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Health Assessment Theory Exam 1 > Ch. 8,9,12,13- Assessment Techniques, General Surgery, Nutrition Assessment, Skin, Hair, and Nails > Flashcards

Ch. 8,9,12,13- Assessment Techniques, General Surgery, Nutrition Assessment, Skin, Hair, and Nails Flashcards

1
Q

In most cases perform assessment techniques in what order?

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
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2
Q

What are you assessing when using palpation?

A
  • texture/temp/moisture (use back of hands)
  • swelling
  • pulsations
  • organ location/size
  • muscle rigidity/spasticity
  • crepitus (“rice Krispy sensation”)
  • lumps/masses
  • tenderness/pain
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3
Q

What is percussion?

A

Tapping person’s skin with short, sharp strokes to assess underlying structures

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4
Q

Percussion has what uses?

A
  • Mapping location and size of organs

- Signaling density or a structure by a characteristic note

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5
Q

When using percussion, a structure with more air produces what sounds?

A

louder, deeper compared with denser structures

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6
Q

When using percussion only what should be touching the patient s skin?

A

distal joint and tip of middle finger

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7
Q

Explain the quality and location of a resonant percussion note?

A

amp: medium/loud
pitch: low
quality: clear/ hollow
duration: moderate
sample location: over normal lung tissue

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8
Q

Explain the quality and location of a tympany percussion note?

A

amp: loud
pitch: high
quality: musical and drum like
duration: sustained longest
sample location: over air-filled viscous (ex: stomach, intestines)

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9
Q

Explain the quality and location of a dull percussion note?

A

amp: soft
pitch: high
quality: muffled thud
duration: short
sample location: relatively dense organ as liver or spleen

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10
Q

The diaphragm of a stethoscope is what?

A

Flat edge, for high-pitched sounds

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11
Q

The bell of a stethoscope is what?

A

Deep, hollow, cuplike, for low pitched sounds

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12
Q

The general survey is a study of the whole person which includes what?

A

-Overall immediate impression of a person

including physical appearance, body structure, mobility, behavior

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13
Q

What objective data do we include when assessing a persons physical appearance?

A
  • Age
  • LOC/orientation
  • Skin color
  • Facial features
  • Overall appearance
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14
Q

What objective data do we include when assessing a persons body structure?

A
  • Stature
  • Nutrition
  • Symmetry
  • Posture
  • Position
  • Physical deformities
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15
Q

What objective data do we include when assessing a persons mobility?

A
  • Gait
  • Extremity movement
  • ROM
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16
Q

What objective data do we include when assessing a persons behavior?

A
  • Facial expression
  • Mood and affect
  • Speech
  • Dress
  • Personal hygeine
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17
Q

What things should be done when obtaining weights?

A
  • Aim for same time of day
  • trend weights/ observe changes
  • outpatient= remove shoes and heavy outer clothing
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18
Q

What things should be done when obtaining heights?

A
  • use wall-mounted/pole on scale devices

- pt. shoed be shoeless, standing straight, looking straight ahead

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19
Q

What is BMI?

A

-Practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

20
Q

The aging adult typically has what physical appearances?

A
  • sharper body contour
  • more angular facial features
  • subcutaneous fat lost from face and periphery
21
Q

The aging adult typically has what posture characteristics?

A

forward flexion occurs by eighth or ninth decade

22
Q

The aging adult typically has what type of gait?

A
  • wider base to compensate for diminished balance

- steps may be shorter or uneven

23
Q

Adult emergence of metabolic syndrome is a concern leading to what risk?

A

increased cardiac risk

24
Q

What is sarcopenia?

A

age-related loss of muscle mass

25
Q

What is sarcopenia obesity?

A

low muscle mass with excess fat

26
Q

Who are at increased risk to develop undernutrition or over nutrition?

A

people as they age

27
Q

What are major risk factors for malnutrition in older adults?

A
  • poor physical or mental health
  • social isolation
  • alcoholism
  • limited functional ability
  • poverty
  • polypharmacy
28
Q

What are the purposes of nutritional assessment?

A
  • identify individuals who are malnourished or a at risk of developing malnutrition
  • provide data for designing a nutrition plan of care
  • various data collection methods
29
Q

What are types of nutritional objective data?

A
  • Observation of general appearance
  • Height
  • Weight
  • BMI
30
Q

What are other areas to asses during a skin inspection?

A
  • under large breasts
  • obese abdomen
  • groin
31
Q

What areas should always be assessed for skin breakdown?

A

Pressure points and folds

32
Q

What objective data is collected when assessing skin color?

A
  • General pigmentation, freckles, moles, birthmarks

- widespread color change

33
Q

What objective data is collected when assessing skin temperature?

A
  • Use back of hands to palpate person
  • skin should be warm, and temp equal bilaterally
  • hands and feet may be slightly cooler in a cool environment
34
Q

What objective data is collected when assessing skin moisture?

A
  • Diaphoresis

- Dehydration

35
Q

What other objective data is collected when assessing skin?

A
  • Texture/thickness
  • edema
  • mobility and turgor (use fold under clavicle)
  • vascularity and bruising
36
Q

What are compound nevus?

A

macular and papular.

intradermal nevus has nevus cells in only the dermis

37
Q

What is Vitiligo?

A

acquired condition: complete absence of melanin pigmentation in patchy areas white or light skin on the face, neck, hands, feet, and body folds around orifices

38
Q

What are vascular lesions?

A

Vascular lesions are relatively common abnormalities of the skin and underlying tissues, more commonly known as birthmarks. There are three major categories of vascular lesions: Hemangiomas, Vascular Malformations, and Pyogenic Granulomas.

39
Q

If any lesions are present, note what objective data?

A
  • Color
  • Elevation
  • Pattern or shape
  • Size
  • Location and distribution on body
  • Any exudate (drainage): note color and odor
40
Q

Wat objective data should be noted when assessing nails?

A
  • Shape and contour
  • Consistency
  • Color
  • CRT (normal is <3 seconds)
41
Q

What is clubbing?

A

Lost profile sign associated with chronic lung disease.

42
Q

What objective data should be recorded when assessing hair?

A
  • Color
  • Texture
  • Distribution
  • Lesions
43
Q

What hair/skin/nails changes do we see in the aging adult?

A
  • Elasticity lost, skin folds and sags
  • Sweat and sebaceous glands decrease, dry
  • Senile purpura (discoloration due to increasing capillary fragility)
44
Q

What is the ABCDEF skin assessment used for?

A

Teach skin self-examination to rule to detect suspicious lesions

45
Q

What is the ABCDEF skin assessment?

A
  • A: Assymmetry
  • B: Border
  • C: Color
  • D: Diameter (>6mm is concerning)
  • E: Elevation
  • F: Ugly Duckling (does it stand out?)

Health Assessment Theory Exam 1 (8 decks)

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