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Block 1 Nursing SCC > Assessment > Flashcards

Assessment Flashcards

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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
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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
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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
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4
Q

What are the steps in the Nursing Process?

A

Assessment, Diagnosis, Planning, Implementing, Evaluating.

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5
Q

Types of Physical Assessments?

A

Comprehensive
Focused
Ongoing
Emergency

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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
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7
Q

Integrate Assessment during routine Nursing Care when doing …

A

…vitals, bathing, ROM, ADL’s.

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8
Q

What are the 4 categories of Assessment?

A

Inspection, Palpation, Percussion, and Auscultation.

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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

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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
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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.

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12
Q

Basic Neuro Assessment Responsibilities?

A

LOC, Orientation, Emotional/Behavioral, PERRLA(pupils equal round reactive to light & accommodation), Grips/Pushes/Pulls.

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13
Q

Complete Neuro Assessment

A

Cerebral Function (mental status), Cranial Nerves, Reflexes, Sensory a Function, Motor and Cerebellar Function.

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14
Q

Determining Orientation?

A

Person
Place
Date

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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

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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
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17
Q

Mental Status/Cognitive Function

A

Behavior, mood/affect, speech, memory, thought processes, judgement/insight.

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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.

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19
Q

Motor/Cerebellar Function

A

Movement/coordination
Muscle Tone
Posture
Equilibrium

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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.

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21
Q

Abnormal Neuro Findings

A

Cerebral function, cranial nerves, reflexes, sensory function, motor and cerebellar function(gait/grips/pushes/pulls).

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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.

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23
Q

What are the structures of the Skin?

A

Epidermis, dermis, hypodermis. Hair and nails.

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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.

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25
Q

Performing Skin Assessment

A

Inspect and Palpate

Note: color, temperature, moisture, texture, vascularity, lesions, distinguishing marks, turgor, edema.

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26
Q

Abnormal Skin Findings

A

Pallor
Jaundice
Cyanosis
Erythema

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27
Q

Define Pallor

A

Due to inadequate blood supply, anemia, blood loss, the patient looks pale.

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28
Q

Define Jaundice

A

Due to an increase of liver enzymes, anemics can be jaundice, yellow of color.

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29
Q

Define Cyanosis

A

Due to a lack of oxygen the gums, lips, and nails will be a blue color.

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30
Q

Define Erythema

A

Various reasons from allergic reaction, sunburn, rash, it is a redness of the skin usually to the face and neck.

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31
Q

Skin Assessment: Excessive Moisture can be from…

A

Hyperthermia
Anxiety
Overactive Thyroid

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32
Q

Skin Assessment: Dry Skin can be from…

A

Dehydration

Hypothyroidism

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33
Q

Factors affecting Skin Texture

A

Exposure, age, endocrine disorders, and impaired circulation

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34
Q

Check Skin for Bleeding/Bruising, it can be indicative of what systemic problems?

A

Cardiovascular
Hematologic
Liver

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35
Q

What is Eccymosis?

A

Extravasation (leakage) of blood into the skin or mucous membranes, purple discoloration.

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36
Q

What is Petechiae?

A

Small hemorrhagic spots caused by capillary bleeding, common in blood clotting disorders.

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37
Q

What are some normal variations of skin lesions?

A

Moles, freckles, birthmarks, skin tags, striae(stretch marks).

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38
Q

What are some abnormal skin lesions?

A

Primary- result of disease or irritation

Secondary- develop from primary lesions as a result of continued illness, exposure, or infection.

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39
Q

What do you note when assessing skin lesions?

A
  • Assess size, shape, pattern, color, distribution, texture, exudate (oozing), pain, itching.
  • Describe lesions in terms of: type, size, elevation, coloring, presence of drainage, itching.
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40
Q

Define Contusion

A

A bruise, caused by blunt force trauma, injury where skin is discolored, but not broken.

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41
Q

Define Rash

A

Change in skin which affects its color, appearance, or texture. Maybe localized or may affect all skin, usually itchy, may blister.

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42
Q

Define Abrasion

A

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.

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43
Q

What factors determine turgor?

A

Dehydration, edema, age, hydration

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44
Q

Define Edema

A

Swelling caused by excessive amount of fluid in tissues. Pitting Edema and non-pitting edema.

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45
Q

Define Ascities

A

Type of edema, shiny and tight skin

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46
Q

What is the purpose of Capillary Refill?

A

Measures amount of blood flow to tissue, normal is less than three seconds.

47
Q

Inspect the head for what?

A

Size, shape, facial features, lesions

48
Q

Palpate the head for what?

A

Nodules, tenderness, lesions

49
Q

Assess hair for…

A

Color, quality(shiny,soft,brittle), quantity(thin/thick), texture(coarse or fine), distribution

50
Q

When assessing the neck…

A

Inspect for flexion and extension.

Inspect and Palpate lymph nodes, thyroid enlargement, carotid pulses, and trachea position(midline and symmetrical).

51
Q

Assessing Lymph Nodes

A

Inspect and Palpate for:
Enlargement
Tenderness
Warmth

52
Q

Define JVD

A

Jugular vein distention, venous congestion, indicative of heart problems.

53
Q

Assessing the Eyes

A

Inspect:

Eyelids, conjunctiva, Iris, sclera, cornea, pupils

54
Q

Assessing Pupils

A

PERRLA: pupils, equal, round, reactive to, light and, accommodation.
Note size and reaction time

55
Q

Assessing Ears

A

Inspect and palpate: alignment, auricles, hearing, deformities

56
Q

Assessing Nose

A

Inspect: shape, symmetry, septum, mucosa
Palpate: sinuses

57
Q

Nose Abnormalities

A

Nasal polyp- red bumps, can be benign
Deviated Septum
No Septum- absent or rotted away from drug use

58
Q

Define Candidasis

A

Thrush, yeast infection from Candida albicans, or from medications.
Common meds- mycostatin or nistatin

59
Q

Herpes Simplex

A

A mouth abnormality, STD

60
Q

Abnormal findings for the HEENT

A

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
Q

Cardiac Anatomy

A 
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
Q

Data Collection for Cardiovascular System of Assessment

A

Chest pain/tightness, fatigue, cyanosis or pallor, cardiac history, family history, edema, medications, cardiac risk factors, shortness of breath.

63
Q

Inspection of Cardiovascular System

A

JVD, edema, clubbing, capillary refill, apical impulse(PMI)

64
Q

Palpation of Cardiovascular System

A

Pulses, Apical Impulse(PMI), assess for pulsation, thrills, heaves

65
Q

Where to Auscultate for heart sounds…

A

All People Enjoy Time Magazine
Aortic, Pulmonic, Erb’s point, Tricuspid, Mitral

66
Q

Where is the Aortic sound located?

A

2nd intercostal space, right side

67
Q

Where is the Pulmonic heart sound located?

A

2 intercostal space, left side

68
Q

Where is Erb’s point located?

A

3rd intercostal space, left side

69
Q

Where is the Tricuspid heart sound located?

A

5th intercostal space, left side

70
Q

Where is the Mitral heart sound located?

A

5th intercostal space, LMCL ( left midclavicular line)

71
Q

Describe Heart Murmur sounds

A

Blowing or swooshing sound occurring with blood flow in the heart (valve mechanics)

72
Q

Describe a Friction Rub heart Sound

A

High pitched, scratchy, like sandpaper

73
Q

Describe prosthetic heart valve sounds

A

Click or ping

74
Q

Assessment of Peripheral Perfusion:

Homan’s Sign

A

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
Q

Normal adult heart rate

A

60-100 beats per min

76
Q

Respiratory System : Lungs- lobes

A

Right lung has 3 lobes.

Left lung has 2 lobes.

77
Q

Normal Respiratory Findings

A

Rate 12-20 breaths per min
Respirations even and unlabored
O2 Sats >92% on RA
Lungs clear to Auscultation

78
Q

Chest and Lung Assessment

A

Assess rate, rhythm, depth, symmetry

79
Q

Inspection of Respiratory a System

A 
Shape of thorax
Chest symmetry
Trachea
Color and skin condition
Respiratory effort and muscles
Presence and color of sputum
80
Q

What is Tactile Fremitus?

A

Use palms on patients lower back, have patient say “99” make sure you do not feel vibrations

81
Q

What to look for in Auscultation of Breath Sounds

A

Pitch, quality, duration, location (visualize)

82
Q

3 types of normal breath sounds

A

Bronchial, Bronchovesicular, Vesicular

83
Q

Describe Bronchial Lung Sound

A

High pitched, harsh, hollow, tubular.

- heard over trachea, louder on expiration

84
Q

Describe Bronchovesicular Lung Sounds

A

Medium intensity

  • heard at 1st and 2nd ICS anteriorly
  • heard at T4 medial to scapula posteriorly
85
Q

Describe Vesicular Lung Sounds

A

Low pitch, soft intensity, over peripheral lung fields

- sounds like wind rustling in trees, louder on inspiration

86
Q

Why do nurses obtain Health/Medical History?

A

It provides guidance for care. It includes subjective (told by the patient) and objective (measurable) data.

87
Q

GI Assessment data to collect

A

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
Q

Define Peristalsis

A

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
Q

Auscultation of bowel sounds

A

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
Q

Classifying bowel sounds

A

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
Q

Palpation of the abdomen

A

Assess for tenderness or pain, masses, lumps or irregularities, firmness, guarding

92
Q

Abnormal GI Findings

A

Distention, ascites, splenomegaly, hernia, hematemesis(bloody vomit), dysphasia

93
Q

GU Assessment

A

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
Q

Assessment of male genitalia

A

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
Q

Define Hypospadius

A

Urethra opens on the underside of the penis

96
Q

Define Epispadius

A

Urethra opening on the upper side of the penis

97
Q

Define Phimosis

A

Foreskin cannot retract

98
Q

Define Pariphimosis

A

For skin gets stuck behind the head of phallus

99
Q

Abnormal findings of the male genitalia

A

Scrotal swelling, lesions, inflammation, nodules, enlarged inguinal lymph nodes, absent or atrophied testes, marked tenderness, hernia

100
Q

Nursing History of Male Genitalia

A

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
Q

Assessment of female genitalia

A

Inspect external genitalia for: skin color, hair distribution, lesions

102
Q

Abnormal findings of the female genitalia

A

Lesions, inflammation, nodules, discharge

103
Q

Factors affecting urination

A

Age, food and fluid intake, activity and muscle tone, pathologic conditions, medications, urgency, pain or burning

104
Q

Urinary system data: the nurse determines…

A

Pattern and frequency, appearance, problems with urination, influencing factors

105
Q

Physical assessment GU Tract

A
  • 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
Q

Musculoskeletal Assessment

A

CMS- circulation, movement, sensation

107
Q

General assessment of musculoskeletal

A

Overall appearance, bone structure, posture, gait, mobility

108
Q

Inspection of musculoskeletal

A

Muscle size shape and function, joint contours, bilateral symmetry, use of assistive devices, balance and movement, coordination

109
Q

Palpation of musculoskeletal

A

Joints in periarticular tissue note tenderness or crepitus, range of motion, muscle tone, muscle strength: 5-strong 0-no movement

110
Q

ROM

A

Flexion/extension, abduction/adduction, pronation/supination, rotation, circumduction, inversion/eversion, protraction/retraction

111
Q

Health history of musculoskeletal

A

Medical history, surgical history, injuries and accidents, special needs, working environment, health checkups

112
Q

Abnormal musculoskeletal findings

A

Muscular atrophy, tremors, flaccidity, decreased muscle strength and tone, decreased range of motion, uncoordinated movement, pain or swelling, nodules in joint, crepitation

113
Q

Effects of immobility

A

Lungs, heart and vessels, G.I., metabolism, skin, GU, psychological

Block 1 Nursing SCC (11 decks)

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