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Health Assessment COM > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Health Histoy consits of what type of data?

A

Subjective date

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2
Q

Subjective Data

A

Info about current state of health of patient, meds they take, previous illnesses, and surgeries, family history, and review of systems

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3
Q

Primary source data

A

Subjective data acquired directly from the patient

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4
Q

Secondary source data

A

Data acquired from another individual like family

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5
Q

Physical examination

A

A collection of objective data, sometimes referred to as signs. Data is collected by using techniques of inspection, palpation, percussion and auscultation. Also includes height, weight, blood pressure, temp, pulse rate, and respiratory rate

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6
Q

Signs

A

Objective data observed, felt, heard, or messured. Exp: rash, enlarged lymph nodes, and swelling of extremity

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7
Q

Symptoms

A

Subjective data perceived and reported by the patient. Exp: pain, itching, and nausea

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8
Q

Documentation of data

A

Require data to be recorded accurately, concisely, without bias or opinion, and at the point of patient care

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9
Q

Context of care

A

Circumstances contribute to the setting or environment; physical, psychological, or socioeconomic circumstances involving patients, and nurse expertise

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10
Q

Patient needs

A

Patient’s: age, general level of health, presenting problems, knowledge level, and support systems are among the variables that impact patient need

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11
Q

Types of health assessments(5)

A

Comprehensive assessment, Problem-based/focused assessment, Episodic/follow-up assessment, Shift assessment, and Screening assessment/examination

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12
Q

Comprehensive assessment

A

A detailed history and physical examination performed at the onset of care in a primary care setting

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13
Q

Problem-based/focused assessment

A

History and examination that are limited to a specific problem or complaint

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14
Q

Episodic/follow-up assessment

A

The assessment is done when a patient is following up with a health care provider for a previously identified problem

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15
Q

Shift assessment

A

Identify changes to a patient’s condition from the baseline

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16
Q

Screening assessment/examination

A

A short examination focused on disease detection

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17
Q

The nursing process(systemic)

A

Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

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18
Q

Health promotion

A

A behavior motivated by the desire to increase well-being and actualize human health potential

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19
Q

Health protection

A

A behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within constraints

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20
Q

3 levels of health promotion

A

Primary prevention: promotion of healthy lifestyles
secondary prevention: screening efforts for early detection
tertiary prevention: minimizing the disability from acute and chronic disease and maximize health

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21
Q

Interview process

A

How the health history is obtained and the success of an interview is the communication skills of the nurse

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22
Q

Phases of the interview(3)

A

Introduction, discusion, and summary

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23
Q

Introduction phase

A

Introduce self to patient and describes her role in the patients care, describe the purpose and process of the interview, you want a respectful and effective relationship

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24
Q

Discussion phase

A

Facilitates and maintains a patient-centered discussion and uses various communication techniques to collect data, detect disease early and prevent complications

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25
Q

Summary phase

A

Summarizes the data with the patient, allows the patient to clarify the data, and communicates an understanding of the problems to the patient, emphasize health promotion and disease prevention

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26
Q

Physical settings

A

Patient should be physically comfortable during the interview, the amount of space the patient needs varies and is influenced by her culture and previous experiences in similar situations

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27
Q

Techniques that enhance data collection

A

The question-answer format is the esential tool, active listening facilatation, clarification, restatement, reflection, confrontation, interpretation, and summary

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28
Q

Techniques that diminish data collection

A

Using medical terminology, expressing value judgements, interurupting the patient, being authoritarian or paternalistic, and using why questions

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29
Q

Silence in an interview

A

Silence is awkard and there is often an urge to break it with a comment or question, patient may need the silence as time to reflect or gather courage. May indicate that they are not ready to discuss this topic or that the approach needs to be evaluated

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30
Q

Interpretation

A

Nurse uses interpretation to share with patients the conclusion drawn from data they have given

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31
Q

Clinical judgement

A

Influenced more by the nurse’s experience, knowledge, attitudes, and perspectives that the data alone. There are four components: noticing, interpreting, responding, and reflection

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32
Q

Symptom analysis: OLD CARTS

A

Onset, location, duration, characteristics, aggravating factors, related symptoms, treatment by the patient, and severity

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33
Q

Onset

A

Exp:When did the symptoms begin? Suddenly or over a period of time? Where were you when symtoms began?

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34
Q

Location

A

Exp: Where are the symptoms? Are they in a specific area? Do the symptoms radiate to another area?

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35
Q

Duration

A

Exp: How long do the symptoms last? Have they become worse? Are they constant? If so does the severity fluctuate?

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36
Q

Characteristics

A

Exp: Describe the characteristics of the symptoms, describe how they look or feel, and describe the sensation

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37
Q

Aggravating factors

A

Exp: What affects the symptoms? What makes the symptoms worse? What makes the symptoms better?

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38
Q

Related symptoms

A

Exp: Have you noticed other symptoms?

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39
Q

Treatment

A

Exp: What methods of self-treatment have you tried? Have any of those methods been effective? Have you seen a doctor for this before?

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40
Q

Severity

A

Exp: Describe the severity of the symptoms, describe the size, extent, number, or amount. Rate you symptoms on a scale of 0-10

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41
Q

General inspection

A

Requires paying attention to details and provided clues about any possible problems they may be experiencing, beginning this the moment you meet the patient

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42
Q

Initial impressions

A

Physical appearance, body structure and position, body movement, emotional status, disposition, and behavior

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43
Q

Initial impressions

A

Exp: Dressed appropriate for the weather, mood is appropriate, emotional state appropriate, what is the patients body posture, is patient sluped and seem sad or are they walking briskly with a smile, tone of voice, monotone or happy, is the conversation flow logical

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44
Q

Physical appearance

A

Exp: appearance, age, skin, and hygiene, tremors or facial drooping, do they appear close to their age, some look older due to drugs, alcohol use, excessive sun exposure, chronic disease, and endocrine disorders. Notice color and condition of skin, presence of lesions, what is the hygiene of the patient, are they clean, and are the odors?

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45
Q

Baseline indicators

A

Vital signs, temp, heart rate, respiratory rate, bp, oxygen saturation, height, and weight. Assessing for presence of pain is standard base line data

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46
Q

Full physical examination

A

Inspection, palpation, auscultation, and percussion will all be used

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47
Q

Vital signs

A

All are within normal limits. bp 84-120 systolic, 54-80 diastolic, heart rate 75-100, and respirations 18-30

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48
Q

Hand hygiene

A

Single most important action to reduce the transmission of infection, it’s an essential element of standard precautions. Preformed before and after contact with patients

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49
Q

Inspection

A

Physical examinations begin with inspection of every body system. A visual examination of the body including body movement and posture. Data can also be obtained by smell

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50
Q

Tangential lighting

A

Penlight used to increse light in certain places like looking in a mouth or skin lesions or to create shadows by directing light at right angles to the area being inspected

51
Q

Palpation

A

Involves using the hands to feel texture, size, shape, consistency, palpation, and locating several parts of patients body. Used to identidy areas the patient reports as being painful or tender

52
Q

Palmar surface

A

Of the fingers and pads are more sensitive to palpation than the finger tips

53
Q

Ulnar surface

A

Of the hands extending to the 5th finger is the most sensitive to vibration

54
Q

Dorsal surface(back)

A

Of the hand is more sensitive to temperature

55
Q

Light palpation

A

Accomplished by pressing down to a depth of approx 1cm and is used to assess skin, pulsations, and tenderness

56
Q

Deep palpation

A

Accomplished by pressing down a depth of 4cm with one or two hands used to determine organ size

57
Q

Bimanual palpation

A

Uses both hands, one anterior and one posterior to assess shape and size of organs

58
Q

Percussion

A

Preformed to evaluate the size, borders, and consistency of internal organs: detect tenderness: and determine the extent of the fluid in a body cavity. There are two techniques: direct and indirect

59
Q

Direct percussion

A

Striking a finger or hand directly against the patient’s body

60
Q

Indirect percussion

A

Use of both hands, place the nondominant hand palm down and gently tapping with fist

61
Q

5 percussion tones

A

Tympany, resonance, hyperresonance, fullness, and flatness

62
Q

Tympany

A

Heard over the abdomen

63
Q

Resonance

A

Heard over healthy lung tissue

64
Q

Hyperresonance

A

Heard over in over inflated lungs(emphysema)

65
Q

Dullness

A

Heard over the liver

66
Q

Flatness

A

Heard over bones and muscles

67
Q

Auscultation

A

Listening to sounds within the body, a stethoscope is usually used because it blocks out extra noises. Listen for intensity, pitch, duration, and quality

68
Q

Equipment

A

Thermometer, stethoscope, equipment to measure bp, pulse oximeter, scales for weight and height, visual acuity charts, opthalmoscope, otoscope, penlight, ruler and tape measure, nasal speculum, tuning fork, percussion hammer and neurologic hammer, doppler, goniometer, calipers for skinfold thickness, vaginal speculum, audioscope, monofilament, transilluminator, wood’s lamp, and magnification device

69
Q

Thermometer

A

Used to measure temperature which is regulated by the hypothalamus, expected temp ranges from 96.4-99.1 with an average of 98.6 or 35.8-37.3 with an average of 37

70
Q

Standard electronic thermometer

A

Used for measuring oral, axillary, or rectal temps

71
Q

Tympanic membrane thermometer

A

Measures temp near the tympanic membrane in the ear

72
Q

Temporal artery thermometer

A

Measures temp from the temporal artery across the forhead. High level of accuracy amongs kids and adults in critical care

73
Q

Stethoscope

A

Used to auscultate sounds within the body that are not audible with the naked ear. There are four parts: earpieces, binaurals, tubing, and the head that has two parts the diaphragm and the bell

74
Q

Diaphragm

A

A flat surface used to hear high pitched sounds such as breath, bowel, and normal heart sounds

75
Q

Bell

A

Used to hear soft, low pitched sounds such as extra heart or vascular sounds

76
Q

Bp equipment

A

Bp is measured noninvasively using a manual or automated bp device, the automated bp can be used with confidence to measure systolic accurately but caution when reading diastolic

77
Q

Pulse oximeter

A

Measures the O2 saturation in arterial blood, LED probe emits light waves that reflect off oxygenated and deoxygenated hemoglobins, estimates the % of oxygenated saturation in arterial blood and a pulse rate, accurarate over the 70-100% usually applied on finger, toe, or earlobe

78
Q

Visual acuity charts

A

Used as screening examination for visual acuity, color perception, and field perception

79
Q

Distance vision charts

A

Snellen charts is hung 20 feet from patient and top # is distance from chart and bottom number is the line they can read. E chart is for kids or non english speaking individuals

80
Q

Near vision examination

A

Rosenbaum used to evaluate near vision consits of Es, Xs, Os

81
Q

Opthalmoscope

A

Consits of a series of lenses, mirrors, and light apertures. It permits inspection of the internal structure of the eye

82
Q

Head of opthalmoscope

A

Has two movable parts: Lens selector dial that allows the nurse to adjust a set of lenses that control focus, unit strength is diopter
Aperture: permits light variations

83
Q

PanOptic head

A

Designed to allow for a wider field and greater magnification

84
Q

Otoscope

A

Used for inspection of the external auditory canal and tympanic membrane, choose the largest size speculum that fits in the ear canal

85
Q

Head of the otoscope

A

Consits of magnifying lens, a light source, and a speculum that is inserted into the auditory canal

86
Q

Nasal speculum

A

Used to spread the opening of the nares so the internal surface can be inspected, there are two types: simple nasal speculum and a broad-tipped-cone-shaped device

87
Q

Tuning fork

A

Two purposes: auditory screening and assessment of vibratory sensation

88
Q

Percussion Hammer and Neurologic Hammer

A

Deep tendon reflexes

89
Q

Doppler

A

Amplifies sounds that are difficult to hear with a stethoscope, ultrasonic waves are used to hear fetal heartbeats or peripheral pulses

90
Q

Goniometer

A

Two piece ruler jointed in the middle with a protractor type used to meassure the degree of flexion or extension of a joint

91
Q

Transiluminator

A

Used to differentiate the characteristics of: tissue, fluid, and air withing a specific body cavity

92
Q

Wood’s lamp

A

Produces a blacklight effect and used to detect fungal infections or corneal abrasions to the eye

93
Q

Magnification device

A

Helps inspect: wounds, skin lesions, and parasites

94
Q

Oral temperature

A

Safe and relatively accurate

95
Q

Axillary temperature

A

Infrequently used site for temp measurement in adults, usually one degree below the normal temp taken orally

96
Q

Rectal temperature

A

Reflecta core body temp and is considered more accurate than non invasive approaches

97
Q

Heart rate

A

Commonly assessed indirectly by palpating the pulse. Changes in heart rate include: physical excersion, fever, anxiety, hypotension, hormonal imbalances

98
Q

Respiratory rate

A

Factors that increase rates: fever, anxiety, exercise, and increased altitude. Assess the rythm regular or irregular, depth is normal or shallow. Shallow breathing can be observed by the effort. Normal breathing should be even and quiet and efortless

99
Q

Blood pressure

A

Force of blood against the arterial walls reflects the relationship between cardiac output and peripheral resistance and it is measured in millimeters of mercury, and ankle site is prefered when upper arm is unavailable

100
Q

Cardiac output

A

Volume of blood ejected from the heart

101
Q

Peripheral resistance

A

The force that opposes the flow of blood through the vessels

102
Q

Systolic bp

A

The maximum pressure exerted on arteries when the ventricles contract or eject blood from the heart

103
Q

Diastolic bp

A

The minimum amount of pressure exerted on the vessels this occurs when the ventricles are relaxed and fill with blood

104
Q

Types of pain

A

Acute, persistent(chronic), nociceptive, and nerupathetic

105
Q

Acute pain

A

Recent onset of pain, less than 6 months and results from tissue damage, usually self limiting, and ends when the tissue heals

106
Q

Persistant pain(chronic)

A

May be intermittent or continuous, lasting more than 6 months

107
Q

Nociceptive pain

A

Pain arises from stimulation of somatic structures such as bone, joint, muscle, skin, and connective tissue or from stimulation of visceral organs such as gi tract or pancrease

108
Q

Nerupathic pain

A

Occurs from an abnormal processing of sensory input by the central or peripheral nervous system

109
Q

Standards for pain assessment

A
  1. Initial assessment of pain and regular assessment, taking into account the patients personal, cultural, spiritual, and ethnic beliefs
110
Q

Standards for pain assessment

A
  1. Education of all relevant health care personnel in pain assessment and management
111
Q

Standards for pain assessment

A
  1. Education of patients and their families on their roles in managing pain and the potential limitations and side effects of the treatment of pain
112
Q

Pallor

A

Loss of color white/lighter than normal
Location: face, conjunctivia, nail beds, palms, lips, buccal mucosa
Indication: Anemia, shock, or lack of blood flow

113
Q

Cyanosis

A

Bluish color/ashen gray color
Location: nail beds, lips, oral mucosa, skin palms
Indication: hypoxia or impaired venous return

114
Q

Jaundice

A

Yellow to orange color/yellowish green
Location: skin, sclera, mucous membranes
Indication: liver dysfunction, red blood cell destruction

115
Q

Erythema

A

Redness/deeper brown purple
Location: face, skin, trauma, and pressure sore areas
Indications: inflammation, localized vasodilation, substance use, sun exposure, rash, and elevated body temp

116
Q

Turgor

A

Elasticity of skin, you assess by pinching the skin on forearm or under the clavicle, should return when released

117
Q

INSPECT SKIN: general skin color and localized variations

A

N:Color should be even
A:abnormal skin color could be local or systemic disease: cyanosis, pallor, and jaundice
N:Pigmented nevi moles 10-40 less than 5 mm, freckles are small flat macules, patch a darker skin pigmentation, and striae are pink or silver stretch marks
A:elanoma and vitiligo are abnormal

118
Q

PALPATE SKIN: texture, temperature, moisture, mobility, turgor, and thickness

A

N:smooth, soft, calluses, skin should be dry, the skin should be elastic
A:cool and hot skin, diaphoresis, edema, and tenting, increase in skin thickness

119
Q

Inspect and Palpate the scalp and hair

A

N scalp:smooth, no flaking, lesions, no redness, soft, shiny

A scalp: dull, coarse, brittle hair, lice, alopecia

120
Q

Inspect facial and body hair

A

N: normal distribution evenly where hair is meant to be
A: hair loss in legs may mean poor peripheral perfusion, thining eyebrows is related to hypothyroidism, hirsutism hair growth in women

121
Q

ABCDEF Carcinoma

A 
A: asymmetry not round
B: border irregular
C: color uneven
D: diameter greater than 6mm
E: elevation change from flat to raised
F: feeling, itching tingling
122
Q

Macule

A

Flat, change in color

Freckles, flat nevi moles, measles

123
Q

Papule

A

Elevated firm

Wart, elevated moles, cherry angioma

Health Assessment COM (1 decks)

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