Chapter 22: Health Assessment Flashcards
Health Assessment is?
an assessment that asses the physical, mental, spiritual, socioeconomics, and cultural states.
Nursing Assessment is?
Focuses on clients functional abilities and physical responses to illness and other stressors.
Physical Assessment is?
Consists of Techniques used to gather (objective data)
What does a complete Health Assessment include?
- Nursing History
2. Physical Examination
The purpose of the Baseline Data
Data about the patients physical status to compare any health changes.
The type of physical examination you perform will depend on clients…
Health status, nature of encounters, and settings.
For an Annual Physical perform a…
Comprehensive Physical Assessment:
complete head to toe exam, health history interview.
Focused Physical Assessment
a particular topic, problem, body part
Systemic Specific Assessment
1 body system
What is the order of the Body System approach when preparing to perform a physical examination?
Musculoskeleton, Cardiovascular, Neurological
Percussion
tapping your fingers on skin.
tapping->produce->vibration= determine location size and density
Auscultation
using hearing to gather data
Direct Auscultation
listening without using an instrument
Indirect Auscultation
listening with the help pf stethoscope
Stethoscope Diaphragm
high pitched sounds of the heart, lung, and abdomen
Stethoscope Bell
low pitch sounds murmurs, bruits (turbulent blood flow)
Olfaction
sense of smell
During olfaction, you notice the client is slurring. You think is was caused by…
stroke
Which age group are self conscious, want privacy, and are going through puberty?
13-20 adolescence
What type of position is used to measure musculoskeleton, neurological system, asses gait?
standing position
If you want to asses vital signs, what position is common to use for patient?
Sitting position
When patient is in a supine position and is having a hard time breathing, what passion do you recommend they do next?
Fowler’s position: head elevated 60 degree
semi Fowler’s postion: 30 to 50 degrees
What position is used when females get a pelvic exam?
Lithotomy
What are the 2 positions use to examine rectal are of the patient
sims and knee chest on hands and knees
What is the correct order of physical examination?
Inspection, palpation, percussion, Auscultation
When palpating the patient, the nurse uses the dorsum of the hand to…
temperature deterimation
When palpating the patient, the nurse uses the palmer surface of the hand to…
locate pulsation
When palpating the patient, the nurse uses the fingertips of the hand to…
skin texture, swelling, pulsation, masses
In the Integumentary System, you must notice the characteristics of the skin such as…
color, temperature, and moisture
If a patient is sweating, this maybe a sign of
finished exercising, thyroid problem, overreacted sweating gland
cafe au lait spot is?
On infants/ neonates Light brown birthmark: generic disorder/ medical problem
Capillary hemoangiomas
small irregular pink areas that can disappear
Mangolian Spot
blue black birthmark that are found is specific nationality. They usually fade by age 2
erythema
site of infection
If a patients skin temperature feels cooler than usual…then you assume
poor peripheral circulation, shock, hypothermia
If a patients skin is pale and have a loss of red in their skin tone then…
pallor
cyanosis
blue/green skin color because hypoxia
yellow/orange skin color
Jaundice
Ecchymosis
blue green yellow area: sign of abuse/ internal bleeding.
Mottling
blush
What happens when a patient has Edema
abnormal fluid in the tissue, common with heart failure, kidney disease, low albumin levels, swollen tissue.
Milia is known as
white heads
Nevi is also known as
moles and freckles and birthmarks
striae is also know as
stretch marks
what is the hair type of a patient with hyperthyroidism?
very fine and silky
what is the hair type of a patient with hypothyroidism?
dry
Another term for hair loss
Alopecia
Hirsutism is known as
having a lot of facial and trunk hair possibly do to steroid use
Bumpy Nail is usual sign of
Respiration Problem
what is a typical nail plate angle?
160 degree and more
HEENT
Head, eye, ear, nose, teeth
Temporomandibular joint syndrom
jaw cracks too much
Graves disease
man looks like women
women look like men
myopia
far sightness
hyperopia
near sightness
persbyopia
diminished near vision (45)
cross eye
strabismus
lazy eye
amblyopia
what cranial nerves control pupillary reaction to light
iii ocululomotor
ii optic
how many teeth should adult have
28 or 32 including wisdom teeth
glossitis
inflammation of the tongue
What type of test do you use to test color blindness?
Itinerary Cards Test
When palpating the ear, what do you use?
otoscope
Webber test
use running fork (vibrate) at the center of the head..should have equal vibration in both ears
Rinne Test
compares air conduction (bone conduction)
Romberg Test
asses equilibrium…standing with feet together eyes closed. If you see swaying they have vestibular/cerebellar disorder
The normal pupil size
3mm
Cervical lymph nodes have to be what size?
1cm
if larger= infection
S1
lub closure of valve between atria and ventricles
S2
dub closure for semilunar valve between the ventricles and greater arteries exiting the heart)
crepitis
popping sound
Pulmonary Arteries
carry O2 from blood tot he right ventricle->lung
Systemic Arteries
carry oxygen blood from left ventricle to the body periphery
veins carry blood
towards the heart
arteries carry blood
away from the heart
peripheral vessels
both vein and arteries
stereognosis
recognize form of object
graphesthesia
outline number on hand
point localization
identify if one is being touched
