitting edema.
45
Define Ascities
Type of edema, shiny and tight skin
46
What is the purpose of Capillary Refill?
Measures amount of blood flow to tissue, normal is less than three seconds.
47
Inspect the head for what?
Size, shape, facial features, lesions
48
Palpate the head for what?
Nodules, tenderness, lesions
49
Assess hair for...
Color, quality(shiny,soft,brittle), quantity(thin/thick), texture(coarse or fine), distribution
50
When assessing the neck...
Inspect for flexion and extension.
Inspect and Palpate lymph nodes, thyroid enlargement, carotid pulses, and trachea position(midline and symmetrical).
51
Assessing Lymph Nodes
Inspect and Palpate for:
Enlargement
Tenderness
Warmth
52
Define JVD
Jugular vein distention, venous congestion, indicative of heart problems.
53
Assessing the Eyes
Inspect:
| Eyelids, conjunctiva, Iris, sclera, cornea, pupils
54
Assessing Pupils
PERRLA: pupils, equal, round, reactive to, light and, accommodation.
Note size and reaction time
55
Assessing Ears
Inspect and palpate: alignment, auricles, hearing, deformities
56
Assessing Nose
Inspect: shape, symmetry, septum, mucosa
Palpate: sinuses
57
Nose Abnormalities
Nasal polyp- red bumps, can be benign
Deviated Septum
No Septum- absent or rotted away from drug use
58
Define Candidasis
Thrush, yeast infection from Candida albicans, or from medications.
Common meds- mycostatin or nistatin
59
Herpes Simplex
A mouth abnormality, STD
60
Abnormal findings for the HEENT
Tenderness or lesions to the head, face, neck, mouth. Asymmetry of facial features, uneven or abnormally large or small pupils, sinus tenderness, hearing or vision loss.
61
Cardiac Anatomy
```
4 Chambers:
-R and L atria
-R and L Ventricles
3 Layers:
-endocardium
-myocardium
-epicardium
Heart Valves:
-Atrioventricular Valves: Tricuspid and Mitral
-Semilunar Valves: Aortic and Pulmonic
```
62
Data Collection for Cardiovascular System of Assessment
Chest pain/tightness, fatigue, cyanosis or pallor, cardiac history, family history, edema, medications, cardiac risk factors, shortness of breath.
63
Inspection of Cardiovascular System
JVD, edema, clubbing, capillary refill, apical impulse(PMI)
64
Palpation of Cardiovascular System
Pulses, Apical Impulse(PMI), assess for pulsation, thrills, heaves
65
Where to Auscultate for heart sounds...
All People Enjoy Time Magazine
Aortic, Pulmonic, Erb's point, Tricuspid, Mitral
66
Where is the Aortic sound located?
2nd intercostal space, right side
67
Where is the Pulmonic heart sound located?
2 intercostal space, left side
68
Where is Erb's point located?
3rd intercostal space, left side
69
Where is the Tricuspid heart sound located?
5th intercostal space, left side
70
Where is the Mitral heart sound located?
5th intercostal space, LMCL ( left midclavicular line)
71
Describe Heart Murmur sounds
Blowing or swooshing sound occurring with blood flow in the heart (valve mechanics)
72
Describe a Friction Rub heart Sound
High pitched, scratchy, like sandpaper
73
Describe prosthetic heart valve sounds
Click or ping
74
Assessment of Peripheral Perfusion:
| Homan's Sign
An indicator of DVT, present when passive dorsiflexion of the foot produces pain in the calf. Swelling, redness, and pain in calf.
If you suspect DVT, do not do Homan's Sign!!
75
Normal adult heart rate
60-100 beats per min
76
Respiratory System : Lungs- lobes
Right lung has 3 lobes.
Left lung has 2 lobes.
77
Normal Respiratory Findings
Rate 12-20 breaths per min
Respirations even and unlabored
O2 Sats >92% on RA
Lungs clear to Auscultation
78
Chest and Lung Assessment
Assess rate, rhythm, depth, symmetry
79
Inspection of Respiratory a System
```
Shape of thorax
Chest symmetry
Trachea
Color and skin condition
Respiratory effort and muscles
Presence and color of sputum
```
80
What is Tactile Fremitus?
Use palms on patients lower back, have patient say "99" make sure you do not feel vibrations
81
What to look for in Auscultation of Breath Sounds
Pitch, quality, duration, location (visualize)
82
3 types of normal breath sounds
Bronchial, Bronchovesicular, Vesicular
83
Describe Bronchial Lung Sound
High pitched, harsh, hollow, tubular.
| - heard over trachea, louder on expiration
84
Describe Bronchovesicular Lung Sounds
Medium intensity
- heard at 1st and 2nd ICS anteriorly
- heard at T4 medial to scapula posteriorly
85
Describe Vesicular Lung Sounds
Low pitch, soft intensity, over peripheral lung fields
| - sounds like wind rustling in trees, louder on inspiration
86
Why do nurses obtain Health/Medical History?
It provides guidance for care. It includes subjective (told by the patient) and objective (measurable) data.
87
GI Assessment data to collect
N/V, diarrhea/constipation, heartburn, GERD(gastroesophageal reflux disease), gas, indigestion, food intolerance/allergies, rectal bleeding, LBM, appetite, weight loss, elimination pattern, abdominal pain, distention, dysphasia, medication
88
Define Peristalsis
Contractions to pass stool through intestines.
- 3 to 12 min
- Mass peristalsis sweeps occur 1 to 4 times each 24 hour period
- 1/3 to 1/2 of food waste is excreted in stool within 24 hours
89
Auscultation of bowel sounds
Auscultate and four quadrants, listen in several areas in all four quadrants, usually heard within 5 to 15 seconds.
-if bowel sounds are absent, listen for five minutes maximum in each quadrant
90
Classifying bowel sounds
Active: heard every 5-15 seconds
Hyperactive: loud and rushing, very frequent every 2-3 seconds
Hypoactive: soft, infrequent, heard less than every 15 seconds
Absent: no bowel sounds heard after five minutes of listening
91
Palpation of the abdomen
Assess for tenderness or pain, masses, lumps or irregularities, firmness, guarding
92
Abnormal GI Findings
Distention, ascites, splenomegaly, hernia, hematemesis(bloody vomit), dysphasia
93
GU Assessment
Inspect external genitalia and hair distribution, inspect urine color and clarity, palpate for the presence of a hernia, lumps, enlarged lymph nodes, or distended bladder.
94
Assessment of male genitalia
Inspect and palpate the penis, urinary meatus should be centrally positioned.
Should be free from lesions, discharge, lumps, tenderness, induration, meatus should be free from Purulent discharge.
95
Define Hypospadius
Urethra opens on the underside of the penis
96
Define Epispadius
Urethra opening on the upper side of the penis
97
Define Phimosis
Foreskin cannot retract
98
Define Pariphimosis
For skin gets stuck behind the head of phallus
99
Abnormal findings of the male genitalia
Scrotal swelling, lesions, inflammation, nodules, enlarged inguinal lymph nodes, absent or atrophied testes, marked tenderness, hernia
100
Nursing History of Male Genitalia
Past problems with genitals, penis: pain, lesion, discharge, scrotum: pain, lumps, self-care behaviors: testicular self exam, sexual activity and contraceptive use, STD exposure
101
Assessment of female genitalia
Inspect external genitalia for: skin color, hair distribution, lesions
102
Abnormal findings of the female genitalia
Lesions, inflammation, nodules, discharge
103
Factors affecting urination
Age, food and fluid intake, activity and muscle tone, pathologic conditions, medications, urgency, pain or burning
104
Urinary system data: the nurse determines...
Pattern and frequency, appearance, problems with urination, influencing factors
105
Physical assessment GU Tract
- Palpation percussion of the kidneys and bladder: could you text areas of tenderness, palpate for Contor, size, tenderness, or lumps, bladder distention.
- examine the urethral meatus, look for swelling, discharge, or inflammation
106
Musculoskeletal Assessment
CMS- circulation, movement, sensation
107
General assessment of musculoskeletal
Overall appearance, bone structure, posture, gait, mobility
108
Inspection of musculoskeletal
Muscle size shape and function, joint contours, bilateral symmetry, use of assistive devices, balance and movement, coordination
109
Palpation of musculoskeletal
Joints in periarticular tissue note tenderness or crepitus, range of motion, muscle tone, muscle strength: 5-strong 0-no movement
110
ROM
Flexion/extension, abduction/adduction, pronation/supination, rotation, circumduction, inversion/eversion, protraction/retraction
111
Health history of musculoskeletal
Medical history, surgical history, injuries and accidents, special needs, working environment, health checkups
112
Abnormal musculoskeletal findings
Muscular atrophy, tremors, flaccidity, decreased muscle strength and tone, decreased range of motion, uncoordinated movement, pain or swelling, nodules in joint, crepitation
113
Effects of immobility
Lungs, heart and vessels, G.I., metabolism, skin, GU, psychological
