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Nursing Foundations Test 1 > Chapter 25 > Flashcards

Chapter 25 Flashcards

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1
Q

Purposes of the Health Assessment

A
  • Establish the nurse–patient relationship.
  • Gather data about the patient’s general health status.
  • Identify patient strengths.
  • Identify actual and potential health problems.
  • Establish a base for the nursing process.
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2
Q

Types of Health Assessments

A

Comprehensive
Ongoing partial
Focused
Emergency

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3
Q

Comprehensive Health Assessment

A

conducted upon admission to health care facility

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4
Q

Ongoing partial Health Assessment

A

conducted at regular intervals

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5
Q

Focused Health Assessment

A

conducted to assess a specific problem

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6
Q

Emergency Health Assessment

A

conducted to determine life-threatening or unstable conditions

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7
Q

Components of a Preventive Health Assessment

A
  • Health history
  • Risk for depression
  • Functional ability
  • Level of safety
  • Physical examination
  • Patient education and counseling
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8
Q

Considerations When Performing Health Assessment

A
  • Lifespan considerations
  • Cultural considerations and sensitivity
  • Patient preparation
  • Environmental preparations
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9
Q

Factors to Assess During a Health History

A
  • Biographical data
  • Reason for seeking health care
  • History of present illness
  • Past health history
  • Family history
  • Functional health
  • Psychosocial and lifestyle factors
  • Review of systems
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10
Q

Preparing the Patient for Physical Assessment

A
  • Consider the physiologic and psychological needs of the patient.
  • Explain the process to the patient.
  • Explain that physical assessments will not be painful
  • Explain each procedure in detail as it is conducted.
  • Ask the patient to change into a gown and empty bladder.
  • Answer patient questions directly and honestly.
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11
Q

Preparing the Environment for Physical Assessment

A

-Agree on a time for the assessment.
The time should not interfere with meals, daily routines, or visiting hours.
-Make sure patient is as free of pain as possible.
-Prepare the examination table.
-Provide a gown and drape for the patient.
-Gather the supplies and instruments needed.
-Provide a curtain or screen if the area is open to others

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12
Q

Equipment Used During a Physical Examination

A
  • Thermometer and sphygmomanometer
  • Scale
  • Flashlight or penlight
  • Stethoscope
  • Metric tape measure and ruler
  • Eye chart
  • Tuning fork
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13
Q

Supine position

A
  • lying flat on back
  • used to assess head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
  • allows relaxation of abdominal muscles
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14
Q

Sims Position

A
  • lying on side with lower arm below the body and upper arm flexed at shoulder and elbow
  • used to assess the rectum and vagina
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15
Q

dorsal recumbent position

A
  • lying on back with legs separated and knees flexed
  • used for patients having difficulty maintaining supine position
  • used to assess head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
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16
Q

Prone position

A
  • lying on stomach with head turned to the side

- assessment of hip joint and posterior thorax

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17
Q

Standing position

A

assessment of posture, balance, and gait

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18
Q

Sitting position

A

allows visualization of upper body

19
Q

Lithotomy position

A
  • assessment of female genitalia and rectum

- giving birth position

20
Q

Knee–chest position

A

assessment of anus and rectum

21
Q

Inspection

A
  • the process of performing deliberate, purposeful observation in a systematic manner
  • assessing size, color, shape, position, and symmetry
22
Q

Palpation

A
  • touch

- assessing temperature, turgor, texture, moisture, vibrations, and shape

23
Q

Percussion

A
  • is the act of striking one object against another to produce sound
  • assessing location, shape, size, and density of tissues
24
Q

Auscultation

A
  • the act of listening with a stethoscope to sounds produced in the body
  • assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration
25
Q

Characteristics of Masses Determined by Palpation

A
  • Shape
  • Size
  • Consistency
  • Surface
  • Mobility
  • Tenderness
  • Pulsatile
26
Q

Right Upper Quadrant

A
  • Pylorous
  • Duodenum
  • Liver
  • Right kidney and adrenal gland
  • Hepatic flexure of colon
  • Head of pancreas
27
Q

Left Upper Quadrant

A
  • Stomach
  • Spleen
  • Left kidney and adrenal gland
  • Splenic flexure of colon
  • Body of pancreas
28
Q

Right Lower Quadrant

A
  • Cecum
  • Appendix
  • Right ovary and fallopian tube(female)
  • Right ureter and lower kidney pole
  • Right spermatic cord(male)
29
Q

Left Lower Quadrant

A
  • Sigmoid colon
  • Left ovary and fallopian tube(female)
  • Left ureter and lower kidney pole
  • left spermatic cord(male)
30
Q

Midline

A
  • urinary bladder

- urethra(female)

31
Q

Characteristics of Sound Heard When Using Auscultation

A
  • Pitch: ranging from high to low
  • Loudness: ranging from soft to loud
  • Quality: for example, gurgling or swishing
  • Duration: short, medium, or long
32
Q

General Survey

A
  • General appearance
  • Vital signs
  • Height, weight, waist circumference
  • Calculating BMI
33
Q

Common Thorax and Lung Variations in Older Adults

A
  • Increased anteroposterior chest diameter
  • Increase in the dorsal spinal curve (kyphosis)
  • Decreased thoracic expansion
  • Use of accessory muscles to exhale
34
Q

Cardiovascular and Peripheral Vascular Variations in Newborns and Children

A
  • Visible cardiac pulsation if the chest wall is thin
  • Sinus dysrhythmia (the rate increases with inspiration and decreases with expiration)
  • Presence of S3 (in about one-third of all children)
  • More rapid heart rate (until about 8 years of age)
35
Q

Common Cardiovascular and Peripheral Vascular Variations in Older Adults

A
  • Difficult-to-palpate apical pulse
  • Difficult-to-palpate distal arteries
  • Dilated proximal arteries
  • More prominent and tortuous blood vessels; varicosities common
  • Increased systolic and diastolic blood pressure
  • Widening pulse pressure
36
Q

Common Abdominal Variations in Newborns

A

umbilical cord in newborns; dries and falls off within the first few weeks of life

37
Q

Common Abdominal Variations in Children

A

a “pot-belly” (under 5 years of age), visible peristaltic waves

38
Q

Common Abdominal Variations in Older Adults

A
  • Decreased bowel sounds
  • Decreased abdominal tone
  • Fat accumulation on the abdomen and hips
39
Q

Common Genitalia Variations in Newborns and Children

A
  • Enlarged labia and clitoris
  • Breast enlargement in both boys and girls
  • Vaginal discharge in girls, called pseudomenstruation
  • Pubic hair and breast development occur at puberty and follow a regular sequence of development.
  • Menstruation begins about 2.5 years after puberty begins.
  • Irregular menstrual cycle for first 2 years
40
Q

Risk Factors for Altered Health Assessed in Health History

A
  • History of trauma, arthritis, or neurologic disorder
  • History of pain or swelling in the muscles and/or joints
  • Frequency and type of usual exercise
  • Dietary intake of calcium
  • History of any surgery on muscles or joints
  • History of smoking (how long, how many packs/day)
  • History of alcohol intake
41
Q

Assessing Level of Awareness

A
  • Time: What is today’s date? What day of the week is it? What season of the year is this? What was the last holiday?
  • Place: Where are you now? What is the name of this city? What state are we in?
  • Person: What is your name? How old are you? Who came to visit you this morning?
42
Q

Purposes of Documentation

A
  • Identify actual and potential health problems
  • Make nursing diagnoses
  • Plan appropriate care
  • Evaluate patient’s responses to treatment
43
Q

Nurse’s Role in Diagnostic Procedures

A

-Assist before, during, and after diagnostic tests.
-Be responsible for other activities associated with diagnostic tests.
-Witness the patient’s consent.
-Schedule the test.
-Prepare the patient physically and emotionally for the test.
-Provide care and teaching after the test.
-Dispose of used equipment.
Transport specimens.

Nursing Foundations Test 1 (9 decks)

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