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NUR3120 HEALTH ASSESSMENT > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Cranial Nerve XII

A
  • Name: Hypoglossal
  • Function: movement of tongue
  • Type: Motor
  • Tests: stick out tongue, move side to side & push tongue against cheeks w/ resistance
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2
Q

Male Genitourinary System Preparation

A
  • Experienced colleague
  • Confident, relaxed, unhurried & business-like
  • Non-judgemental, verbalize assessment plan & findings
  • Reassure patient if has an erection
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3
Q

Electronic Health Records (EHR)

A
  • Physician order entry & clinical decision support
  • Allows all providers to access health info, place orders, & receive timely pt updates
  • Incr pt safety
    >dcr transcription & prescribing errors
    >notfy of med interactions, dosage adjustments & additional required testing
    >scanning med admin
    >checklists
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4
Q

Age Related Changes for Female Reproductive

A
  • Menopause can occur from 35-60 (usually late 40s or early 50s)
  • 1-2yrs reduced ovarian function
  • Changing menstrual flow & pattern
  • Reduced estrogen
  • Drying & shrinkage of vagina
  • Shrinkage of uterus
  • Ovarian atrophy
  • Sacral ligament relaxes
  • Shortening cervix
  • Sexual desire / sexual expression
  • Vagina shortens, narrows, loses elasticity
  • Mons pubis appears smaller
  • Labia & clitoris dcr in size
  • Pubic hair thins
  • Without intercourse:
    >vaginal atrophy
    >epithelial atrophy
    >fragile surface
    >bleeding risk & vaginitis
    >alkaline pH
    >reduced glycogen
    >reduced vaginal secretions
    >dyspareunia
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5
Q

Abnormal Female & Male Anal Findings

A
  • Dcrd tone
  • Incrd tone (anxiety, inflammation)
  • Tenderness
  • Polyps
  • Internal & external hemorrhoids
  • Carcinoma
  • Inflamm, lesions, scars, fissures
  • Fistula
  • Pilonidal cyst
  • Rectal prolapse
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6
Q

Urinary & Vaginal Health (hlth promotion for female reproductive)

A

(urinary)
- Hydration
- Voiding at 4-6hr intervals
- Prevention of cystitis (bladder infection)
(vaginal)
- Treat vaginal infections promptly
- STI prevention
- HPV vaccination
- Risk of infection (douching alters acidic pH, oral contraceptives incr glycogen in vaginal secretions & antibiotics kill normal flora)

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7
Q

Anal & Rectal Health Promotion for Female & Male Reproductive

A
  • Keep anal area clean & dry
  • Avoid scratching anus
  • Don’t put objects in anus that don’t belong there
  • Avoid straining during defecation
  • Eat a high fiber diet
  • Avoid lifting extremely heavy items
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8
Q

Age Related Changes for Male Reproductive

A
  • Fertility
  • Dcr in: sperm production, testosterone, pubic hair, penis size, dartos muscle tone & testes size
  • Scrotal sac dangles
  • Slowed sexual response time: medication/stimulants
  • Slowed time for erection
  • Age does not = less libido
  • Causes for withdrawal from sexual activity: death of spouse, depression, work, family conflict, medication, alcohol, or drug use, privacy, economy, emotions, nutrition, & fatigue
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9
Q

Cervical Cancer Screenings (hlth promotion for female reproductive)

A
  • w/in 3 yrs of 1st vaginal intercourse or age 21
  • screen for HPV
  • annual pap smear until age 30
  • after 20 incr time frame to 2-3yrs after 3 consecutive normal pap smears
  • maternal ingestion of DES = annual screening recommended
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10
Q

Abnormal Prostate Findings

A
  • Enlarged smooth gland w/ no central groove (BPH)
  • Nodules
  • Pain, tenderness, swelling
  • Inability to move prostate
  • Excessively hard (fixed)
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11
Q

Female Genitourinary System Assessment Preparation

A
  • Empty bladder
  • Positioned away from door
  • Ask if want a person present
  • Explanation of exam
  • Inform of any pain or discomfort
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12
Q

Required Equipment for Head-to-Toe

A
  • Platform scale w/ height attachment
  • Sphygmomanometer
  • Stethoscope w/ bell & diaphragm
  • Thermometer
  • Pulse oximeter
  • Paper & pencil/pen
  • Flashlight or penlight
  • Otoscope/ophthalmoscope
  • Tuning fork
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13
Q

Expected Changes in Nose, Mouth, & Throat for Aging Adult

A
  • Dryness in mouth (xerostomia)
  • Lost or broken teeth
  • Changes in sense of taste or smell
  • Prominent nose
  • Mouth & lips fold in
  • Yellowing of teeth
  • Gum margins recede
  • Tongue smoother
  • Buccal mucosa thinner
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14
Q

Nose Subj Data & Health Hx

A
  • Discharge
  • Frequent URIs
  • Sinus pain
  • Trauma
  • Epistaxis (nosebleeds)
  • Surgeries
  • Allergies
  • Smell alts
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15
Q

Cranial Nerve XI

A
  • Name: (Spinal) Accessory
  • Function: movement of trapezius & sternomastoid muscles
  • Type: Motor
  • Test: shrug shoulders & rotate head against resistance
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16
Q

Cranial Nerve I

A
  • Name: Olfactory
  • Function: Smell
  • Type: Sensory
  • Test: recalling familiar smell with eyes closed
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17
Q

Cranial Nerve IX

A
  • Name: Glossopharyngeal
  • Function: (motor); pharynx - phonation & swallowing / (sensory); taste
  • Type: Motor & Sensory
  • Tests: (motor); swallow & gag reflex / (sensory); taste on 1/3 tongue
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18
Q

Cranial Nerve II

A
  • Name: Optic
  • Function: Vision
  • Type: Sensory
  • Tests: Snellen chart (visual acuity), Confrontation test (seeing fingers at same time as pt), Ophthalmoscope to view optic disc
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19
Q

Occipital Lobe

A

Primary visual center

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20
Q

Neurological Developmental Considerations for Older Adults

A
  • General loss of muscle & muscle tone in face, neck & around spine
  • Dcrd muscle strength
  • Impaired fine coordination & agility
  • Loss of vibratory sense at ankle
  • Dcrd or absent achilles reflex
  • Loss of position sense at great toe
  • Irregular pupil shape
  • Dcr in reaction time
  • Incrd delay at synapse
  • Sensation of pain & touch may be diminished
  • Diminished sense of taste & smell
  • Slowing of motor system
  • Dcr in muscle strength & agility
  • Possible muscle tremors & dyskinesias
  • Progressive dcr in cerebral bld flow
21
Q

Health Promotion for Female Reproductive System

A
  • Perimenopausal period 40-55yrs hormonal shifts resulting in vasomotor instability
  • Hormone replacement therapy discussion
    >benefits: reduce irritability, hot flashes, maintain bone density
    >risks: fluid retention, vaginal bleeding, DVT, incrd breast cancer
22
Q

Cerebellum

A

Motor coordination of voluntary movements, equilibrium, & muscle tone

23
Q

Cranial Nerve IV

A
  • Name: Trochlear
  • Function: Down & inward movement of eye
  • Type: Motor
  • Test: Cardinal Field of Gaze
24
Q

Internal Ear Assessment

A

(pull pinna up & back - adult)
- Cone of Light: 5 o’clock = right eardrum
- Cone of Light: 7 o’clock = left eardrum
- Look for redness or fluid
- Scars look like white patches
- Describe drum color
- Check for holes or perforations

25
Q

Health Promotion For Male Reproductive

A
  • High fiber, dietary supplements
  • Fluid intake
  • Laxative use
  • last digital rectal exam, fecal blood colonoscopy or sigmoidoscopy
  • PSA (prostate specific antigen) blood test
  • Monogamous relationships; better for preventing STIs/STDs
  • Safe sex
26
Q

Prostate Health Promotion

A
  • Diet rich in fruits & veggies
  • Use of herbs; palmetto & soy (not scientific)
  • Exercise & maintain health weight
  • Fluid intake
  • Enlarged prostate: limit fluid intake 3-4hrs before bed
27
Q

Sinus Assessment

A
  • Palpate frontal & maxillary sinuses
  • Should feel pressure but no pain
  • Non-palpable: ethmoid & sphenoid
28
Q

Cranial Nerve III

A
  • Name: Oculomotor:
  • Function: (motor); Extraocular eye movement & opening eyelids / (sensory); pupil constriction & lens shape
  • Type: Motor & Parasympathetic
  • Tests: (motor); follow moving target / (parasympathetic); PERRLA
29
Q

External Ear Assessment

A
  • Size, shape, & placement
  • Condition of skin
  • Move pinna & push on tragus
  • Palpate mastoid process
30
Q

Initial Assessment

A
  • Performed once preferably in early part of day
  • Complete head-to-toe acute care assessment
  • Provides baseline so that changes can be detected early & a baseline prior to any invasive procedure
31
Q

Cranial Nerve VI

A
  • Name: Abducens
  • Function: lateral movement of eye
  • Type: Motor
  • Test: follow moving target
32
Q

Parietal Lobe

A

Primary center for sensation; touch, taste, temperature

33
Q

Cranial Nerve V

A
  • Name: Trigeminal
  • Function: (motor); muscles of mastication / (sensory); ophthalmic, maxillary, & mandibular
  • Types: Sensory & motor
  • Test: (motor); palpate temporal masseter muscles / (sensory); touching face w/ cotton & blunt pin on jaw, cheek, & forehead
34
Q

Cranial Nerve X

A
  • Name: Vagus
  • Function: (motor); pharynx & larynx - talking & swallowing / (sensory); sensation from carotid body, carotid sinus, pharynx, viscera
  • Types: Motor & Sensory
  • Tests: (motor); say “ah” / (sensory); taste on 1/3 tongue
35
Q

Neurologic Health Hx

A
  • Headache
  • Head injury or spinal cord injury
  • Dizziness/vertigo
  • Seizures
  • Tremors
  • Weakness
  • Incoordination
  • Numbness or tingling
  • Difficulty swallowing or speaking
  • Environmental/occupational hazards
36
Q

Abnormal Female Genitalia Findings

A
  • Pigmented nevi or lesions
  • Nits or lice
  • Swelling, inflammation, redness
  • Excoriation
  • Nodules
  • Rash
  • Polyps
  • Foul smelling irritating discharge: yellow, white, or gray-green, curdlike
  • Tenderness
  • Urethral discharge
  • Induration along urethra
  • Pain
  • Incontinence
  • Pallor
  • Cyanosis
37
Q

Method & Purpose for SBAR

A
  • Used to improve verbal communication & reduce errors
  • Situation
  • Background
  • Assessment
  • Recommendation
38
Q

Male Testicular Self-Exam (TSE)

A
  • Teach self care at 13yrs
  • Normal testicle: egg-shaped, movable, rubbery, smooth surface
  • Abnormalities: lumps, bumps, lesions
  • Notify Provider: firm, painless lump, hard area, overall enlarged testicle
  • Testicular Cancer: rare before 15yrs, typically 15-35, associated w. cryptorchidism, no early symptoms, early detection & before metastasis = 100% cure rate
39
Q

Documenting Health Assessment (head-to-toe) Findings

A
  • Not documented = never happened
  • Record soon after assessment
  • Chart relevant, normal, or negative findings
    >charting by exception
    >WNL or WNL except
40
Q

Temporal Lobe

A
  • Hearing
  • Memory
  • Language
41
Q

Sequence of Head-to-Toe

A
  • Health hx
  • General appearance
  • Measurement
    >empty bladder prior to exam & put on gown
  • Skin
  • Vital signs
  • Head & face
  • Ears
  • Eyes
  • Nose
  • Mouth & throat
  • Neck
  • Chest
    >anterior & posterior
  • Female or male breasts
  • Heart
  • Abdomen
  • Inguinal area
  • Upper extremities
  • Lower extremities
  • Musculoskeletal
  • Neurologic
  • Male or female genitalia
  • Rectum
42
Q

Cranial Nerve VIII

A
  • Name: Vestibulocohlear
  • Function: hearing acuity
  • Type: Sensory
  • Test: hearing normal conversation, whisper test, Weber tuning fork (heard midline w/out lateralization), Rinne tuning fork (AC>BC)
43
Q

Sexual & Fertility Health (hlth promotion for female reproductive)

A

(sexual)
- Open expression
- Referral PRN
(fertility)
- Treat STIs promptly
- Ovarian cancer is silent: seek health care for persistent pelvic pain, lower abdominal pain/bloating or changes in bowel & bladder habits
- Fertility work-up if no pregnancy w/in a full yr of unprotected vaginal intercourse

44
Q

Key Observations of Mouth, Lips, Tonsils, Uvula, & Palates

A
  • Lips, buccal mucosa, & mouth intact
  • Sores & lesions
  • Uvula rising to midline (CN X) & gag reflex (CN IX & X)
  • Strength of tongue
  • Smooth tongue movement (CN XII)
  • Tonsils present & rating
  • Lingual fenulum, veins, & sublingual duct intact
45
Q

Frontal Lobe

A
  • Personality
  • Behavior
  • Emotions
  • Intellectual function
46
Q

Focused Assessments

A
  • Focus on a specific problem
  • Limited or short term
  • Mini database smaller & more targeted
  • EX:
    >postoperative assessments
    > new cast application for a fracture extremity (CMS = circulation, movement, & sensation)
47
Q

Cranial Nerve VII

A
  • Name: Facial
  • Function: (motor); temporal, zygomatic, & buccal nerves / (sensory); taste on 2/3 of tongue - sweet, salty, sour, bitter
  • Types: Motor & Sensory
  • Tests: (motor); temporal - frown, wrinkle forehead, lift up eyebrows. zygomatic - close eyes tightly try to open. buccal - puff out cheeks & smile / (sensory); apply taste on 2/3 tongue
48
Q

Mouth & Throat Subj Data & Health Hx

A
  • Sores & Lesions
  • Pain
  • Bleeding gums
  • Toothache
  • Hoarseness
  • Dysphagia
  • Taste Alts
  • Smoking
  • ETOH consumption
  • Surgeries
  • Self care behaviors
49
Q

Reassessment

A
  • Performed whenever nurses see changes in pts
  • Certain procedures require a schedule of continuous reassessments
  • Pts admitted for observation

NUR3120 HEALTH ASSESSMENT (3 decks)

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