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Nursing 104 > Ch 26 Health Assessment > Flashcards

Ch 26 Health Assessment Flashcards

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1
Q

Activities of daily living (ADLs)

A

Self care activities such as eating, bathing, dressing and toileting

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2
Q

Adventitious breath sounds

A

Abnormal breath sounds over the lungs

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3
Q

Auscultation

A

Listening for sounds in the body

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4
Q

Body mass index (BMI)

A

Ratio of height to weight

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5
Q

Bronchial breath sounds

A

Those heard over the larynx and trachea are high pitched, harsh blowing sounds, with sound on expiration being longer than inspiration

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6
Q

Comprehensive health assessment

A

Broad health assessment that includes a complete health history and physical assessment; it is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessment

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7
Q

Cyanosis

A

Bluish coloring of the skin and mucous membranes

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8
Q

Diaphoresis

A

An excessive amount of perspiration, such as when the entire skin is moist

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9
Q

Ecchymosis

A

Collection of blood in subcutaneous tissues that cause a purplish discoloration

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10
Q

Edema

A

Accumulation of fluid in extra cellular spaces

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11
Q

Emergency health assessment

A

Type of rapid focused assessment conducted in when addressing a life threatening or unstable situation

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12
Q

Erythema

A

Redness of the skin

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13
Q

Focused health assessment

A

Assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient

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14
Q

Health history

A

A collection of subjective information that provides information about the patient’s health status

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15
Q

Inspection

A

Purposeful and systematic observation

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16
Q

Instrumental activities of daily living (IADLs)

A

The activities of daily living needed for independent living

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17
Q

Jaundice

A

Yellow appearance of the skin

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18
Q

Ongoing partial health assessment

A

Also known as follow up assessment, is one that is conducted at regular intervals during care of the patient; concentrate on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions

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19
Q

Pallor

A

Paleness of the skin

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20
Q

Palpation

A

Method of examining by feeling a part of the body with fingers or hand

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21
Q

Percussion

A

Act of striking one object against another for the purpose of producing a sound; used to access the location, shape, size and density of body tissues

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22
Q

Petechiae

A

Small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure

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23
Q

Physical assessment

A

Systematic examination of the patient for objective data to better define the patient’s condition and to help the nurse in planning care, usually preformed in a head to toe format; a collection of objective data about changes in the patient’s body systems

24
Q

Precordium

A

Anterior surface of the chest wall overlying the heart and it’s related structures

25
Q

Review of systems

A

Physical examination of all body systems in a systematic manner as part of a nursing assessment

26
Q

Turgor

A

Tension of the skin determined by its hydration

27
Q

Vesicular breath sounds

A

Normal sound of respirations heard on auscultation over peripheral lung areas

28
Q

Waist circumference

A

A numerical measurement of the waist, used to assess an individual’s’ abdominal fat and establish ideal body weight

29
Q

Right upper quadrant

A 
Pylorous
Duodenum 
Liver
Right kidney and adrenal gland 
Hepatic flexure of colon
Head of pancreas
30
Q

Left upper quadrant

A 
Stomach 
Spleen 
Left kidney and adrenal gland 
Splenic flexure of colon
Body of pancreas
31
Q

Left lower quadrant

A

Sigmoid colon
Left ovary and Fallopian tube
Left ureter and lower kidney pole
Left spermatic cord

32
Q

Right lower quadrant

A 
Cecum
Appendix
Right ovary and Fallopian tube
Right ureter and lower kidney pole
Right spermatic cord
33
Q

Midline

A

Urinary bladder
Urethra female


34
Q

Cranial nerve I

A

Name: olfactory
Function: sense of smell
Test: ask patient to smell substance with eyes closed
Type: sensory

35
Q

Cranial Nerve II

A

Name: optic
Function: vision
Test: Snellen chart, ophthalmoscopic exam, confrontation to check peripheral vision
Type: sensory

36
Q

Cranial Nerve III

A

Name: oculomotor
Function: eye movement, controls most eye-movement, pupil constriction and upper eyelid rise
Test: look up down and inward, ask the patient to follow your finger as you move it towards their face
Type: memory

37
Q

Cranial Nerve IV

A

Name: Trochlear
Function: controls downward and inward Eye movement
Test: look up and down and inward, ask the client to follow your finger as you move it towards their face
Type: memory

38
Q

Cranial Nerve V

A

Name: trigeminal
Function: motor mastication, sensory facial sensation
Test: pressure on the forehead cheek and jaw with a cotton swab to check sensation, ask patient to open mouth and then bite down
Type: both

39
Q

Cranial Nerve VI

A

Name: abducens
Function: controls parallel eye-movement, abduction, moving laterally away from the midline
Test: look up down and Inward, ask the patient to follow your finger as you move it towards their face
Type: memory

40
Q

Cranial Nerve VII

A

Name: facial
Function: motor facial expression, sensory taste sweet and salty
Test ask client to do different facial expression frown, smile, raise eyebrows, close eyes, blow, test tongue by giving clients sweet bitter and salty substances
Type: both


41
Q

Cranial Nerve VIII

A

Name: vestibulocochlear/acoustic
Function: balance and hearing
Test: stand with eyes closed, otoscopic exam, Rhine and Weber Test
Type: sensory

42
Q

Cranial Nerve IX

A

Name: glossopharyngeal
Function: motor tongue movement and swallowing, sensory taste sour and bitter
Test: test tongue by giving client sour bitter and salty substances
Type both

43
Q

Cranial Nerve X

A

Name: Vagus
Function: motor swallowing, speaking and cough, sensory facial sensation
Test: sensation coming from skin and around the ear
Type: both

44
Q

Cranial Nerve XI

A

Name: spinal accessory
Function: control strength of neck and shoulder muscles
Test: ask the client to rotate their head and shrug their shoulders
Type: memory

45
Q

Cranial Nerve XIi

A

Name: hypoglossal
Function: tongue movement, swallowing and speech
Test: inspect tongue and ask patient to stick their tongue out
Type: memory

46
Q

Comprehensive assessment

A

Conducted upon admission to healthcare facility

47
Q

Ongoing partial assessment

A

Conducted at regular intervals

48
Q

Focused assessment

A

Conducted to assess a specific problem

49
Q

Emergency assessment

A

Conducted to determine life-threatening or unstable conditions

50
Q

Techniques used during a physical assessment

A

IPPA

Inspection, palpitation, percussion and auscultation

51
Q

Inspection

A

Assessing size, color, shape, position and symmetry

52
Q

Palpitation

A

Assessing temperature, tyrgor, texture, moisture, vibrations and shape

53
Q

Percussion

A

Assessing location, shape, size, and density of tissues

54
Q

Auscultation

A

Assessing the forecast eristics of sound that is pitch, loudness, quality, and duration

55
Q

PERRLA

A

Pupils are equal round reactive to light and accommodation

Nursing 104 (32 decks)

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