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Health Assessment and Promotion Exam 1 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What is a Health Assessment?

A

Subjective and objective data gathered from physical assessment, lab studies, and imaging from database. Used to make diagnosis and pan of care.

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2
Q

What considerations should have for older adults?

A
  1. Mode of address
  2. Elderspeak
  3. Fatigue
  4. Use of touch
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3
Q

Complete health history and physical exam from birth to present

A

Complete Database

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4
Q

Mini database that focuses on one problem

A

Focus (problem) Centered Database

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5
Q

Used when seeing client for second time and tracks progress, changes, and effectiveness of treatment

A

Follow-Up Database

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6
Q

Used for urgent collection of crucial information

A

Emergency Database

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7
Q

General Survey

A

Physical Appearance
Body Structure
Mobility
Behavior

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8
Q

Nursing Process

A

Assessment
Diagnose
Plan
Implement
Evaluate

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9
Q

Subjective Data

A

Anything client tells you about themselves

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10
Q

Objective Data

A

Data you can prove or verify with another person or test

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11
Q

Physical Assessment

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
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12
Q

Inspection

A

Using eyes, ears, nose, to observe clients whole body and compare sides for symmetry

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13
Q

Palpation

A

Using touch to assess skin temp., texture, moisture, organ location/size, swelling, vibration, lumps/masses

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14
Q

Percussion

A

Tapping on persons skin with short sharp strokes to assess underlying structure.

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15
Q

Percussion Tone: Bone

A

Flat

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16
Q

Percussion Tone: Organs

A

Dull

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17
Q

Percussion Tone: Healthy Lungs

A

Resonant

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18
Q

Percussion Tone: Fluid in lungs or healthy children’s lungs

A

Hyperresonant

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19
Q

Percussion Tone: Air-filled Organs

A

Tympanic

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20
Q

Auscultation

A

Listening to sounds produced by the body

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21
Q

Factors Affecting Temperature

A
  1. Diurnal Cycle: lowest in morning - peaks afternoon/early evening
  2. Menstrual Cycle
  3. Exercise
  4. Age
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22
Q

Adult Pulse

A

50-95 beats per minute
Rhythm: Even tempo
Force: Should not be weak or bounding

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23
Q

Documenting Force of Pulse

A

0=Absent
1+=Weak/Thready
2+=Normal
3+=Full/Bounding
Weak=Blood Loss
Full/Bounding= Anxiety, Exercise, or Abnormal Conditions

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24
Q

Respirations

A

10-20 Breaths per minute

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25
Q

Blood Pressure

A

Normal: 120/80
Hypertension: higher than 130 and higher than 80

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26
Q

Systolic Pressure

A

Max pressure felt on artery during ventricular contraction - first sound heard when measuring

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27
Q

Diastolic Pressure

A

Resting pressure that blood exerts between each contraction - typically last sound you hear

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28
Q

Pulse Pressure

A

Difference between systolic and diastolic blood pressure readings

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29
Q

Mean Arterial Pressure

A

Systolic plus diastolic blood pressure divided by 2

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30
Q

Pain Assessment

A

Provocation
Quality
Region
Severity
Timing
Understanding

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31
Q

Nociceptors

A

Specialized nerve endings designed to detect painful sensations from periphery and transmit them to CNS

32
Q

Nociceptive Pain

A

Pain caused by damage to body tissue

33
Q

Neuropathic Pain

A

Health condition affects the nerves that carry sensations to the brain

34
Q

Referred Pain

A

Pain felt at particular site but comes from another location where both sites are innervated by same spinal nerve

35
Q

Visceral Pain

A

Originates from large organs

36
Q

Deep Somatic Pain

A

Originates from musculoskeletal tissues and body surface

37
Q

Breakthrough Pain

A

Recurrence of pain before next scheduled dose of medication

38
Q

Cultural Competence

A

Identifying your own values and beliefs before caring for others

39
Q

Cultural Humility

A

Understanding the complexity of identities and opening up conversation in a way that attempts to understand a persons identities related tp race, ethnicity, gender, sexual orientation

40
Q

When might you consult a chaplain to support your client?

A
  1. When client receives news of serious illness
  2. Person indicates they don’t have advanced directive but would like one
  3. When someone is coping with a situation where they may have a permanent disability
41
Q

4 Question Screening Tool for Alcohol Abuse

A

Cut Down
Annoyed
Guilty
Eye-opener

42
Q

Components of Mental Assessment

A

Appearance
Behavior
Cognition
Thought Process/Content Perceptions

43
Q

Intimacy Vs. Isolation (20-40 years old)

A

Independence from parents, form intimate bonds with another person, set up/manage a household, make friends and establish social group, begin parental role

44
Q

Generativity Vs. Stagnation (40-65 years old)

A

Accepting/adjusting to physical changes, reviewing career goals, developing hobby/leisure activities, adjusting to aging parents/ death of a parent, accepting and relating to spouse, attaining desired career performance

45
Q

Integrity Vs. Despair (Starts Age 65)

A

Adjusting to changes in physical strength/health, affiliating with one’s age group, adjusting to retirement/reduced income, arranging safe living quarters, adjusting to death of spouse/family members/friends, conducting life review, preparing for one’s own death

46
Q

Components of Culture

A

Culture is learned, adapted, sharing beliefs, dynamic

47
Q

Types of Cognitive Assessments

A
  1. Time Orientation
  2. Place Orientation
  3. Three Words Test
  4. Serial 7’s
  5. Repetition
  6. Comprehension
  7. Reading
  8. Writing
  9. Connect dots or draw intersecting polygons
48
Q

Nurses Role With Client With Substance Abuse Condition:

A

Advising and assisting the client regarding substance use and abuse

49
Q

Nutritional Status

A

Balance between nutrient intake and nutrient requirements - balance affected by physiologic, psychosocial, development, cultural, and economic factors

50
Q

Physiological changes that Affect Nutrition:

A

Poor Dentition
Decreased vision
Decreased Saliva
Slowed GI Motility
Decreased GI Absorption
Diminished sense of taste and smell
Decreased Energy Requirements

51
Q

Optimal Nutrition

A

Person has sufficient intake to support body’s day to day needs and any increased metabolic needs based on clients circumstances

52
Q

Undernutrition

A

Nutritional reserves are depleted and/ or nutrient intake is inadequate to meet day to day needs or metabolic demands

53
Q

Overnutrition

A

When we consume more nutrients especially calories sodium and fat in excess of our body’s needs

54
Q

24 hour Food Recall

A

Nutritional Assessment Test

55
Q

Health Effects of Abuse and Neglect of Older Adults:

A

Malnutrition
Dehydration
Skin Breakdown
UTI’s
Medication Withheld
Injury
Fear
Emotional Distress

56
Q

Subjective Data (Hair, Skin, Nails)

A

History of skin disease/allergies
Info about moles
Hypo- and hyper-pigmentation
Sores that won’t heal
Bruising/Injuries
Rashes/Lesions
Medications
Hair loss/unusual growth/changes in hair texture
Changes in nail shape/color/brittleness
Environmental/Occupational Hazards
Sun Exposure
Insect Bites
Self-care for hair, skin, nails

57
Q

Basal Cell Carcinoma

A

Most Common Skin Cancer
Slow Growing - face, ears, scalp, shoulders
1. Skin colored papule with pearly translucent top and overlying broken blood vessel
2. Develops round pearly borders with red ulcer or open pore with central yellowing

58
Q

Squamous Cell Carcinoma

A

Erythematous scaly patches with sharp margins (1cm) - heads and hands
1. Usually develops central ulcer and surrounding erythema

59
Q

Malignant Melanoma

A

Brown but can be tan, black, pink,-red, purple, or mixed pigmentation
Found on trunk, back of legs, palms, soles and nails
1. Irregular or notched borders and scaling, flaking, or oozing texture

60
Q

Assess for Skin Lesions (ABCDEF)

A

Asymmetry
Border
Color
Diameter
Elevation
Funny looking

61
Q

Assess for Edema

A

*Press thumb on skin for 3-4 seconds
0=No edema
1+=Mild pitting, slight indentation no perceptible swelling
2+=Moderate pitting, indentation subsides rapidly
3+=Deep pitting, indentation remains for short time, visible swelling
4+=Very deep pitting, indentation lasts long time, very swollen

62
Q

Stage 1 Pressure Ulcer:

A

Skin intact and unbroken, localized redness and skin doesn’t blanch or turn lighter with pressure

63
Q

Stage 2 Pressure Ulcer:

A

Partial thickness, skin erosion with loss of epidermis and also dermis. Superficial ulcer looks shallow like abrasion or open blister.

64
Q

Stage 3 Pressure Ulcer:

A

Full thickness extending into subcutaneous tissue and resembling crater. May see subcutaneous fat but not muscle/bone/tendon.

65
Q

Stage 4 Pressure Ulcer:

A

Full thickness that involves all skin layers and extends into supporting tissues. Exposed muscle, bones, tendons may show.

66
Q

Tool used to help predict pressure injury risk:

A

BRADEN scale

67
Q

When you move a part of your body by using your muscles:

A

Active ROM

68
Q

A part of your body can move when someone or something is creating the movement:

A

Passive ROM

69
Q

Review All ROM For Body Joints

A
70
Q

Used to help predict fall risk:

A

MORSE

71
Q

Sign of chronic oxygen deprivation:

A

Clubbing

72
Q

Bluish mottled color from decreased skin perfusion:

A

Cyanosis

73
Q

Sign of dehydration:

A

Dry mucous membranes

74
Q

Normal change with aging:

A

Less elasticity and subcutaneous fat

75
Q

Normal finding when assessing capillary refill:

A

Return to color in less than 3 seconds

76
Q

Body part at highest risk of skin breakdown:

A

Bony prominence

77
Q

Risk factors on BRADEN scale:

A

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear

Health Assessment and Promotion Exam 1 (1 decks)

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