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Health Assessment > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Research

A

Most recent techniques to provide best patient outcome. In literature.

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2
Q

Clinical expertise

A

Experience gained in the clinical setting, recognition of signs and clues from previous experience and literature.

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3
Q

Subjective

A

What the patient tells us.

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4
Q

Objective

A

What we see or observe, is measurable.

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5
Q

1st level priorities

A

A-Airway
B-Breathing
C-Circulation

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6
Q

2nd level priorities (urgent)

A

Acute pain
Change in mental status
Infection

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7
Q

3rd level priorities

A

Lack of knowledge
Coping
Activity
Rest

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8
Q

Physical Appearance

A

Age
Sex
Level of consciousness
Skin color
Facial features
Overall appearance

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9
Q

Body structure

A

Stature
Nutrition
Symmetry
Posture
Position
Body build, contour

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10
Q

Mobility

A

Gait
Food placement
Range of motion
Note involuntary movement

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11
Q

Behavior

A

Facial expression
Mood and affect
Speech
Dress
Personal hygiene

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12
Q

Temperature

A

Oral
Normal- 35.8-37.3 C
Rectal norm- 0.4-0.5 C

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13
Q

Pulse

A

Palpable flow felt in the periphery.
Use pads of first 3 fingers.
At wrist.
Force- 2+ is norm.
Rhythm- reg or irreg.
Rate- norm- 60-100
Bradycardia- <50
Tachycardia- >95-100

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14
Q

Respirations

A

Inspiration and expiration
Should be relaxed, regular, automatic and silent.
Count for 30 secs then x2 unless irregular.
Reg- 10-20 per min.

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15
Q

Pulse ox

A

Measure of oxygen saturation.
Norm- 97%-99%
Every shift assessment.
Can be continuous or intermittent.

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16
Q

BP

A

Force of blood pushing against vessel wall.
Systolic- max pressure on artery during left ventricular contraction (systole).
Diastolic- elastic recoil pressure that blood exerts constantly between each contraction.
Pule- stroke volume.
MAP- pressure forcing blood into tissues.

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17
Q

BP continued

A

Norm- LESS than 120/80
Elevated- 120-129/less than 80
Hypertension I- 130-139/80-89
Hypertension II- 140 or higher/90 or higher
Hypertensive crisis- higher than 180/higher than 120

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18
Q

Orthostatic Hypotension

A

Sharp drop in bp when rising from a sitting position to a standing.
-Drop in 20 in systolic and/or drop of 10 in diastolic.

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19
Q

BP technique

A

Pt must be sitting or lying, legs uncrossed. Brachial is most common. 2.5 inches above brachial artery, line up cuff as stated on the cuff. listen with diaphragm, puff up until pulsation is no longer heard. Add 30 to it and deflate cuff. Wait 15-30 seconds then inflate to the sum. Listen for first pulsation sound (systolic) and then listen for final muffled sound (diastolic).

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20
Q

Assessment Technique

A

Inspection
Palpitation
Percussion
Auscultation

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21
Q

Inspection

A

Observing.
Use good lighting, compare right and left sides if applicable, obtain adequate exposure, use tools as needed.

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22
Q

Palpitation

A

Use sense of touch.
Assess texture, temp, moisture, organ location and size. Detecting a lump or mass, or disease state of organ. Both light and deep palpation.
Ask pt if any pain or tenderness, palpate that area last.

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23
Q

Percussion

A

Tapping the skin with short, long strokes that produce a vibration (with a sound) to assess underlying structures.
Use middle finger, place distal joint and fingertip firmly on skin. Strike distal joint with your dominant hand. Should hear deep sounds or soft sounds.

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24
Q

Auscultation

A

Listening with stethoscope.
Reduce movement of pt and external noise. Always listen under clothing, directly on skin.
Bruit- whooshing sound.

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25
Q

Stethoscope

A

Diaphragm- high pitched sounds (lungs, abdomen, heart).
Bell- low pitched sounds (vascular sounds, extra heart sounds).

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26
Q

Abdominal Assessment

A

Inspection
auscultation
percussion
palpitation

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27
Q

Assessment key points

A

Use logical routine/order, make sure pt is comfortable, always clean equipment before and after.

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28
Q

Mental status

A

A person’s emotional and cognitive functioning.
-Optimal is satisfaction in work, caring relationships, and within self.

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29
Q

Mental Disorder

A

Clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities

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30
Q

Organic Disorder

A

Due to brain disease of known specific organic cause. Ex: dementia.

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31
Q

Psychiatric Mental Illness

A

Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.
Organic etiology has not been established.

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32
Q

Anxiety scale

A

GAD-7 (generalized anxiety disorder).
-Higher the score, greater likelihood.

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33
Q

Suicidal thoughts

A

Begin with more general questions and proceed if you hear affirmative answers. Be cautious and considerate, always report to a mental health professional. Key point is they have a plan to harm themselves or someone else.

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34
Q

Depression scale

A

PHQ-2: asking about a depressed mood and lack of interest.
If confirmed then use PHQ-9.
-Frequency and occurrence of symptoms. Higher score, greater likelihood.

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35
Q

Dementia vs. Delirium

A

Dementia: develops over time, more cognitive deficits.
Delirium: quick onset, medical condition, no history of dementia.

36
Q

Levels of consciousness

A

Awake- interactive
Lethargic- sleepy but rousable.
Stuporous- arousable with stimuli, resists arousal.
Obtunded- cannot maintain arousal without repeated stimuli, groans/moans to stimuli.
Comatose- non interactive with surroundings.

37
Q

Glasgow coma scale

A
38
Q

Global aphasia

A

Most common, speech is absent or only a few words, no comprehension, can’t repeat, write or read.
Cause by a large lesion in the brain that affects both anterior and posterior language areas.

39
Q

Broca’s aphasia

A

Expressive
Able to understand but can’t self express with language
Can’t repeat or read aloud
Auditory and reading are intact
Lesion in the motor cortex or the anterior brain

40
Q

Wernicke aphasia

A

Receptive
Opposite of Broca
Can hear sounds but can’t relate to them
Speech is fluent and pt has great urge to speak, but words don’t make any sense and are made up (Stephanie at vicinia gardens)
Impaired repetition, reading and writing

41
Q

Mini Mental status exam

A

a tool that can be used to systematically and thoroughly assess mental status.can be usedto assess 6 areas of mental abilities, including: orientation to time and place — knowing the date and where you are. attention / concentration. short-term memory (recall)

42
Q

Pain

A

Always what the patient says it is.

43
Q

Pain treatments

A

-Medications (including non opioids)
-Music, relaxation, massage, biofeedback, acupuncture
-Tubes to decompress/relieve pressure
-Anxiolytics
-Improving breathing and oxygenation
-Positioning
-Heat or cold

44
Q

Types of Pain

A

Neuropathic- Abnormal processing of pain message (phantom limb pain)
Visceral- from larger interior organs, presents with autonomic response (vomiting, nausea, pallor and diaphoresis)
Deep somatic- blood vessels, joints, tendons, bones, muscles (aching or throbbing, localized)

45
Q

Types of Pain pt. 2

A

Cutaneous- skin surface and subcutaneous tissue (sharp or burning sensation, superficial)
Referred- felt at particular site but originates in another location

46
Q

Acute vs Chronic

A

Acute- short, self-limitng, follows a trajectory, dissipates after injury heals, has protective quality, malignant pain can also have acute components, vital sign indications.
Chronic- continues beyond expected time, malignant and nonmalignant, in cancer an increase in pain is an increase in disease, doesn’t stop when injury heals, no protective qualities, may not correspond with physical findings.

47
Q

Pain in aging

A

NOT NORMAL
-Common in >65 yrs.
-Indicates pathology or injury
-Should not be considered something that should be tolerated

48
Q

PQRST

A

Provocation, Quality, Region/Radiation, Severity, and Time

49
Q

Numeric scale

A

Rate pain 0-10, 0 being the lowest or none and 10 being the worst
Don’t assume pt knows, explain when asking

50
Q

PainAid

A
51
Q

FLACC

A
52
Q

Cultural considerations of pain

A

African America- inevitable and endured, sign of disease/illness, high tolerance, spiritual/religious beliefs related, praying and laying hands to treat

53
Q

Cultural considerations of pain pt.2

A

Mexican American- Accepted as a necessary part of life, consequence of immoral behavior, seek to restore balance between person and environment with pain relief methods, perception may delay seeking treatment, type and amount divinely predetermined

54
Q

Aging Adult skin

A

-drier, flatter
-Decreased sebum and sweat production
-Decreased elasticity
-Decreased # of functioning melanocytes
-Decreased elastin, collagen, subcutaneous fat
-Changes in temp regulation
-Changes in nails

55
Q

Aging skin

A

-Hair changes
-increased vascular fragility
-Skin lesions are more common
-Higher risk for pressure ulcers (due to changes in circulation and decreased ability to form collagen)

56
Q

Conditions affecting the skin

A

-Obesity
-Being very thin
-Fluid loss
-Excessive perspiration
-Skin diseases
-Inability to sense temp and friction
-Nutritional deficits

57
Q

Conditions affecting the skin pt.2

A

-Diabetes
-GI problems resulting with diarrhea
-Bed rest
-Casts
-Medications
-Lifestyle
-Body piercings

58
Q

Alterations in Skin Integrity

A

-External pressure
-Friction and shear
-Immobility
-Nutrition and hydration
-Moisture
-Mental status
-Age

59
Q

Braden Scale

A
60
Q

Pressure ulcer stages

A
61
Q

R

A

-Red=Protect
-Gentle cleansing, moist dressings, changing when necessary

62
Q

Y

A

-Yellow=Cleanse
-Oozing from wound, can be whitish yellow, cream yellow, yellowish green, or beige
-Wet to moist dressing, nonadherent dressing
-Topical antimicrobial medication

63
Q

B

A

-Black=Debride
-Eschar (necrotic tissue)
-Can also be brown, gray or tan
-Typically done by advanced practice nurses
-Removal of necrotic tissue
-Mechanical: physically removing the tissue
-Chemical: collagenase or enzyme agent for an autolytic debridement

64
Q

Abdominal Quadrants

A

-Right lower
-Right upper
-Left upper
-Left lower

65
Q

Dysphagia

A

-Difficulty swallowing
-Why?

66
Q

Inspection

A

-Contour: flat, rounded, scaphoid, protuberant
-Symmetry
-Umbilicus: characteristics
-Skin
-Pulsation or movement?
-Hair

67
Q

Auscultation

A

-Warm stethoscope
-Use diaphragm
-Hold lightly against skin in each quadrant starting in RLQ, listen for bowel sounds

68
Q

Bowel sounds

A

-Norm: high-pitched gurgling, 5-30 per minute
-Hypoactive: <5 per min.
-Hyperactive: >30 per minute
-Absent: must listen for 5 min. to make determination

69
Q

Vascular sounds

A

-Use bell
-Aortic (in line with umbilicus, below xiphoid process)
-Renal: on left and right side above umbilicus
-Iliac: left and right side below umbilicus
Normal to not hear anything
-Listening for bruits

70
Q

Percussion

A

-Zigzag pattern
-Dull sound over organs
-Flat sound over bones
-Tympany is expected sound

71
Q

Palpation

A

-Zigzag patterns
-Light palpation
-Ask beforehand if any pain or tenderness, if so palpate last

72
Q

Aging adults abdomen

A

-Abdominal muscles relax
-Decreased overall functions
-Increased incidents of gallstones

73
Q

Costovertebral tenderness

A

-Indication of kidney issue

74
Q

Special exams

A

-Fluid wave test: Another physical sign of ascites is demonstration of a transmitted fluid wave. The patient or an assistant presses a hand firmly against the abdominal wall in the umbilical region. The examiner places the flat of the left hand on the right flank and then taps the left flank with his right hand.

75
Q

Abnormal Findings

A

-Enlarged liver, nodular liver, gallbladder, spleen, kidney, abdominal distention, hernias, aortic aneurysm.

76
Q

Lung Lobes

A

-Right lung has 3 lobes
-Left lung has 2 lobes

77
Q

Mechanics of respiration

A

-Changing chest size during respiration
-Inspiration
-Expiration
-Control of respiration

78
Q

Subjective data

A

-Cough
-Shortness of breath
-Chest pain with breathing
-Smoking history
-Environmental exposure
-Self-care behaviors

79
Q

Physical abnormalities

A

-Barrel chest (COPD)
-Pectus excavatum: chest sunken in
-Pectus carinatum: chest protrudes out
-Scoliosis (spine)
-Kyphosis (hunchback)

80
Q

Sounds (lung)

A

-Bronchial (trachea)
-Broncho vesicular (close to sternum)
-Vesicular- outer areas of lungs

81
Q

Heart Sounds

A

S1: First sound, “Lub”
S2: Second sound, “Dub”
S3 and S4: extra heart sounds
Murmurs

82
Q

Blood flow through heart

A

-From liver
-Inferior Vena cava
-Superior vena cava
-Right atrium
-Tricuspid valve
-Right ventricle
-Pulmonic valve
-Pulmonary artery
-Unoxygenated blood to lungs
-Lungs oxygenate blood
-Pulmonary veins
-Left atrium
-Mitral valve
-Left ventricle
-Aortic valve
-Aorta
-Rest of the body

83
Q

Subjective data

A

-Chest pain
-Dyspnea
-Orthopnea
-Cough
-Fatigue
-Cyanosis or pallor
-Edema
-Nocturia
Cardiac history
-Family cardiac history
-Personal habits that effect cardiac

84
Q

Heart assessment

A

-Inspect
-Palpate
-Percuss
-Auscultate: 5 areas
-Aortic
-Pulmonic
-Erb’s point
-Tricuspid
-Mitral

85
Q

Murmur assessment

A

Have pt lie slightly to left side and auscultate at mitral area to listen for murmurs

86
Q

Murmur grading

A

-Timing
-Loudness
-Pitch
-Pattern
-Quality
-Location
-Radiation
-Posture

Health Assessment (2 decks)

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