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Health Assessment > Final > Flashcards

Final Flashcards

1
Q

medical dx

A

only made by doctors

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2
Q

nursing dx

A

used to evaluate the response of the whole person to actual or potential health problems

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3
Q

nursing process

A
  • iterative process allowing practitioners to move back and forth while caring for the needs of complex pts.
  • Includes six phases: assessment, diagnosis, outcome identification, planning, implementation, evaluation
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4
Q

“A Delicious Orange PIE”

A

Assessment- collect data

Diagnosis- interpret data

Outcome identification- identify the expected outcomes

Planning

Implementation- doing what you planned

Evaluation- was the outcome we wanted achieved?

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5
Q

inspection phase

A

concentrated watching. Checking for abnormalities before continuing. Inspection begins the moment you first meet a person and develop a “general survey”

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6
Q

purpose of percussion

A
  • mapping out the location and size of an organ by exploring where the percussion note changes b/n the borders of an organ and its neighbors
  • signaling the density (air, fluid, or solid) of a structure by a characteristic note
  • detecting an abnormal mass if its fairly superficial; the percussion vibrations penetrate a/b 5 cm deep—a deeper mass would give no change in percussion
  • eliciting a deep tendon reflex using the percussion hammer
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7
Q

diaphragm

A

used for high-pitched sounds → breath, bowel, and normal heart sounds. Hold the diaphragm firmly a/g the person’s skin, firm enough to leave a slight ring afterwards

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8
Q

bell

A

used for soft,low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly a/g the person’s skin, just enough that it forms a perfect seal

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9
Q

1st level priorities

A

emergent, life threatening

airway, breathing, circulation, vital signs

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10
Q

2nd level priorities

A

requires prompt intervention to forestall further deterioration

acute pain, mental status change, abnormal labs, risk of infection

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11
Q

3rd level priorities

A

those that are important to the pt’s health but can be addressed after more urgent problems. Interventions to treat these problems are more long term, and the response to treatment is expected to take more time

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12
Q

subjective data

A

what the pt says, biased

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13
Q

objective data

A

unbiased, what the pt cannot see, labs

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14
Q

how do you prioritize patient problems/diagnosis?

A

airway → breathing → circulation → perfusion

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15
Q

spirituality

A

broader term focused on a connection to something larger than oneself and a belief in transcendence

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16
Q

religion

A

organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services

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17
Q

role of nurse with DM

A

for neglect in the elderly and children, report your suspicions to the proper authorities. No evidence is needed, when in doubt, REPORT

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18
Q

BMI

A

weight (lbs.) / height (in.) * 703

  • normal = 18.5-24.9
  • <18.8 → underweight
  • want to be less than 25 > 30 = obese
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19
Q

negative effects on elderly nutritional status

A

lack of taste, medications, teeth issues, decreased GI motility, decrease visual acuity, decreased saliva production

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20
Q

how long would you monitor a heart rate if it is irregular

A

1 full minute

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21
Q

proper way to take a BP

A

palpate pulse in radial artery,

Let air out 2-4 mmHg/second.

Listen for first and last sounds, Pt shouldn’t cross legs, chew gum, drink caffeine, etc in the past 30 minutes or smoked in the past 5 minutes.

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22
Q

best indicator of pain

A

pt report of pain, subjective data

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23
Q

systolic number (top #)

A

indicates how much pressure your blood is exerting a/g your artery walls when the heart beats

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24
Q

diastolic number (bottom #)

A

indicates how much pressure your blood is exerting a/g your artery walls while the heart is resting b/n beats

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25
Q

uvula

A

rises on phonation, midline to soft palate, CN 9 (glossopharyngeal)

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26
Q

frenulum

A

midline fold of tissue that connects the tongue to the floor of the mouth

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27
Q

strabismus

A

a disorder in which the eyes don’t look in the same direction at the same time; “cross eyed”

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28
Q

anisocoria

A

condition characterized by an unequal size of the eye’s pupils

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29
Q

tympanic membrane, normal findings on internal ear exam:

A

separates outer and middle ear; pearly grey in color, prominent cone of light, drum is oval and slightly concave

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30
Q

external ear

A

auricle or pinna

consists movable cartilage and skin

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31
Q

middle ear

A
  • chamber between the eardrum and cochlea
  • contains auditory ossicles: the malleus, incus, and stapes.
  • Functions: vibrations, protection by reducing sounds, equalization of air pressure, conducts sound waves from external ear to internal ear
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32
Q

inner ear

A
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33
Q

Inner Ear

A

contains the bony labyrinth

holds the sensory organs for equilibrium and hearing.

Not visible but function can be tested

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34
Q

examination considerations for a child

A

the infant’s eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult’s; thus it is easier for pathogens from the nasopharynx to migrate through to the middle ear. These factors place the infant at greater risk for middle ear infections than the adults. The infant and the young child’s external ear canals are shorter and have a slope opposite to that of the adult’s

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35
Q

cerumen

A
  • yellow, waxy material that lubricates and protects the ear
  • wet, honey-brown wax → occurs in Caucasians and AA
  • dry, flaky white wax → occurs in East Asians and Native Americans
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36
Q

Peau d’Orange

A

Breast tissue: edema exaggerates the hair follicles, giving a “pigskin” or “orange-peel” look

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37
Q

when is a breast mass suspicious of cancer during an exam

A

solitary, unilateral, nontender mass. Single focus in one area, although it may be interspersed w/ other nodules.

Solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Borders are irregular and poorly delineated. Grows constantly. Often painless, although the person may have pain. Most common in upper outer quadrant. Firm and hard irregular axillary nodes as cancer advances; skin dimpling, nipple retraction, elevation and discharge

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38
Q

Know blood flow through the heart

A

inferior/superior vena cava → RA → tricuspid valve/semilunar → RV → pulmonic valve → pulmonary artery → lungs → pulmonary vein → LA → mitral valve → LV → aortic valve → aorta → body

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39
Q

orthopnea

A

difficulty of breathing when laying down

the need to be upright position to breath. *note # of pillows used

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40
Q

Paroxysmal nocturnal dyspnea

A

awakening from sleep w/ SOB. Pt wakes up after 1-2 hours of sleep w/ the perception of needing fresh air (drowning syndrome)

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41
Q

aortic aneurysm

A

unilateral distention of external jugular veins (JVD); murmur is harsh, systolic, or continuous and accented w/ systole.

Marked pulsations/prominent lateral pulsations can indicate aortic aneurysm

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42
Q

orthostatic hypotension

A

sudden drop in systole more than 20 mmHg or diastole more than 10 mmHg, in BP when rising to sit or stand

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43
Q

iliopsoas

A
  • supine, lift right leg straight up, flexing at the hip, push down over lower part of thigh as person tries to hold leg up.
  • negative = pt feels no pain
  • positive = pt feels pain; pain in RLQ is indicative of appendicitis
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44
Q

obturator

A

lift right leg, flexing at the hip, and 90 degrees at the knee. Hold pt ankle and rotate leg internally and externally. There should be no pain; less specific than iliopsoas test but could indicate appendicitis as well

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45
Q

Murphy’s tests

A

Check gallbladder/cholestasis. Ask pt to take a deep breath while palpating the right subcostal area.

Inflammation of the gallbladder will result in pain (positive sign)

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46
Q

blumberg’s sign

A

“rebound tenderness”

indicative to peritonitis

positive = pain on release

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47
Q

borborygmi

A

loud, gurgling sounds;

increased motility

early mechanical bowel obstruction (high-pitched)

gastroenteritis, brisk diarrhea, laxative used

subsiding paralytic ileus

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48
Q

upper GI bleeding

A

black, tarry stool due to occult blood

vomiting blood or coffee grounds

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49
Q

lower GI bleeding

A

bright red blood in stool

dark blood mixed with stool

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50
Q

how do you assess the mental status?

A

ABCT

appearance (posture, dress, grooming, hygiene) behavior (LOC, facial expression, speech, mood) cognitive function (judgement, recent and remote memory)

thought process (thought content/perception)

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51
Q

flat affect

A

lack of emotional response; no expression of feeling, voice is monotone and face immobile

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52
Q

epispadias

A
  • dorsal location of meatus; meatus opens on the dorsal (upper) side of the glans penis
  • less common that hypospadias but more disabling b/c of associated urinary incontinence and separation of the pubic bones
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53
Q

hypospadia

A

ventral location of meatus; urethral opens on the ventral (under) side of the glans or shaft or at the penoscrotal junction. A groove extends from the meatus to the normal location at the tip. This congenital defect is important to recognize at birth. The newborn should not be circumcised b/c surgical correction may need to use foreskin tissue to extend urethral length

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54
Q

testicular torsion

A
  • spermatic cord get twisted and cuts off blood flow to testicles. Often during sleep or following trauma
  • S&S: sudden onset excruciating pain in testicle, N/V, NO fever
  • obj. findings- red, swollen, one testes (usually left) is higher due to rotation and shortening
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55
Q

epididymitis

A
  • acute infection of epididymis commonly caused by prostatitis, after prostatectomy b/c of trauma, or chlamydia, gonorrhea, or other bacterial infections
  • subjective: severe pain in scrotum, relieved by elevation (+ Prenn sign) elevation of testes causing pain relief, rapid swelling, fever
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56
Q

priapism

A
  • prolonged painful erection w/o sexual stimulation. Unrelieved by intercourse or masturbation. most common in 30s-40s; rare.
  • ischemia can happen in 4h. Medical emergency b/c necrotic fast
  • SE of some meds: street drugs, sickle cell, leukemia, malignancy, local trauma, spinal cord injury w/ ANS dysfunction
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57
Q

know where sperm production occurs

A

seminiferous tubules

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58
Q

Gonorrhea

A

Vaginal discharge, dysuria, abnormal bleeding, abscess in Bartholin or Skene glands

often no signs are apparent.

Dx by positive culture of organism.

Treat w/ antibiotics and retest in 3-6 months

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59
Q

Candidiasis

A

intense pruritus; discharge is usually white, thick, curdy, “like cottage cheese;”

vulva and vagina are erythematous and edematous

causes are recent use if antibiotics, wearing tight underwear, douching, diabetes (undiagnosed)

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60
Q

Chlamydia

A

minimal or no symptoms

yellow/green discharge

untreated leads to PID and sterility

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61
Q

pap smears, screen for what?

A

cervical cancer

62
Q

Chadwick’s sign

A

cyanotic (blue) appearance of vagina. Mucosa and cervix; during 2nd trimester (8-12 wks)

63
Q

normal weight gain

A

25-35 lbs in a singleton pregnancy of a woman with a normal BMI

64
Q

overweight weight gain

A

28-40 lbs

65
Q

underweight weight gain

A

15-25 lbs

66
Q

BMI of pregnant women

A

19-25

67
Q

estimating delivery date

A

280 days from the last menstrual period

68
Q

Angle of Louis

A

sternal angle, good clinical anatomical location; 2nd rib

69
Q

normal mechanism of respirations

A

relaxed, regular, automatic and silent

check if pt is using accessory muscles to breath (abnormal)

70
Q

atelectasis

A

complete or partial collapse of a lung or section (lobe) of a lung (airway obstruction, compression on lung, lack of surfactant)

71
Q

mediastinum

A

middle section of the thoracis cavity containing the esophagus, trachea, heart, and great vessels

The right and left pleural cavities on either side of the mediastinum contain the lungs

72
Q

APGR

A

newborn’s first respiratory assessment scored 1-5 minutes after birth

  • 0-2: severely depressed newborn needing full resuscitation, ventilatory assistance, and subsequent intensive care
  • 3-6: indicates a moderately depressed newborn needing more resuscitation and subsequent close observation
  • 7-10: newborn in good condition, needing only suctioning of the nose and mouth and otherwise routine care
73
Q

Principles of Prioritization

A
  1. complete health history, including allergies, medications, current medical problems, reason for visit
  2. Determine if problems are related and set priorities
  3. Priority setting will evolve over time, address accordingly
74
Q

sources of pain

A
  1. visceral- large internal organs
  2. somatic- surface musculoskeletal
  3. deep somatic- blood vessels, joints, tendons, muscle, bone
  4. cutaneous- skin surface, subcutaneous tissue
  5. referred- felt in one place but comes from another
75
Q

acute pain

A

short-term, self-limiting, often predictable trajectory; stops after injury heals

76
Q

chronic pain

A

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

77
Q

nociceptive pain

A

pain from a normal process that results in noxious stimuli being perceived as painful

78
Q

neuropathic pain

A

abnormal processing of pain message; pain from a lesion or disease in the somatosensory nervous system

79
Q

CN 1 Olfactory

A

Abnormal:

ansomia (loss of smell)

head trauma, brain lesion

80
Q

CN 2 Optic

A

Abnormal:

visual field loss

papilledema (increase ICP)

optic atrophy

81
Q

CN 3, 4, 6

oculomotor, trochlear, abducens

A

Ptosis (myasthenia gravis) Horner syndrome, Cushing Reflex (increased ICP), unequal pupil dilation, non reactive pupil, nystagmus (vestibular, cerebellum or brainstem disease)

82
Q

CN 5 Trigeminal

A

Abnormal:

unilateral weakness (lesion on pons or cancer)

decreased or uneaqual sensation (stroke, hemiparesis, aphasia)

83
Q

CN 7 Facial

A

Abnormal:

muscle weakness flat nasolabial fold, drooping face, air escapes one side (stroke), upper and lower affected on one side is Bell’s Palsy

84
Q

CN 8 Acustic/Vestibulocochlear

A

Abnormal:

hearing acuity decrease, unable to detect high-frequency sounds (whispers); conductive hearing loss

85
Q

CN 9 Glossopharyngeal

CN 10 Vagus

A

Abnormal:

absence or asymmetry of soft palate, risk for aspiration (stroke), hoarse or brassy voice (vocal cord dysfunction)

86
Q

CN 11 Spinal Accessory

A

Abnormal:

Atrophy, muscle weakness

paralysis after stroke

peripheral nerve damage

87
Q

CN 12

A

Atrophy, Fasciculations, tongue deviates to paralyzed side after stroke

88
Q

Motor System evaluation

A

Abnormal:

LMN disease, disuse, injury

paresis (weakness, decreased strength)

paralysis/plegia (absence of strength)

hypertrophy (increased muscle size)

limited ROM

Flaccidity (decreased resistance)

hypertonia

spacity and regidity with central weakness

89
Q

Cerebellar Function evaluation

A

Abnormal:

lack of coordination

slow, clumsy, sloppy response

dysdiadochokinesia (w/ cerebellar disease)

Dysmetria or drunkeness

90
Q

Balance Test Evaluation

A

Abnormal:

stiff immediate posture, staggering, widened gait

lack of swaying arms

ataxia, uncoordinated/unsteady gait

tandum walk: in ability due to upper motorneuron lesion, MS, drunkeness, acute cerebellar dysfunction

Romberg Positive = loss of proprioception

decrease in vestibular function

91
Q

Sensory Evaluation

A

sharp/dull Abnormal:

hypoalgesia (decreased pain sensation)

analgesia (absence of pain sensation)

hyperalgesia (increased pain sensation)

92
Q

Deep Tendon Reflex Evaluation

A

Abnormal:

Clonus: rapid, rhythmic contractions of same muscle

Hyperreflexia: exaggerated reflex (stroke)

Hyporeflexia: absense of reflex (spinal cord injury)

93
Q

resonant

A

clear, hollow (lungs)

94
Q

Hyperresonance

A

lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax (lungs)

95
Q

tympany

A

high-pitched, musical, drum like percussion note heard when percussing over the stomach and intestine

96
Q

dull

A

muffled thud, dense organs; liver, spleen

97
Q

flat

A

dead stop of sound; thighs, bones, tumor

98
Q

mobility and turgor

A

mobilty the skin’s ease of rising, and turgor ability to return to place promptly when released normally < 3sec, reflects elasticity of skin

99
Q

dehydration

A

dry mucous membrane, dry lips, tenting skin

100
Q

Edema 4-point Scale

A

1+ mild pitting; slight indentation, no perceptible swelling of the leg

2+ moderate pitting; indentation subsides rapidly

3+ deep pitting; indentation remains for a short time; leg is very swollen

4+ very deep pitting; indentation lasts a long time; leg is very swollen

101
Q

vellus hair

A

pale, fine body hair of children and adult females

102
Q

terminal hair

A

coarse, long hair of eyebrows, scalp, axillary, and pubic regions

103
Q

profile sign in nails

A

should be less 160 degrees, smooth, pink, capillary refill <3 seconds

104
Q

Head

A

normocyphalic- average; normal

macrocephalic- larger than normal

microcephalic- smaller than normal

105
Q

Stroke vs Bell’s Palsy

A

Stroke: signs of mental cloudiness, confusion

Bell’s Palsy: normal mental function

106
Q

Teeth

A

normal adult mouth 28 teeth 32 with wisdom teeth

107
Q

hard palate

A

anterior, white

108
Q

soft palate

A

posterior, pink, moist

109
Q

Tonsils graded in size as follows:

A

1+ visible

2+ halfway between tonsillar pillars and uvula

3+ touching the uvula

4+ touching each other; “kissing”

110
Q

limbus

A

border between cornea and sclera

111
Q

lacrimal gland

A

gland located in the upper outer region above the eyeball that secretes tears

112
Q

palpebral conjunctiva

A

covers the inner surface of the eyelids

113
Q

bulbar conjunctiva

A

overlays the eyeball, with the white sclera showing through

114
Q

cultural taboos

A

no vaccines

blood transfusions

obstain from medications with caffeine, pork, other prohibited substances

115
Q

Symptom or Sign

A

symptom: subjective

sign: objective

116
Q

Nosocomial infections are

A

hospital acquired infections

117
Q

Normal pulse is

A

60-100 bpm

118
Q

4 functions of respiratory system

A
  1. supplies oxygen for energy production
  2. removes CO2
  3. maintains homeostasis of arterial blood
  4. maintains heat exchange, stabilized body temperature
119
Q

involuntary control of respirations

A

pons and medulla (brainstem)

120
Q

bronchial

A

over trachea and larynx

high-pitched

loud

anterior only

heard less on inspiration than expiration

121
Q

bronchovescicular

A

over major bronchi

moderate pitch/amplitude

anterior and posterior

heard the same on inspiration and expiration

122
Q

vescicular

A

peripheral lung fields

low pitch

soft

anterior and posterior

heard greater on inspiration than expiration

123
Q

adventitious breath sounds

A

crackles (rales)- popping

wheeze (rhonchi) - high pitch squeeking

pleural friction rub - coarse, low-pitched grading

stridor- high-pitched crowing sound

124
Q

Tachypnea

A

rapid breathing

125
Q

bradypnea

A

abnormally slow breathing

126
Q

Hyperventilation

A

the condition of taking abnormally fast, deep breaths

127
Q

Kussmual respirations

A

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.

128
Q

Cheyne-Stokes respiration

A

repeated breathing pattern characterized by fluctuation in the depth of respiration: first deeply, then shallow, then not at all

129
Q

S1

A

loudest at the apex

represents the closure of the AV valves (tricuspid & mitral)

begins systole

is the LUB sound

130
Q

S2

A

loudest at the base

represents th closure of the semilunar valves (pulmonary & aortic)

begins diastole

is the DUB sound

131
Q

Bruit

A

abnormal blowing or swishing sound heard during auscultation of an artery or organ

132
Q

heave

A

forceful thrusting of the ventrcile during systole; seen at the apex

133
Q

thrill

A

palpable vibration on the chest wall accompanying severe heart murmur

134
Q

arterial blood

A

moves forward by the pressure of the pumping of the heart

moves away from the heart

135
Q

venous blood

A

moves forward by the contraction of skeletal muscles and has a one-way valve that does not allow blood to flow backwards;

moves towards the heart

136
Q

grade pulses

A

4+ (bounding)

3+ (full/increased; may be normal)

2+ (normal)

1+ (weak, barely palpable)

0 (absent)

137
Q

claudication

A

pain caused by too little blood flow to muscles during exercise

138
Q

barrel chest

A

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

139
Q

Glascow Coma Scale (GCS)

A

Neurologic assessment of a patient’s best verbal response, eye opening, and motor function

lowest is 3, highest is 15

eye 1-4

motor 1-6

verbal 1-5

a score of less than 7 is coma

140
Q

Sequence of abdominal assessment

A

Inspect, Auscultate, Percuss, Palpate

141
Q

contours of the abdomen

A
  1. flat
  2. scaphoid- abdominal wall is sunken & presents a concave rather than convex contour
  3. rounded
  4. protuberant- unusual convexity caused by poor muscle tone or excessive subcutaneous fat
142
Q

normal bowel sounds

A

5-30 per minute

143
Q

costovertebral tenderness

A

***often associated w/ RENAL DISEASE

  1. warn pt what you’re about to do
  2. have pt sit up on exam table
  3. use heel of closed fist to strike pt firmly over costovertebral angles
  4. compare left and right sides
144
Q

no bowel sounds

A

must listen for a total of 5 minutes in the RLQ

145
Q

ROM scale

A

5 - full ROM against gravity, no resistance

4 - full ROM against gravity, slight resistance

3- Full ROM with gravity

2 - slight contraction

1 - no contraction

146
Q

3 things that influence temperature

A

time of day

diurnal cycle

exercise

age

147
Q

3 causes of tachycardia

A

fever

sepsis

pneumonia

148
Q

pulse pressure

A

difference between systolic and diastolic pressure

149
Q

Korotkoff sounds

A

sounds heard while taking the blood pressure

150
Q

Babinski reflex (sign) positive

A

a reflex action, fanning of the toes; in adults is indicative of abnormalities in the motor control pathways leading from the cerebral cortex

Health Assessment (5 decks)

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