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Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Subjective data

A

What the person says about himself or herself during history taking (symptom, health history)

Cough, shortness of breath

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2
Q

Objective data

A

What you as a health professional observe by inspecting, percussing, palpating and auscultating during the physical exam (sign)

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3
Q

Source of History

A

Record who furnishes information; judge reliability of informant and how willing he or she is to communicate

Verify all data; you must make the most accurate decision by verifying data first

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4
Q

Reason for seeking care

A

Brief spontaneous statement in persons own words describing their reason for visit

Document exact words

Usually involves a description of one or two symptoms and a duration

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5
Q

Biographical data

A

Includes name, address, phone number, birth date, age, birthplace, gender, race, occupation, etc. primary language

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6
Q

Present health or history of present illness

A 
Documented using the eight critical behaviors:
Location
Character or Quality
Quantity or severity 
Timing
Setting
Aggravating or relieving factors 
Associated factors 
Patient's perception
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7
Q

Location

A

Be specific; ask the person to point to location

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8
Q

Character or quality

A

Specific descriptive terms such as burning, sharp, dull, aching, throbbing

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9
Q

Quantity or Severity

A

How bad is the pain; mild, moderate, severe; use the pain scale to quantify pain

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10
Q

Timing

A

Onset, duration, frequency; when did symptom first appear?

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11
Q

Setting

A

Where was the person; what was the person doing when he symptom started

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12
Q

Aggravating or relieving factors

A

What makes pain better or worse; what seems to help

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13
Q

Patients perception

A

What do you think is going on; how does it affect daily activities

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14
Q

Past Health

A

Childhood illnesses- measles, mumps, chickenpox
Accidents/injuries- auto accidents, fractures, burns
Chronic illnesses- asthma, depression, hypertension,
Hospitalizations- cause, name of hospital, how long, how it was treated
Operations- type of surgery, date, how they recovered
OB history- pregnancies, deliveries
Immunizations- vaccine history
Last exam date- physical, dental, vision, Amy exam
Allergies- allergen and reaction
Current medication-prescription and over the counter

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15
Q

Family history

A

Accurate family history highlights diseases and conditions for which a particular patient may be at an increased risk; may seek early screenings

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16
Q

Review of systems

A

Assessing objective data; general overall health state; if the patient says yes, stop and access further

Evaluate health promotion practices

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17
Q

Functional assessment including activities of daily living (ADLs)

A

How are they doing?; measures a persons self care ability in the areas of general physical health or absence of illness

ADLs- bathing, dressing, eating, toileting, walking

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18
Q

CAGE

A 
C: cut down
Have you ever thought you should cut down your drinking?
A: annoyed 
Have you ever been annoyed by criticism of your drinking? 
G: guilty 
Have you ever felt guilty?
E: eye opener 
Do you drink in the morning?
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19
Q

Perception of health

A

How do you define health?
What are your concerns?
What are your health goals?

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20
Q

Children

A

Caregiver is usually giving the information; nutrition; developmental milestones; how labor and delivery went

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21
Q

Adolescent

A

Usually includes sensitive subjects: drugs, sexuality, suicide and depression

Home life, education, job, activities, eating

HEEADSSS- home, education/employment, eating, activities, drugs, sexuality, suicide, safety

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22
Q

Older Adult

A

May shrug off symptoms as evidence of growing old; may have chronic problems; may take time to figure out why older person has come for an examination

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23
Q

Final Statement

A

Should be the persons reason for seeking care, not your assumption of the problem

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24
Q

Obstetric History

A

Recorded as Grav (number of pregnancies), term(reached full term), preterm (premise), Ab(abortion), living

Grav 6
Term 4
Preterm o
Ab 2
Living 4
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25
Q

Genogram or pedigree

A

Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members

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26
Q

Skin

A

The body’s largest organ system

Waterproof, protective, adaptive, regulates temperature, produces vitamin D

Guards the body from environmental stresses

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27
Q

Epidermis

A

Outer layer; highly differentiated; replaced every 4 weeks

Basal cell layer forms new skin cells

Outer horny cell layer consists of dead keratinized cells

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28
Q

Dermis

A

Inner supportive layer consisting mostly of connective tissue, or collagen; also has elastic tissue that allows the skin to stretch with body movements

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29
Q

Subcutaneous Layer

A

Beneath the epidermis and dermis; layer of adipose tissue

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30
Q

Newborn Infants (skin related development considerations)

A

Lanugo, vernix caseosa, sebum

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31
Q

Lanugo

A

Fine downy hair of a newborn infant

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32
Q

Vernix Caseosa

A

Thick, cheesy substance made up of sebum and shed epithelial cells; will go away with repeated washings

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33
Q

Sebum

A

Holds water in the skin; present in the first few weeks of life, can produce milla which looks like little baby acne

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34
Q

Children

A

Epidermis- thickens, toughens and darkens and the skin becomes better lubricated

Hair- growth accelerates

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35
Q

Adolescents

A

Sweat glands- increase secretions

Subcutaneous fat- deposits increase especially in females

Secondary sex characteristics- begin to develop; breast tissue develops, coarse pubic hair

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36
Q

Linea nigra

A

Change in hormone levels results in increased pigment in the areolae and nipples, vulva, and sometimes in the midline of the abdomen (pregnant women)

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37
Q

Chloasma

A

Discoloration on the face, “mask of pregnancy”, can occur in women taking oral contraceptive pills

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38
Q

Striae Gravidarum

A

Stretch marks for pregnancy, develop over abdomen, breast and thighs. Typically fade but never go away

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39
Q

Older adults(skin)

A

Elasticity: loses elasticity, it folds, and says
Sweat and sebaceous glands: decreases, leaves skin dry
Hair matrix: function of melanocytes decreases; hair looks grey and fine
Senile Purpura

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40
Q

Senile Purpura

A

Discoloration, tend to bruise easier, capillaries are more fragile;

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41
Q

Melanin

A

Substance responsible for the various colors and tones of skin in people

Dark skinned people have a genetic advantage in the protection against skin cancer because of melanin. It protects the skin against harmful UV rays. Exposure to UV radiation is the most important risk factor of skin cancer.

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42
Q

Pallor

A

Unhealthy pale appearance, best assessed in nail beds and lips

Black people will be ashen, gray or dull

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43
Q

Erythema

A

Red appearance; intense redness is from excess blood in the dilated superficial capillaries.

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44
Q

Cyanosis

A

Blue appearance; the tissues have high levels of deoxygenated blood

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45
Q

Jaundice

A

Yellowish appearance; increase amounts of bilirubin in the blood

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46
Q

Hypothermia

A

Excessive coolness; temperature lower than expected

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47
Q

Hyperthermia

A

Excessive warmth; temperature higher than normal

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48
Q

Diaphoresis

A

Refers to perfuse sweating that’s caused by an increased metabolic rate

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49
Q

Dehydration

A

Loss or removal of water

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50
Q

Skin turgor

A

Indicated of hydration status, notes the skins elasticity

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51
Q

Hyperthyroidism

A

Results in smooth velvety skin

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52
Q

Hypothyroidism

A

Results in rough, dry, flaky skin

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53
Q

Thickness

A

Epidermis is thin over most of the body, although thickened callus areas are normal on palms and soles

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54
Q

Edema

A

Fluid accumulating in the intracellular spaces, this is not normal

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55
Q

Peripheral edema

A

Edema in the feet and hands

56
Q

Dependent edema

A

Found in areas such as the feet, sacrum of a client bed bound

57
Q

Pitting

A

Press finger in the area of edema for 2-3 seconds and note depth of indentation

58
Q

Lesions

A

ABCDE: asymmetry, border, color, diameter, elevation and enlargement; should be described in great detail

59
Q

Macules

A

Color change seen on skin, flat, less than one centimeter (freckles)

60
Q

Patch

A

Color change seen on skin greater than one centimeter (Mongolian spots, measles rash)

61
Q

Papules

A

Skin lesion you can feel, solid, elevated, less than one centimeter (moles, warts)

62
Q

Plaques

A

Papules form a mass, wider than one centimeter(psoriasis)

63
Q

Nodules

A

Skin lesion, solid, can be hard or soft, larger than 1 centimeter

64
Q

Tumor

A

Digs deeper into the chest, benign or malignant

65
Q

Wheals

A

Transient(come and go) and red raise in the skin, irregular shape (mosquito bite, allergic reaction)

66
Q

Urticaria (hives)

A

Multiple wheals come together to form this, severe itching

67
Q

Vesicles

A

Elevated cavity that contains fluids, also known as blister(herpes)

68
Q

Bullas

A

Larger than one centimeter (contact blisters, burns)

69
Q

Cysts

A

Fluid filled cavity, located in dermis and subcutaneous layer, elevates skin (sebaceous cyst)

70
Q

Pustules

A

Pus in the cavity, round and elevated (acne)

71
Q

Vestigial

A

Hair for humans is no longer needed for protection from cold and skin trauma

72
Q

Eccrine glands

A

Coiled tubules that open directly onto the skin surface and produce sweat; no odor

73
Q

Apocrine glands

A

Produce a thick, milky secretion, and open into the hair follicles; create a musky odor

74
Q

Xerosis

A

Dryness of the skin

75
Q

Seborrhea

A

Oily of the skin

76
Q

Pruritus

A

Severe itching of the skin

77
Q

Alopecia

A

Hair loss

78
Q

Sulfonamides, thiazides, diuretics, oral hypoglycemic agents, and tetracycline

A

Drugs that increase sunlight and give a burn response

79
Q

Vitiligo

A

The complete absence of melanin pigment in patchy areas of white or light skin

80
Q

Senile angiomas

A

Small, smooth, slightly raised bright red dots that commonly appear on the trunk

81
Q

Lichenification

A

Results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules

82
Q

Trichotillomania

A

Self induced hair loss

83
Q

Pleurae

A

Visceral pleura lines outside of lungs

Parietal pleura lines inside of chest wall and diaphragm

Pleural cavity is potential space filled only with few millimeters of lubricating fluid

84
Q

Trachea and Bronchi

A

Transport gases between the environment and lungs

Make dead space: space that is filled with air but is not available for gaseous exchange

85
Q

Bronchial tree

A

Protects alveoli from inhaled foreign particles

86
Q

Bronchi

A

Lined with cells that secrete mucus to trap foreign particles

87
Q

Gas exchange

A

Occurs across respiratory membrane in alveolar duct and in millions of alveoli

88
Q

Vertebra prominens

A

Spinous process of C7

89
Q

Skeletal deformities

A

Barrel chest, kyphosis, scoliosis

90
Q

Barrel Chest

A

Characterized by a rounded appearance, horizontal ribs, slight kyphosis; the chest appears in constant inspiration; associated with normal aging, and infants chest, and with chronic emphysema and asthma

COPD

91
Q

Kyphosis

A

Humpback; exaggerated posterior curvature of the thoracic spine. Causes significant back pain and limited mobility. Associated with aging, especially in women. Related to physical fitness

92
Q

Scoliosis

A

Lateral S-shaped curvature of the thoracic and lumbar spine.

93
Q

Lordosis

A

Exaggerated curvature of the lumbar vertebrae

94
Q

Upper airway

A

Nasopharynx(nose), oropharynx(mouth), laryngopharynx, larynx

95
Q

Lower airway

A

Trachea, bronchi, bronchioles, and alveoli

96
Q

Lungs

A

Right lung: 3 lobes, upper middle and lower, shorter

Left lung: 2 lobes, upper and lower, narrower

97
Q

Tripod position

A

Leaning forward with arms braced against their knees, chair, or bed. Gives them leverage so the abdominal, intercostal, and neck muscles all can aid in expiration

98
Q

Hypoxia

A

Depletion of oxygen

99
Q

Tachypnea

A

Rapid, shallow breathing, with an increased rate greater than 24 per minute

Causes: normal response to fear, exercise, and fever

Also occurs with pain, pneumonia, pleurisy, alkalosis, and lesions in the pons.

100
Q

Bradypnea

A

Slow breathing; decreased but regular rate of less than 10 per minute.

Causes: can occur with drug induced depression of the respiratory center in the medulla, increased intracranial pressure and diabetic coma.

101
Q

Apnea

A

Total absence of breathing; may be periodic

102
Q

Hyperpnea

A

Increased depth of respirations; can occur during strenuous exercise and diabetic ketoacidosis

103
Q

Hyperventilation

A

An increase in both rate and depth of inspirations

Causes: exertion, fear, or anxiety; seen in many acidotic states.

104
Q

Hypoventilation

A

Irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain

105
Q

Cheyne-Stokes

A

Cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth, then decreasing. The breathing cycle lasts 30-45 seconds, with periods of apnea alternating the cycle.

Causes: severe heart failure (most common), renal failure, meningitis, drug overdose

Occurs normally in infants and aging persons duri sleep

106
Q

Biots

A

Similar to cheyne stokes, but the pattern is irregular. Lasting anywhere from 10 seconds-1 minute.

Causes: seen with spinal meningitis, heat stroke, head trauma, brain abscess, encephalitis

107
Q

Kussmaul’s

A

Panting labored kind of respiration with increased rate and depth. Associated with severe metabolic acidosis and renal failure.

108
Q

Ribs

A

Inserted to the spine at about a 45 degree angle

May be increased on a person with emphysema

109
Q

Costal angle

A

Should be less than or equal to 90 degrees

110
Q

Accessory muscles

A

Include sternocleidomastoid, trapezius, and abdominal muscles

111
Q

Anterior Thoracic Landmarks

A

Suprasternal notch, sternum(breast bone), angle of Louis, costal angle

112
Q

Suprasternal notch

A

Hollow ushaped depression just above the sternum, between the clavicles.

113
Q

Sternum

A

The “breastbone”, three parts: manubrium, body, xiphoid process

114
Q

Sternal angle

A

Also called angle of Louis; articulation of the manubrium and body of the sternum, and it is continuous with the second rib

Marks the site of tracheal bifurcation into the right and left main bronchi.

115
Q

Posterior Thoracic Landmarks

A

Vertebra prominens, spinous processes, inferior border of the scapula, twelfth rib

116
Q

Reference lines anterior chest

A

Midsternal, midclavicular

117
Q

Lateral reference lines

A

Anterior axillary line, posterior axillary line, midaxillary line

118
Q

Deep inspiration

A

Lung expansion, lungs have lower border level, will drop to t12 vertebra

119
Q

Hypoxemia

A

Decrease of oxygen in the body

120
Q

Hypercapnia

A

Increase of carbon dioxide in the blood

121
Q

Pectus carinatum

A

Sternum protruding forward; results in increase AP diameter

122
Q

Anteroposterior to lateral diameter

A

Ratio of 1:2

In older adults, you will observe an increase in the AP diameter which is normal

123
Q

Sinus Tracts

A

Narrow openings or passageways underneath the skin that results in dead space with potential for abscess formation

124
Q

Crepitus

A

A coarse, crackling sensation palpable over the skin surface that indicates air has escaped from the lung and enters the subcutaneous tissue of the chest

May be present in emphysema, pneumothorax, open thoracic injury, or thoracic surgery

125
Q

Primary muscles of respiration

A

Diaphragm and intercostals

126
Q

Respiratory excursion

A

Performed to access range and symmetry of respiratory movement

127
Q

Tactile fremitus

A

Strongest between the scapula and around the sternum because this is where the major bronchi are closest to the chest wall; normally decreases progress downwards; feels greater over a thin chest wall than over an obese or heavily muscular one

Palpable vibration

128
Q

Increased fremitus

A

Occurs with compression or consolidation of lung tissue; may be due to a mass, pneumonia, or other inflammatory processes

129
Q

Decreased fremitus

A

Occurs when anything obstructs the vibration; may be due to an obstructed bronchus, pleural thickening, pleural effusion, pnuemothorax, emphysema

130
Q

Percuss

A

Gently tap; normal lung should be air filled, producing a resonance sound that is loud intensity and low pitched.

131
Q

Dull percussion

A

Abnormal density in the lung; lung tumor, pneumonia, pleural effusion and atelectasis will cause

132
Q

Hyperresonant

A

Too much air is present; caused by emphysema and pneumothorax

133
Q

Diaphragmatic excursion

A

Movement of the diaphragm as it descends on inspiration and rises on expiration

134
Q

Vesicular Breath sounds

A

Soft, low pitched rustling sounds located over the periphery of the lung; most predominant breath sounds; if decreased over the periphery, this may indicate pneumonia, emphysema, pleural effusion, or atelectasis.

135
Q

Bronchial or tracheal breath sounds

A

Loud, high pitched tubular sounds over the trachea and major bronchi; if auscultated over periphery, it may indicate consolidation or atelectasis

136
Q

Bronchovesicular breath sounds

A

Moderately pitched breath sounds located between the scapulae posteriorly and in either side of the sternum at the first and second intercostal space anteriorly. If heard over periphery, it may indicated consolidation.

Expected near major airways

137
Q

Inaudible breath sounds

A

May indicate atelectasis or pneumothorax

Health Assessment (5 decks)

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