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U of R SCHOOL OF NURSING > CLASS 1 - COMPREHENSIVE HEALTH ASSESSMENT > Flashcards

CLASS 1 - COMPREHENSIVE HEALTH ASSESSMENT Flashcards

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1
Q

NONVERBAL COMMUNICATION

A
  • Listening w/ the eyes

- Tells if the patient is upset, agitated, maintaining eye contact

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2
Q

VERBAL COMMUNICATION

A
  • Asking open-ended or close-ended questions
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3
Q

OPEN-ENDED QUESTIONS

A
  • “Tell me about why you’re here today”
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4
Q

CLOSE-ENDED QUESTIONS

A
  • “Tell me where you’re hurting”
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5
Q

SUBJECTIVE DATA

A
  • What the patient tells you through open-ended and close-ended questions
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6
Q

EXAMPLES OF SUBJECTIVE DATA

A
  • Health History
  • Symptoms (pain, nausea)
  • Feelings (happy, sad, nervous)
  • Perceptions (beliefs, desires)
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7
Q

OBJECTIVE DATA

A
  • What the nurse assesses
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8
Q

EXAMPLES OF OBJECTIVE DATA

A
  • Observations
  • Vital signs (blood pressure, pulse, respirations)
  • Physical exam findings
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9
Q

ANTHROPOMETRIC MEASURES

A
  • Height/Weight

- BMI

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10
Q

UNDERWEIGHT BMI VALUE

A
  • < 18.5
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11
Q

NORMAL BMI VALUE

A
  • 18.5 - 24.9
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12
Q

OVERWEIGHT BMI VALUE

A
  • 25.0 - 29.9
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13
Q

OBESE BMI VALUE

A
  • > 30.0
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14
Q

VITAL SIGNS

A
  • Temperature
  • Pulse
  • Respiration
  • Blood Pressure
  • Pulse Oximetry
  • Pain
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15
Q

AVERAGE ORAL TEMPERATURE

A
  • 37 degrees C or 98.6 degrees F
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16
Q

AVERAGE RECTAL TEMPERATURE

A
  • 0.5 degrees C or 1 degrees F > oral temperature
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17
Q

AVERAGE AXILLARY TEMPERATURE

A
  • 0.5 degrees C or 1 degrees F < oral temperature
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18
Q

AVERAGE TYMPANIC TEMPERATURE

A
  • 0.8 degrees C or 1.4 degrees F > oral temperature
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19
Q

AVERAGE TEMPORAL TEMPERATURE

A
  • Close to core body temperature
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20
Q

PLACEMENT FOR ORAL TEMPERATURE

A
  • Posterior sublingual pockets (hot spots)
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21
Q

FACTORS OF INACCURATE ORAL TEMPERATURE

A
  • Hot and cold foods
  • Unable to close mouth
  • Smoking cigarettes
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22
Q

PLACEMENT FOR TYMPANIC TEMPERATURE

A
  • Beginning of the ear canal and aim the infrared beam at the tympanic membrane
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23
Q

FACTORS OF INACCURATE TYMPANIC TEMPERATURE

A
  • Cerumen

- Hearing aides

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24
Q

PLACEMENT FOR TEMPORAL TEMPERATURE

A
  • Sliding probe across the forehead and down behind the ear
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25
Q

DOCUMENTING TEMPERATURE

A
  • Example: 98.2 degrees F oral/rectal/temporal
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26
Q

PULSE LOCATIONS

A
  • Radial (wrist)
  • Brachial (inside elbow)
  • Carotid (side of neck)
  • Pedal (top of foot)
  • Apical (chest)
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27
Q

MOST ACCURATE PULSE LOCATION

A
  • Apical because you’re listening to the actual beat of the heart
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28
Q

NORMAL PULSE RANGE

A
  • 60 - 100 beats/minute
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29
Q

PULSE EXAM TECHNIQUE

A
  • Palpate for pulse

- Count beats for 30 seconds, multiple x 2

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30
Q

BRADYCARDIA

A
  • Less than 50 beats/minute
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31
Q

TACHYCARDIA

A
  • Greater than 95 - 100 beats/minute
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32
Q

PULSE INTENSITY CATEGORIES

A
  • 3+ - Full, bounding
  • 2+ - Normal
  • +1 - Weak, thready
  • 0 - Absent
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33
Q

DOCUMENTING PULSE

A
  • Example: 80 BPM apical/radial/carotid
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34
Q

T/F : IF BREATHING OR PULSE IS IRREGULAR YOU HAVE TO DO THE TEST FOR 60 SECONDS?

A
  • True
35
Q

NORMAL RESPIRATORY RATE

A
  • 14 - 20 breaths/minute
36
Q

RESPIRATORY RATE EXAM TECHNIQUE

A
  • NEVER tell a patient you are counting respirations
  • After 30 seconds of counting normal pulse, continue with 30 seconds of watching respirations (as if you were still counting the pulse)
37
Q

RESPIRATORY RHYTHM CATEGORIES

A
  • Regular

- Labored

38
Q

RESPIRATORY DEPTH CATEGORIES

A
  • Shallow

- Gasping

39
Q

OXYGEN SATURATION DEFINITION

A
  • Using a pulse oximeter to assess arterial oxygen saturation
  • Measures the % of hemoglobin attached to oxygen
40
Q

NORMAL OXYGEN SATURATION

A
  • SpO2 of 97 - 99%

- SpO2 of > 93% is clinically acceptable

41
Q

FACTORS OF INACCURATE OXYGEN SATURATION

A
  • Nail polish
  • Cold hands
  • If SpO2 is on the low side, have the patient take a couple deep breaths
42
Q

DOCUMENTING OXYGEN SATURATION

A
  • Example: 92% room air

- Example: 92% on 4 L of oxygen nasal cannula (if on oxygen need to report how much)

43
Q

PAIN RATING SCALE

A
  • Pain is subjective
  • 0 - 10 rating scale
  • Pain score > 3 means the patient needs intervention and re-assessment
44
Q

DOCUMENTING PAIN RATING SCALE

A
  • Example: Pain scale 3/10 on left ankle
45
Q

BLOOD PRESSURE EXAMINATION TECHNIQUE

A
  • Palpation for brachial artery
  • Rest patient arm with your own at mid-chest level
  • Center at brachial artery 2.5 cm above antecubital crease
  • Inflate cuff
  • Palpate radial pulse and inflators until pulse disappears
  • Inflate 20-30 mmHg further
  • Place stethoscope over brachial artery
  • Deflate cuff by 2-3 mmHg/second
  • First sound = systolic
  • Second sound = diastolic
46
Q

FACTORS OF INACCURATE BLOOD PRESSURE

A
  • Too large of a cuff doesn’t put enough pressure on the artery –> low BP
  • Too small of a cuff puts too much pressure on the artery –> high BP
  • Releasing the bladder too slowly causes venous congestion –> high diastolic
47
Q

NORMAL BLOOD PRESSURE VALUE

A
  • < 120 / < 80 mmHg
48
Q

PREHYPERTENSION BLOOD PRESSURE VALUE

A
  • 120 - 139 / 80 - 89 mmHg
49
Q

HYPERTENSION (STAGE 1) BLOOD PRESSURE VALUE

A
  • 140 - 150 / 90 - 99 mmHg
50
Q

HYPERTENSION (STAGE 2) BLOOD PRESSURE VALUE

A
  • > 160 / > 100 mmHg
51
Q

HYPERTENSION CRISIS BLOOD PRESSURE VALUE

A
  • > 180 / > 110 mmHg

- Emergency care needed!

52
Q

ORDER OF EXAMINATION

A
  • Inspection (includes impression and all subcategories)
  • Palpation
  • Percussion
  • Auscultation
53
Q

INSPECTION ASSESSMENT

A
  • Process of observation
  • Careful scrutiny of the individual as a whole then of each body system
  • Good lighting
  • Adequate exposure
54
Q

ORDER OF IMPRESSION

A
  • Overall state of health
  • Physical appearance
  • Body structure
  • Behavior
  • Distress
55
Q

OVERALL STATE OF HEALTH ASSESSMENT

A
  • Does the person stand promptly to meet you?
  • Does the person look sick?
  • Does the person fully extend their arm to shake your hand?
  • Are the palms dry or clammy?
56
Q

FACTORS OF PHYSICAL APPEARANCE ASSESSMENT

A
  • Stated vs. apparent age
  • Body fat, stature
  • Level of consciousness
  • Motor activity
  • Body and breath odors
  • Facial expressions
57
Q

STATED VS. APPARENT AGE ASSESSMENT

A
  • The person appears his or her stated age?
58
Q

BODY FAT, STATURE ASSESSMENT

A
  • The height appears within normal range for age, genetic heritage
  • The weight appears within the normal range for height and body build
  • Body fat distribution is even
59
Q

LEVEL OF CONSCIOUSNESS ASSESSMENT

A
  • The person is alert and oriented to person, place, time, and situation
  • Responds appropriately to your questions
  • A & O x 3
60
Q

MOTOR ACTIVITY ASSESSMENT

A
  • The person has smoothness of motion, no tremors, coordinated gait
61
Q

BODY AND BREATH ODOR ASSESSMENT

A
  • The person appears clean and groomed appropriately (if culturally appropriate) for his/her age or occupation, and socioeconomic group
62
Q

FACIAL EXPRESSION ASSESSMENT

A
  • The person maintains eye contact (if culturally appropriate)
  • Expressions are appropriate to the situation (thoughtful, serious, smiling)
63
Q

FACTORS OF BODY STRUCTURE ASSESSMENT

A
  • Posture/Position
  • Range of Motion
  • Gait
  • Stature/Symmetry
  • Nutrition
64
Q

POSTURE/POSITION ASSESSMENT

A
  • The person stands comfortably erect as appropriate for age
65
Q

RANGE OF MOTION ASSESSMENT

A
  • Full mobility for each joint and that movement is deliberate, accurate, smooth, and coordinated.
66
Q

GAIT ASSESSMENT

A
  • Feet approximately shoulder width apart
  • Foot placement accurate
  • Walk is smooth and even
  • Person can maintain balance without assistance
  • Symmetric arm swing present
67
Q

STATURE/SYMMETRY ASSESSMENT

A
  • The height appears within normal range for age, genetic heritage
  • Body parts look equal bilaterally and are irrelative proportion to each other
68
Q

NUTRITION ASSESSMENT

A
  • The weight appears within normal range for height and body build
  • Body fat distribution is even
69
Q

FACTORS OF BEHAVIOR ASSESSMENT

A
  • Dress/grooming
  • Mood/manner
  • Speech
  • Facial expressions
70
Q

DRESS/GROOMING ASSESSMENT

A
  • Clothing is appropriate for the climate
  • Looks clean and fits the body
  • Appropriate to the person’s culture and age-group
  • Culturally determined dress should not be labeled as inappropriate by Western standards
71
Q

MOOD/MANNER ASSESSMENT

A
  • The person is comfortable and cooperative with the examiner and interacts pleasantly
72
Q

SPEECH ASSESSMENT

A
  • Articulation is clear and understandable
  • Stream of talking is fluent, with even pace
  • Conveys ideas clearly
73
Q

FACIAL EXPRESSION ASSESSMENT

A
  • The person maintains eye contact (if culturally appropriate)
  • Expressions are appropriate to the situation (thoughtful, serious, smiling)
74
Q

FACTORS OF DISTRESS ASSESSMENT

A
  • Physiological
  • Pain
  • Emotional
75
Q

PHYSIOLOGICAL ASSESSMENT

A
  • The person has no apparent distress
76
Q

PAIN ASSESSMENT

A
  • Is the person short of breath, grimacing, guarding a certain area of the body?
77
Q

EMOTIONAL ASSESSMENT

A
  • What kind of emotions is the person showing? Pleasant, relaxed, angry, distressed
  • Flat affect: no smiling, monotone - can be hard to read
78
Q

FACTORS OF PALPATION ASSESSMENT

A
  • Fingertips
  • Ball of hand
  • Dorsa of hands and fingers
  • Base of fingers
79
Q

FINGERTIP PALPATION ASSESSMENT

A
  • Best for fine tactile discrimination
  • Skin texture
  • Swelling
  • Pulsation
  • Determining lumps
  • Crepitation
  • Organ size
80
Q

BALL OF HAND PALPATION ASSESSMENT

A
  • Vibration

- Can also be felt with ulnar surface of hand

81
Q

DORSA OF HANDS AND FINGERS ASSESSMENT

A
  • Best for determining temperature
82
Q

PERCUSSION ASSESSMENT

A
  • Tapping the person’s skin with short, sharp strokes to assess underlying structures
  • Produces vibration and subsequent sound waves in body
  • Determine location and size of organ
  • Signaling density (air, fluid, or solid)
83
Q

AUSCULTATION ASSESSMENT

A
  • Listening to sounds produced by the body (heart, blood vessels, bowels)
  • Stethoscope used to block out sounds and concentrate on the sound

U of R SCHOOL OF NURSING (12 decks)

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