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Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Diagnostic Process

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation
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2
Q

Assessment- 2 types of data

A

Subjective- what pt states about himself

Objective- what the health professional observes/assesses

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3
Q

critical thinking

A

developed as the nurse progresses from novice to expert

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4
Q

Thinking like a nurse involves 3 nursing diagnoses:

A
  1. Actual- whats actually happening
  2. Risk- when patient is at risk for something (infection after surgery, sepsis.. etc)
  3. Wellness- how well can the pt cope with daily activities
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5
Q

what determines how a problem is prioritized?

A

the acuity of illness often determines order of priorities

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6
Q

3 levels of setting priorities

A

first-level priority: emergency and life threatening problem

2nd-level priority: when you don’t intervene promptly, pt starts to deteriorate

3rd-level priority: important but not as urgent

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7
Q

what type of health history is taken when patient is admitted into hospital?

A

Complete (total health) database

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8
Q

what type of health history is taken when pt is sent to emergency room?

A

Focused or Problem-Centered Database

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9
Q

What type of health history is taken when pt is discharged and sent to be re-assessed

A

Follow-up database

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10
Q

Type of health history usually taken when happening in emergency situations

A

Emergency Database

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11
Q

health promotion ____

A

encourages patients to do preventative care

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12
Q

The interview process is made up of 2 facrors:

A

Internal and External Factors

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13
Q

Internal factors that should be used during the interview process are:

A
  • liking others
  • empathy
  • listening
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14
Q

External factors that should be used during the interview process are:

A

Privacy
Interruptions
Environment
Note-taking

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15
Q

The 2 most used techniques of communication that can be used in the interview process;

A
  1. Open-ended question: “tell me what you’re in for today”

2. Closed or directed question: “what medication are you taking, rate your pain on a scale of 0-10”

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16
Q

When do you use an open-ended question?

A
  • to facilitate beginning of interview
  • introduce a new section of questions
  • introduce new topic
  • to end an interview and ease into closure
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17
Q

when do you use a closed or directed question?

A
  • need specific info where short answers are rquired

- to force a choice

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18
Q

Common nonverbal skills you project onto patient

A
  • physical appearance
  • posture
  • gestures
  • facial expressions
  • eye contact
  • voice
  • touch
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19
Q

Interpreters are ___

A
  • mandated by law

- NEVER a family member

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20
Q

A complete health history includes 7 aspects:

A
  1. biographic data
  2. source of history
  3. reason for seeking care
  4. present health history/illness
  5. past health information
  6. family history
  7. cultural
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21
Q

What type of assessment is geared towards how the pt takes care of themselves?

A

Functional Assessment

should leave towards the end of the assessment

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22
Q

Assessment Techniques

A

Inspection- look at skin, breathing, smell, use senses
Palpation- always comes after inspection
Percussion- to determines whats beneath a structure
Auscultation- listening to normal body structures

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23
Q

Percussion Sounds:

A

Amplitude- how loud or soft the sound is
Pitch- high vs low pitch (based off of vibration)
Quality- what makes different area of body sound diff.
Duration- how long does sound last?

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24
Q

Percussion Characteristics

A

Resonant- over lungs, normal sound for lung tissue
Hyperresonant- booming sound (lungs) in kids
Tympany- drum like sound, found in abdomen
Dull- muffled thud
Flat- bones

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25
Q

Ausculation is mainly used in what 3 body areas

A

heart, lungs, abdomen

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26
Q

The diaphragm and bell are used for which sounds?

A

diaphragm- high pitched sound

bell- low pitched sound

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27
Q

A general survey includes:

A
  • physical appearance
  • body structure
  • mobility
  • behavior
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28
Q

Measurement of Pt includes:

A
  1. Weight
  2. Height
  3. BMI
  4. Waist Circumference
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29
Q

Vital Signs:

A 
Temperature
Pulse
Respirations
Blood Pressure 
5th vital sign: PAIN
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30
Q

vital signs should be assessed:

A

Every 4 hours

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31
Q

Types of temperature that can be taken

A 
Oral- most used, most reliable
Axillary
Tympanic
Temporal Artery
Rectal
32
Q

Pulse should be taken:

A

count 30-60 seconds
begin at zero
use pads of fingers for radial pulse

Assess: rate, rhythm, force

33
Q

You should count respirations for how many seconds?

A

30-60

30 if they are healthy, 60 if not so you can observe abnormality

34
Q

how many feet should you be standing from your pt to ensure comfortability?

A

4-5ft

35
Q

when interviewing adolescents, what should you avoid doing?

A

long bouts of silence,
reflection
be aware of your nonverbal communication skills. they are more sensitive to this.

36
Q

HEEADSSS is used as a questionnaire for what patient population and what does it stand for?

A

adolescents- moves from non threatening questions to personal

-Home environment, Education/employment, Activities, Drugs, Sexualtiy, Suicide/depression, safety from injury and violence

37
Q

what are the most common assessment techniques?

A

inspection, palpation, percussion, Auscultation

38
Q

what is defined as concentrated watching and is the first step of assessment

A

Inspection

39
Q

the step that always follows inspection in the assessment of a new pt

A

Palpation

40
Q

palpation feels for:

A 
texture
temp
moisture
organ location and size
swelling
vibration or pulsation
crepitation
lumps or masses 
tenderness or pain
41
Q

fingers-
grasping action of fingers and thumb-
Dorsa-
Palm-

A

skin texture, swelling, pulsation, lumps
position, shape, and consistency of an organ or mass
Temperature (back of hand)
vibration

42
Q

tapping of the skin with short, sharp strokes to assess underlying structures

A

Percussion

43
Q

Light palpation: cm?

Deep Palpation: cm?

A 
1cm deep (usually abdomen) start with this then move into deep if needed
5-8cm (deep circular motion in clockwise direction)
44
Q

Percussion sounds: 4

A

Amplitude: volume
Pitch: based on vibration speed
Quality: different places make different sounds
Duration: how long does the sound last?

45
Q

The Resonant sound comes from

A

the lungs: clear, hollow sound

Sounds dense if theres a tumor or extra mass

46
Q

Hyperresonnant sound comes from

A

Child’s lung (normal)
Adult lung (Abnormal) –> emphysema, COPD
“Booming” sound

47
Q

Tympany sound comes from

A

air filled visuc (stomach, intestine)

“drumlike”

48
Q

Dull sound comes from

A

an organ

“muffled thud”

49
Q

Flat sound comes from

A

the bone or thigh muscles, tumor.

“dead stop to sound”

50
Q

vital signs should be assessed every ____

A

4 hours

51
Q

what is the purpose of taking someones vital signs?

A

to assess cardiovascular & Pulmonary status
give you info on if pt is declining
include pain scale

52
Q

what are the 4 vital signs>

A

Temp
Puls
Respirations
BP

53
Q

5 types of temperature:

A
  • Oral- most used/reliable
  • Axillary- 1 degree lower than normal (Farenheit)
  • Tympanic- ear
  • Temporal Artery- wave magic wand, not as accurate
  • Rectal- closest temp to core body, avoid in cardiac pt
54
Q

What influences a temperature reading?

A

diurnal cycle- time of day (^ at night)
menstruation- 1 degree higher
Exercise
Age

55
Q

When you’re taking the pulse what should you be assessing for?

A

Rate (50-95 beats per minute)
Rhythm
Force

56
Q

the pressure exerted against arteries when the heart is contracting

A

Systolic BP

57
Q

the resting pressure when ventricles are filling between contraction

A

Diastolic BP

58
Q

Amount of blood ejected from L ventricle per minute

A

Cardiac Output

59
Q

Factors that affect BP (5)

A
  1. Cardiac Output
  2. Vascular Resistance
  3. Volume
  4. Viscosity
  5. Elasticity of arterial walls
60
Q

The Sphygmomanometer measurements

A

width- 40% of pt’s arm

length- 80% of pt’s arm

61
Q

To test a patients orthostatic pressure you should follow these 3 steps:

A
  1. Have pt rest supine for 2-3 minutes
  2. Take BP with them lying down
  3. Assist pt to sitting position and wait 2-3 minutes
  4. Take BP with them sitting
  5. Stan patient up wait 2-3 minutes
  6. Take BP with them standing
  • Compare diastolic pressures. if there is a decrease of 20 mmHg its considered positive orthostatic BP
62
Q

3 common abnormalities of the blood/heart

A
  1. Arterial Obstruction
  2. Coarctation of the aorta
  3. Auscultatory Gap
63
Q

Arterial Obstruction

A
  • stenosis or narrowing of artery
  • difference in systolic BP of 10-15 mmHg between arms
  • check BP in both arms
64
Q

Coarctation of the aorta

A

when your arm BP reads higher than your thigh BP

  • in healthy person BP is always higher in thigh*
  • congenital narrowing of aorta
65
Q

An Auscultatory gap is common in:

A

hypertensive clients or older adults

*caused by atheroscelorsis

66
Q

Order of measurement for infants and toddlers:

A
  1. take an apical pulse*
  2. watch for respirations in the abdomone
  3. Tame temp last ** will cry***
67
Q

Order of measurement for preschoolers:

A
  1. Take BP for 3yrs and older

2. take temp last

68
Q

School-aged kids can be coaxed to cooperate through:

A

explanation of what you are doing

69
Q

In older adults, temperature may be ___

A

lower.

harder to catch a fever and more at risk for hypothermia

70
Q

A normal pulse ox rate is:

A

92-100%

71
Q

when you are unable to palpate a pulse, what do you do?

A
  • Grab a doppler before documentation that they didn’t have a pulse.
  • if still cant find pulse– get doctor immediately
72
Q

Chart documentation follows a simple acronym of:

A 
SOAP
S- subjective data first
O- objective data next
A- assessement and documentation of info
P-- plan, develop a plan and document their work
73
Q

What are the types of pain? (4)

A
  1. Acute
  2. Chronic (persistent)- assoc. with disease process
  3. Malignant- cancer
  4. Nonmalignant- arthritis or some type of musculoskeletal condition
74
Q

What are the sources of pain? (4)

A
  1. Deep Somatic- from joint or vessel (ischemia or injury)
  2. Cutaneous- scrape or born. skin levele
  3. Referred- originates in 1 area but felt in another
  4. Neuropathic- damage of nerve fibers (diabetes, shingles)
75
Q

What is the most reliable indicator of pain?

A

the subjective report given by pt

- allow pt to describe it

76
Q

What are the assessment tools for pain?

A
  • Numeric rating scale
  • descriptor scale
  • faces pain scale

Health Assessment (12 decks)

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