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Health Assessment > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Components of health history

A

biographic data, reason for seeking care, presetn health, past health, family history, review of systems, functional assessment

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2
Q

Biographic data

A

name, age, birthdate, address, gender, race, occupation

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3
Q

reason for seeking care

A

one or two symptoms and the duration

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4
Q

present health

A

OLD CARTs
onset, location, duration, characteristics, aggrevating factors, releiving factors, time

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5
Q

past health

A

childhood illnesses, accidnts, chronic illness, hospitalizations, operations, immunization, last examination date, allergies

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6
Q

medication reconcilliation

A

current vs previous medications

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7
Q

family history

A

conditions for which the patient may be at an increased risk

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8
Q

review of systems

A

collection of subjective data of body systems, limited to patient statements

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9
Q

functional assessments

A

self care ability, alcohol, and tobacco use

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10
Q

Important subjective questions to ask for the ABDOMEN

A

appetite
dysphagia
food intolerance
pain
nausea/vomiting
bowel habits
medications

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11
Q

bowel habits

A

melena, hematochezia, past abdominal history including surgies

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12
Q

nutritional assessment

A

what have you eaten in the last 24 hours

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13
Q

physical assessment abdominal order

A

-inspection
-auscultation
-percussion
-palpation

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14
Q

Preparing pt for abd assessment

A

adequate lighting, empty bladder, lie supine wiht arms at side, small pillow under the knees, assess areas of pain last

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15
Q

Landmarks

A

umbilicus

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16
Q

RLQ pain

A

rebound tenderness with appendix

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17
Q

RUQ pain

A

liver should not be palpable before the liver

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18
Q

Abd inspection

A

overall demeanor
bulging/masses
skin
striae, moles, surgical scars
umbilicus
cullen’s sign
contour
symmertry

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19
Q

Cullen’s sign

A

bluish discoloration around umbilicus, symptom of intraperitoneal bleeding

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20
Q

Coutour

A

flat, scaphoid, rounded, protuberant
-stand on right side and look across the abdomen
-contour helps describe nutritional state

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21
Q

Symmertry

A

usually symmetrical, note any bulding, masses, or asymmetry

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22
Q

Asucultation

A

bowel sounds, borborgymi, hyperactive, vascular sounds
-warm stethescope
-record character and frequency
-norma, hypoactive, hyperactive
absent if not sounds in 2 minutes

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23
Q

Bowel sound auscultation order

A

start at RLQ move to RUQ to LUQ to LLQ

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24
Q

Vascular sounds

A

bruit, hypoactive, hyperactive

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25
Q

Bruit

A

over aorta, renal arteries, iliac arteries, femoral arteries, splenic arteries
-abnormal swishing and rushing
-use the bell

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26
Q

Hypoactive

A

diminished or absent bowel sounds signals decreased motility
occurs in: peritonitis, paralytic ileus from abdominal surgery, late bowel obstruction, pnemonia

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27
Q

Hyperactive

A

loud gurgling sounds “borborygmi” hunger sounds
singals IN motility
Occurs in: early bowel obstruction, gastroenteritis, brisk diarrhea, laxative use, subsiding paralytic ileus

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28
Q

What bowel sounds do you listen for in the diaphram

A

hypo and hyperactive bowel sounds

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29
Q

Percussion

A

tympany
dullness over soild organs
-move clockwise around stomach
-generalized tympany: air in intestines, rises when supine
-hyperresonace
-CVA tenderness

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30
Q

hyperresonance

A

IN air or gas

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31
Q

CVA tenderness

A

indirect percussion at 12th rib, pain show renal inflammation

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32
Q

Where to palpate for liver

A

under pts right rib cage and lift to support abd
-under right costal margin
-client exhale, move fingers up 1-2 cm
-liver edge feels like firm ridge with smooth surface

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33
Q

RLQ

A

cecum, appendix (mcburney’s point, rovsings sign, psoas sign, obturator sign), ileum, ascending colon, right ovary, right uterine tube, right spermatic cord, uterus if enlarged, bladder

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34
Q

RUP

A

liver, gallbladder, stomach, duedenum, pancrease, right suprarenal gland, right kidney, ascending colon, transverse colon

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35
Q

LUP

A

liver left lobe, spleen, stomach, jejunum/ilum, pancreas, left kidney, left suprarenal gland, left colic flexure, transverse colon, descending colon

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36
Q

LLP

A

signmoid colon, descending colon, left ovary, left uterine tube, left ureter, left permatic cord, uteus, bladder

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37
Q

Ascites

A

abd fluid build up
-fluid waves
-shifitng dullness

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38
Q

Fluid waves

A

-stand of right side of pt
- place pt own hand firmly on the midline
-place left hand on pts right flank
- reach across the abdomen
- give the left flank a firm shake
Positive: blow generates a fluid wave and feel tap or virbation on the RIGHT side

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39
Q

Shifting dullness

A

percuss flank to midline, note changes from tympany to dull, fluid settles in flank when ascites pt is supine
-pt turn to side and percuss
-note change from where tympany to dullness occurs

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40
Q

Newborns abd

A

-umbilical cord shows on abd, contains 2 arteries and 1 vein
-liver takes up more space than later in life
-orangs are easier to palpate
-abdomen is protuberant
-umbilical stump dries within one week: hardens, falls off by 10-14 days, skin overs area by 3-4 weeks
Umbilical hernia
-abd shows respriatory movement

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41
Q

umbilical hernia

A

appears at 2-3 weeks and especially prominent when infant cries, disappears by 1 year. Normal, should not continue to get bigger

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42
Q

Abd Infants

A

-ascultation: only bowel sounds, metallic tinkling of peristalsis
-percussion: same as adults
-palpation: liver, spleen, bladder normal to palpate
-note newborn’s first meconium stool
-under 4 years old protuberant abd is normal
-liver is easily palpable

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43
Q

Abd aging

A

-easier to feel organs
-abd wall msuculature relaxes
-DE salivation
-esophagela emptying and gastric acid secretion are delayed
-IN gallstones
-Liver size DE, fxn remains (drug metabolism DE)
- report constipation
-Inspection: IN fat, muscles thinner, organs easier to palpate
- Distened lungs are dpressed diaphragm, liver can be palpated lower

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44
Q

Constipation causes

A

DE physical activity, DE water, low fiber diet, side effects of medications
-bristol stool chart to measure consistency

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45
Q

Nutrtional status

A

the degree of balance between nutrient intake and nutrient requriements

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46
Q

optimal nutrtional status

A

acheived when suffiencet nutrients are consumed to support day to day body needs and increased metabolic demand d/t growth, pregnancy, illness

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47
Q

under nutrtional status

A

occurws when nutrtional reserves are depleted or when nutrient intake is inadequate to meet day to day needs to added metabolic demanedsds

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48
Q

over nutrtional status

A

caused by consumption of nutrients, too many calories, sodium, fat in excess of body needs

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49
Q

nutrtion screening

A

quick 1st step method to obtain data, weight/weight history, conditions associated with increased nutrtional risk, diet information, and routine lab data

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50
Q

comprehensive nutrtional assessment

A

individuals identified at nutrtional risk during screening should undergo, includes health history, physical exam, lab tests

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51
Q

Metabolic syndrome

A

3-5 biomarkers
waist cirumference
glucose level
high densitiy lipoprotein
triglyceride level
hypertension

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52
Q

Inguinal area

A

iliac crest area, hypogastric section, location of hernias

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53
Q

perineum

A

patch of sensitive skin around genitals

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54
Q

polyuria

A

over production of urine

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55
Q

oliguria

A

low production of urine

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56
Q

dysuria

A

painful urination

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57
Q

hydrocele

A

fluid build up in scrotum

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58
Q

hernia

A

buldge or lump when organ pushes through tissue

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59
Q

hypospadias

A

abnormally low urethra opening on penis

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60
Q

epispadias

A

urethra does not fully develop correctly, urine comes out an abnormal place

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61
Q

phimosis

A

difficult to retract penis foreskin

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62
Q

paraphimosis

A

foreskin becomes trapped under corona

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63
Q

cremasteric reflex

A

contraction that elevates the testicles

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64
Q

cryptorchidism

A

one or both testicles don’t descend to scrotum

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65
Q

encopresis

A

toilet trained child has trouble passing bowel movements in inappropriate places

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66
Q

dyschezia

A

difficulty passing stool

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67
Q

prostate

A

gland of the male reproductive system

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68
Q

benign prostatic hypertrophy

A

prostate larger than norma, can cause blockages in urinary tract

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69
Q

lithotomy

A

postion to expose perineum

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70
Q

menstrual history

A

hisotyr of woman’s periods

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71
Q

dysmenorrhea

A

pain ni menstruation

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72
Q

amenorrhea

A

absence of periods

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73
Q

menopause

A

stopping of periods

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74
Q

GU questions to ask about health history

A

pain with urination?
what color is your urine?
what color are your bowel movements?
how often do you have a bowel movement?
what are currently in a relationship involving sexual intercourse?
what is your sexual preference?
ask first about menstruation history, then urination

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75
Q

general GU subjective

A

skin changes
urination
sexual practices
bowel changes
self care behavoirs

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76
Q

subjective male GU

A

penile issues: pain, lesions, discharge
scrotum issues
sexual behavoirs
red flags

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77
Q

circumcisions

A

elective surgical procedure to remove part of all the foreskin
-give unbiased education with rsks and benefits
-Benefits: reduced UTIs, cancer, HV, reduce STDs for women
Risks: minor and treatable, pain, bleeding, swelling

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78
Q

subjective female GU

A

menstrual history
obestetic history
menopause
self care
vaginal discharge
past history
contraceptive use

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79
Q

Observe GU

A

catheter, ileal condiut, nephrostomy tubes, suprapubic catheter, condom catheter
color, presence, nature of odor, vl of urine
irritation? skin integrity, ooze?
STI lesions

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80
Q

Palpate GU

A

subrapubic abdomen to assess for pain, possible urinary retention

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81
Q

Physical exam male

A

inspection, palpation, penis, hernia, urine assessment

82
Q

inspection and palpation

A

penis, scrotum, hernias, lymph nodes
hair distribution
lesions or redness

83
Q

penis

A

discharge or tenderness
foreskin: philmoisis, paraphimosis
scrotum
testes
epiddymis

84
Q

phimosis

A

narrow opening
cannot retract foreskin

85
Q

paraphimosis

A

foreskin is retracted and cannot return to normal position

86
Q

scrotum

A

have pt hold penis to the side, use back of hand
-spread rugae
-life sac, inspect for symmertry and size
-asymmetircal is normal

87
Q

testes

A

oval, firm, smooth
abnormal: hard, bumpy, pain

88
Q

epeiddymis

A

non tender

89
Q

hernia

A

bear down
inguinal and femoral cannula
normal= no buldge
abnormal = buldge

90
Q

urine assessment

A

abnormalies, color, character, ph, specific gravity, glucose, ketones, proteins, bilirubin, blood, nitrates, leukocytes, bacteria

91
Q

physical GU exam female

A

exam positioning
inspect/palpate
normal skin findings

92
Q

exam positioning

A

supine or modifed lithomy

93
Q

inspect/palpate female Gu

A

external: color, edema, lesions, tenderness, discharge, inflammation, SMR
itneral: cervis and vaginal wall
palpate internal: uterus and ovaries, rectovaginal exam

94
Q

colecrectal cacner

A

colonscopy 5-75 ya
annual fecal occult blood testing

95
Q

prostate cancer

A

physical exam with DRE
PSA- prostate specfic antigen blood test

96
Q

testicular cancer

A

no routine screening

97
Q

ovarina cancer

A

yearly pelvic exam, no screening tools, routine screening not recommended

98
Q

cervical cancer

A

pap, HPV cotesting and pelvic exam

99
Q

meconium stool

A

first stool of a newborn

100
Q

male position for GU exam

A

standing

101
Q

female position for GU exam

A

external gentialia: supine or modifeid lithotomy
interal vaginal exam: lithotomy, HOB 45 degrees, feet in stirrups, knees apart, butt to edge of table
modified lithotomy if needed and can’t have head up
rectal: thotomy or left lateral

102
Q

Cardiac assessment landmarks

A

-clavicle
-intercostal space
-ribs
-sternum

103
Q

Subjuective cardiac questions

A

chest pain?
flutter?
nutrtion?
alcohol use?
smoking?

104
Q

Apical impulse

A

left ventricle rotation
-4th/5th intercostal space
MCL line
ask pt to exhale and hold
point of max impulse
how is blood flow?

105
Q

Z pattern

A

aortic area
pulmonic area
erbs point
tricuspid area
mitral area

106
Q

aortic area

A

second right intercostal space
-oxygen rish blood passes through before exiting the heart and coursing through the rest of the body
-valve prevents blood from flowing back to the left ventricle
- S1 < S2 (S1 quieter)

107
Q

pulmonic area

A

second left intercostal space
-pulmonic vlave has deoxygenated blood that flow through it . Closes off the right ventricle and opens to allow the blood to flow to the lungs
-S1<S2

108
Q

Erb’s point

A

third left intercostal space
-not truly a heart sound because not reflective of a specific valve closure
S1 =S2

109
Q

Triscuspid area

A

fourth intercostal space
left lower sternal border
-named because of its 3 flaps called cusps, blood flow through this valve after leaving the righ atrium
S1 >S2

110
Q

mitral

A

fifth left intercostal space on the midclavicular line
-closes off the left atrium, allowing oxygenated blood form the lungs to flow through to the left ventricle
-S1>S2

111
Q

Carotid artery

A

palpate and ausculate- only one side at a time because both can cause dizziness
-listen for bruit with bell side
-keep neck neutral, listen with bell
- angle jaw, mid cervical area, base of the neck

112
Q

S1

A

lub
apex
low
systolic

113
Q

S2

A

dub
base
high
diastole

114
Q

murmurs

A

timing, loudness, pitch, pattern, quality, location, radiation, posutre, variation, innoncent, function

115
Q

timing murmur

A

systolic or diastolic
distole always indicates heart disease

116
Q

loudness

A

grades

117
Q

pitch

A

high
medium
low

118
Q

pattern

A

crescendo
decrescendo

119
Q

quality

A

blowing
harsh
rumbling

120
Q

loction

A

where is ti best heard at

121
Q

radiation

A

heard in neck, back, axilla

122
Q

variation

A

with respiratory phase

123
Q

innocent murmur

A

no vavlular defect, crescendo-decrescendo, healthy childern normally have IN BF

124
Q

function murmur

A

caused by IN BF to heart with fever, pregnancy, or anemia,
normal variation

125
Q

murmur grade 1

A

barely audible
heard only in a quiet room and then with difficulty

126
Q

murmur grade 2

A

clearly audible
but faint

127
Q

murmur grade 3

A

moderatly loud
easy to hear

128
Q

murmur grade 4

A

associated with a thrill palpable on chest wall

129
Q

murmur grade 5

A

very loud
heard with 1 corner of stethescope lifted off chest wall
thrill

130
Q

murmur grade 6

A

loudest
still heard with entire stethoscope lifted just of chest wall, thrill

131
Q

cardiac inspection

A

apical impulse, pulsations
-jugular venous pulsations? heave or lift? color?

132
Q

cardiac palpate

A

apical impulse- left ventricle rotation

133
Q

ausculation cardiac

A

APE To Man
rate and rhtym
S1 and S2

134
Q

pericardium

A

membrane enclosing the heart

135
Q

mediastinum

A

chest pocket that contains the heart

136
Q

systel

A

heart cotracts

137
Q

diastole

A

heart relaxes

138
Q

murmurs

A

extra sound between heart beats

139
Q

preload

A

how much the heart ventricles stretch to contain blood

140
Q

afterload

A

pressure the heart has to overcome to pump blood

141
Q

angina

A

symptom of reduced blood flow that can manifest as chest pain, pressure, or discomfort

142
Q

pulse deficit

A

difference between heart rate and pulse rate

143
Q

heart sounds

A

created by blood flwoing through heart chambers and ventricles closing a nd opening

144
Q

aortic valve

A

left ventricle to the aorta
aortic area is where sound is heard
S1 quiet S2 heard

145
Q

pulmonic valve

A

heart to lungs
S1 quiet
S2 heard
pulmonic area

146
Q

tricuspid valve

A

right atrium to right ventricle
S1 louder than S2
tricuspid area

147
Q

mitral valve

A

left atrium to left ventricle
mitral area
S1 >s2

148
Q

jugular vein assessment

A

pulsations? visible?

149
Q

central venous pressure

A

blood pressure in the vena cava

150
Q

Aortic stenosis

A

aortic valve narrows and doesn’t let enough blood flow through

151
Q

aortic regurg

A

aortic valve doesn’t close properly

152
Q

Cardiac emergent signs

A

6/6 murmur, fhx hypertension, new hypertension, irregular heart rate, tachycardia during rest, bradycardia, chest pain, jugular vein distention, cyanosis, fatigue, SOB, cough, orthopnea

153
Q

venous assessmetn

A

-carries blood back to the heart
-low pressure system
-erythema
-DVT: swelling, redness, warmth
- Edema
- Warming
- Ulcers

154
Q

Arterial assessment

A

-carry blood away from the heart
-high pressure system
-cyanosis, pallor, cold
- numb
- weak pulses or no pedal pulses
- cold
- ulvers- pain

155
Q

cardiac risk factors

A

lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an inflence on coronary artery disease

156
Q

Cardiac critical characteristics

A

past medical history
ROS
fhx
functional history
subjective data
- arm or leg pain
- skin changes
- swelling

157
Q

arm or leg pain questions

A

-describe pain
-aggravated by activity or walking
- how many blocks does it take to produce this pain
- is pain worse with elevation or cool temperature
- does pain wake you up at night
- SOB
- changes in exercises
- what relieves pain
history?

158
Q

venous put legs up

A

better

159
Q

arteriol put legs up

A

worse

160
Q

skin changes questions

A

-any skin changes in arms or legs? redness, pallor, blueness, brown?
- any change in temperature?
- do your leg veins look bulding and crooked?
- use support hose?
- leg sores or ulcers?

161
Q

swelling cardiac questions

A

-swelling bilatera
-start
time of day it is worse?
- what brings it out
-what releives it
- pain, heat, ulceration, hardned skin
-swollwen lymph nodes

162
Q

Cardiac pregnancy changes

A
  • BV IN by 30-40% during pregnancy
  • functional murmur
  • IN CO, arterial BP DE d/t peripheral vasodilation
  • vital signs IN in resting pulse rate of 10-15 bpm and drop BP from normal level
  • apical pulse: moves higher
  • mammary souffle: muffle during lactation
163
Q

aging adult cardiac considerations

A

-closely interrealted with lifestyle, habits, and disease
-gradual rise in systolic blood pressure
-orthostatic hypotension
-left ventricular wall thickness increase
- presence of supraventricular and ventricular dysrhythmias increases with age
-age releated ECG changes occur due to histologic changes in teh conduction system and dysrhtmias

164
Q

Lung landmarks

A

-supraclavicular fossa
-clavicle
-intraclaviular fossa
-xiphoid process
-subrasternal notch
-sternal angle
-anterior axillary line
-mediastinum
-pleural cavities

165
Q

apex of lung

A

highest lung tissue
3-4 cm above clavicles

166
Q

base of lung

A

lowest border of lung tissue
rest of diaphragm

167
Q

lobes and fissures

A

anterior chest
fissures
posterior chest
lateral chest wall

168
Q

anterior chest

A

mostly upper and middle lob with very little lower lobe

169
Q

fissures

A

oblique (major or diagnoal), horizontal (minor fissure)

170
Q

posterior chest

A

contains all lower lobes

171
Q

lateral chest wall

A

right and left lateral

172
Q

inspection lungs

A

postion to breath, clubbing, cyanosis or pallor, pursing lips, flaring nostrils, retractions, shape of chest wall, rate and rhytm

173
Q

shape of chest wall

A

anterioir/postior length (AP)
transverse should be greater than width (otherwise barrel chest)
1:2

174
Q

rate and rhtym concerning signs

A

cyanosis, pallor, tripod position, use of accessory muscles, nasal flaring

175
Q

palpatation
symmetric chest expansion

A

hands should move up and down on posterior as patient inhales and exhales

176
Q

tactile fremitus

A

IN fremitus- consolidation of lung tissue, pnemonia (will IN vibration if consolidated pnemonia), say 99 or blue moon and feel for pt vibration

177
Q

Tactile fremtitus DE

A

thick barrier, obstructed bronchus, pleural effusion, or thickening
check for temperature, tenderness, lumps, masses, and skin

178
Q

lungs percussion

A

hyperresonance
resonance
dullness
flatness

179
Q

lungs auscultation

A

vesiculr, bronchovesicular, bronchial, tracheal

180
Q

vesicular

A

2 seconds in, 1 seconds out
-inspriatory
-soft
- low pitch
- heard over most of the lungs

181
Q

bronchovesicular

A

inpriatory and expriatroy sounds are equal, intermediate sound and pitch, head in teh 1/2 interspcaes anterioirly and between the scapulae

182
Q

bronchial

A

expiratory sounds lasts longer than inspiratory ones, loud sound, high pitch, heard over the manubrium

183
Q

tracheal

A

inspiratory and expiratory sounds are about equal, expiratory sound very loud, pitch is relatively high, heard over the trachea in the neck

184
Q

voice sounds

A

egophony, bronchophony, whispered pectoriloquy

185
Q

normal lung sounds

A

soft, muffled, and indistinct

186
Q

bronchophy

A

pt says 99
abnormal is more clear than normal

187
Q

egophony

A

EE

188
Q

whispered pectoriloquy

A

1-2-3

189
Q

abnormal sounds

A

wheesing, crackles, rhonci, friction rub, stridor

190
Q

crackles

A

discontious popping heard over inspiration
-fine: stand of hair between fingers near your ear
-Coarse: sounds like velcro

191
Q

rhonchi

A

low pitch snore

192
Q

wheeze

A

high pitch musical sound or wheeze
-asthma

193
Q

stridor

A

sounds like a crowing sound
-anaphylaxis

194
Q

pleural friction rubt

A

sounds like leather rubbing together, caused by inflammed, roughed surfaces rubbing together

195
Q

what parts of the exam are simultaneous

A

assessment and diagnosis

196
Q

step 1

A

introduction
door, introduce yourself, hand hygiene, provide privacy, verify name/dob/allergies, provide reason you are examining the pt and brief plan of care

197
Q

step 2

A

general survery and measurements
-snellen eye exam
-screenings

198
Q

step 3

A

VS, pain, AOx4, temperature, radial pulse, respriatrions, blood pressure, pulse ox, pain, orientation

199
Q

step 4

A

head to toe, head/trunk/extremities, skin, head, PERRLA, facial movements

200
Q

step 5

A

lungs, cardiac, abdomen, options

201
Q
A

Health Assessment (3 decks)

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