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Health Assessment > Final > Flashcards

Final Flashcards

1
Q

dysuria

A

•pain/difficulty passing urine

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2
Q

hematuria

A

•visible blood in urine

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3
Q

microscopic hematuria

A

•blood in urine only detected w/ microscopic analysis

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4
Q

stress incontinence

A
  • involuntary loss of urine due to increased intra-abdominal pressure
  • decreased contractility of urethral sphincter
  • poor support of bladder neck
  • coughing, sneezing, laughing, lifting
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5
Q

urge incontinence

A
  • difficulty holding urine once urge to void

* suggests detrusor overactivity

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6
Q

overflow incontinence

A
  • bladder can’t be emptied until bladder pressure exceeds urethral
  • neurogenic abnormality
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7
Q

functional incontinence

A

•involuntary loss of urine due to impaired cognition, musculoskeletal problems, immobility

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8
Q

kidney/flank pain

A
  • visceral
  • dull, steady ache
  • radiates anterior ally toward umbilicus
  • fever, chills, pyelonephritis
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9
Q

pyelonephritis

A

•kidney inflammation/infection

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10
Q

ureteral pain

A
  • visceral
  • originates at CVA
  • radiates around trunk into LQ, thigh, testicle or labium
  • sudden obstruction of ureter from stones/clots
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11
Q

upper urinary system

A

•kidney’s and ureters

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12
Q

lower urinary system

A

•bladder and urethra

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13
Q

UTI

A
  • most involve lower urinary system

* UTI progression up -> pyelonephritis

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14
Q

urine obstruction

A
  • reduced urine flow
  • bacteria can easily travel up ureters
  • caused by BPH, abdominal/pelvic masses, stones in bladder, kidney, ureter
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15
Q

BPH

A
  • benign prostatic hypertrophy

* causes urination problems

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16
Q

bladder palpation

A

•not usually palpable

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17
Q

ureteral stricture

A

•narrowing of the ureteral lumen, causing functional obstruction

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18
Q

kidney palpation

A
  • not usually palpable

* pain on palpation indicates pyelonephritis

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19
Q

polycystic dz

A
  • disorder where clusters of cysts develop within the kidneys
  • bilateral
  • genetic
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20
Q

priapism

A
  • erection > 4 hrs not related to sexual excitement
  • painful
  • damage to penis
  • secondary to venous engorgement
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21
Q

venous engorgement

A

•distention of veins w/ blood or lymph

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22
Q

aging male reproductive system

A
  • decreased penis size
  • testicles hang lower in scrotum
  • prostate gland enlargement (BPH)
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23
Q

hypospadias

A
  • congenital ventral displacement of meatus

* closer to the body

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24
Q

menarche

A

•age at onset of menses

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25
Q

menopause

A
  • absence of menses for 12 consecutive months

* 48-55 y/o

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26
Q

dysmenorrhea

A
  • painful menstruation

* primary or secondary (endometriosis, pelvic inflammatory disease, endometrial polyps)

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27
Q

endometriosis

A
  • tissue lining uterus grows outside of uterus

* painful

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28
Q

pelvic inflammatory dz (PID)

A
  • infection of the female reproductive organs

* usually occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries

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29
Q

premenstrual syndrome (PMS)

A
  • emotional behaviors/symptoms 5 days prior to menses
  • must have sx for at least 3 cycles
  • sleep disturbances
  • poor concentration
  • interference w/ ADLs
  • social withdrawals
  • sx cease w/in 4 days of menses onset
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30
Q

amenorrhea

A

•abnormal absence of menstruation

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31
Q

aging female reproductive/breast

A
  • menopause
  • trophy and hair loss of vulva
  • breast tissue atrophy (replaced w/ adipose)
  • breasts softer/pendulous
  • nipple invert
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32
Q

HRT

A

•hormone replacement therapy

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33
Q

OC

A

•oral contraceptives

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34
Q

BSE

A
  • breast self examination
  • arms at side, above head
  • hands on hips firmly, lean fwd
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35
Q

Gardisil

A

•targets types 16 & 18 HPV

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36
Q

external hemorrhoids

A
  • varicose veins of rectum
  • subjective ℅ itching/pain/burn
  • more visible standing/defecating
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37
Q

thrombosed hemorrhoid

A
  • bluish, shiny edematous mass on the anus
  • clots in anal veins
  • very painful
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38
Q

internal hemorrhoids

A
  • painless unless thromboses, infected, or prolapsed

* bleed w/ and w/o defecation

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39
Q

melena

A
  • dark red blood in stool

* indicates problem upper GI

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40
Q

fistula

A
  • inflammatory tract or tube that opens at one end in the anus/rectum and at the other end onto the skin surface
  • may have serosanguinous or purulent drainage
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41
Q

fissure

A

•tear in anal mucosa

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42
Q

external muscle sphincter of anus

A
  • voluntary
  • holds anus closed
  • pain absent past sphincter
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43
Q

pilonidal cyst

A
  • bottom of coccyx
  • from ingrown hair or trauma
  • can become infected and pilled w/ puss
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44
Q

pilonidal abscess

A
  • infected pilonidal cyst
  • looks like infected pimple at bottom of coccyx superior to butt crack
  • more common in men
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45
Q

hematochezia

A
  • bright red blood in the stool

* indicates lower GI issue

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46
Q

comprehensive physical exam

A

•annual physical exam in clinic

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47
Q

comprehensive admitting assessment

A
  • 30-45 min
  • establish individualized POC
  • provides further HCPs w/ info about pt physical, psychological, fxnl, social, and spiritual abilities
  • completed w/in 24 hrs of admission
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48
Q

data from admitting assessment

A
  • subjective- risk, s/s, PMH
  • objective- gen survey, VS, head-to-toe, fall risk, skin breakdown risk
  • really detailed
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49
Q

baseline shift/bedside assessment

A
  • 10-15 min
  • pt status
  • what we are doing in clinical
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50
Q

focused hospital assessment

A
  • brief (1-20 min)
  • focus on issue that may have changed specifically
  • may require intervention modification
  • Ex: pt w/ SOB- get O2 sat. immediately
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51
Q

prioritizing pts

A
  • follow ABC rule
  • airway
  • breathing
  • consciousness
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52
Q

indicators of unstable status

A
  • cyanosis/pallor
  • dyspnea
  • strained posture
  • anxious facial expression
  • distressed appearance
  • high/low HR or BP
  • change in mental status
  • new onset of chest pain (CP)
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53
Q

if pt has dressing/IV/tubing/O2

A

•check first before beginning BSA

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54
Q

handoff summary

A
  • transfer of care from one HCP to another
  • shift change
  • nurse leaving unit
  • transfer of pt
  • return from PACU/test
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55
Q

CMS

A

circulation, motion, sensation

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56
Q

reflection

A

•echoing pt words

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57
Q

clarification

A

•tell me what you mean by that

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58
Q

functional assessment

A

•measure of self care ability related to:

  1. ) ADLs
  2. ) activities needed for independent living (cooking, cleaning, etc)
  3. ) personal habits (drugs, exercise, etc)
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59
Q

standard precautions

A

•all blood, body fluids, secretions, excretions, non-intact skin, and mucus membranes can possibly transmit pathogens

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60
Q

general survey data

A
  1. ) physical appearance
  2. ) state of health
  3. ) grooming/hygiene
  4. ) mobility
  5. ) behavior
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61
Q

temperature ranges

A
  • 35.8-37.3 C

* 96.4-99.1 F

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62
Q

pulse deficit

A

•diff. b/t apical and peripheral pulse rate

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63
Q

stroke volume

A

•amnt blood exits LV during ctx (beat)

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64
Q

HR increases when…

A

•blood volume decreases

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65
Q

pulse pressure

A
  • SP-DP

* increases w/ age b/c SP increases

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66
Q

BP range

A

•90/60 - 139/89

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67
Q

peripheral vascular resistance

A
  • afterload
  • what heart has to push against during ctx
  • higher w/ narrow arteries
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68
Q

too small BP cuff

A

•false high reading

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69
Q

too large BP cuff

A

•false low reading

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70
Q

Korotkoff sound I

A

•systolic BP

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71
Q

Korotkoff sound IV

A

•muffling

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72
Q

Kortkoff sound V

A
  • diastolic BP

* when sound stops

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73
Q

intractable pain

A
  • severe, constant pain that isn’t curable

* causes bed/house bound state

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74
Q

localized edema

A

•indicates injury

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75
Q

systemic edema

A

•fluid accumulates at dependent part of body

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76
Q

primary lesion

A

•develops on normal skin

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77
Q

secondary lesion

A

•changes to lesion or disturbed skin over time

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78
Q

vascular lesion

A

•develops b/c of blood supply issue to skin

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79
Q

macule

A
  • non palpable

* freckle

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80
Q

vesicle

A
  • palpable- serous fld

* chix pox, blister, herpes

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81
Q

postule

A
  • palpable- puss

* acne

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82
Q

burrow

A
  • tunnel- fluid

* mites/scabes

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83
Q

papule

A
  • palpable- solid

* mole

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84
Q

nodule/tumor

A
  • palpable- bigger solid

* wart; cyst

85
Q

wheal

A
  • palpable- solid

* insect bite/hives

86
Q

erosion

A

•non-scarring/non-bleeding loss of epi

87
Q

ulcer

A
  • deeper loss of epi/dermins

* bleed and scar

88
Q

excoriation

A

•linear erosions caused by scratching

89
Q

lichenification

A
  • thick leathery skin due to rubbing

* eczema

90
Q

scar

A

•extra connective tissue

91
Q

keloid

A

•overgrowth of rubbery tissue around scar

92
Q

purpura

A
  • vascular lesion
  • non-palpable
  • deep red
93
Q

petechiae

A

•small purpura

94
Q

SSE

A 
Asymmetry
Border irregularity
Color variation
Diameter 6 mm or >
Evolving
95
Q

thyroid cartilage

A

•superior lump of trachea

96
Q

thyroid isthmus

A
  • joins thyroid lobes

* inferior to cricoid

97
Q

cricoid cartilage

A

•b/t thyroid cartilage and thyroid gland

98
Q

cornea reflex

A
  • cotton ball touch

* test CN 5 & 7

99
Q

conjunctiva coloring

A
  • pink- normal
  • red- infection
  • pale- anemia
100
Q

confrontation test

A

•wiggle fingers into pt line of gaze

101
Q

Hirschberg test

A

•corneal light reflex

102
Q

consensual light reflex

A

•constriction of pupil that light is not shining on

103
Q

infant eustachian tube

A
  • horizontal

* pull back and up

104
Q

adult eustachian tube

A
  • sloped

* pull back and down

105
Q

uvula inspection

A
  • midline and rises w/ “ahh” shows vagus nerve in tact

* if had stroke, leans toward opp. side

106
Q

tonsil grading

A
  • absent
  • 1+ barely visible
  • 2+ halfway to uvula
  • 3+ touching uvula
  • 4+ touching each other
107
Q

acute dypsnea indicates

A
  • anaphylaxis
  • pulmonary embolism
  • pneumothorax
  • anxiety
108
Q

cough indicates

A
  • L side heart failure
  • URI
  • bronchitis/pneumonia
109
Q

wheezing indicates

A
  • airway obstruction
  • tissue inflammation
  • asthma
110
Q

normal percussion over supraclavicular

A
  • resonance

* where apex of lungs is

111
Q

normal breath sounds

A
  • vesicular

* inspiration longer than expiration

112
Q

crackles (rales)

A
  • air passing thru fld or expanding airways
  • discontinuous
  • non musical
  • not cleared w/ cough
  • fine or coarse
113
Q

wheezes

A
  • turbulent flow
  • continuous
  • high pitched musical
  • over tissue
114
Q

rhonchi

A
  • turbulent flow
  • continuous
  • high pitched musical
  • over bronchi
  • coarse mucus related
  • clear w/ cough
115
Q

spleen

A
  • stores RBCS
  • makes RBCs and WBCs
  • normally not palpable
116
Q

diastole

A
  • blood from A to V
  • aortic/pulmonic valve closed
  • mitral/tricuspid open
  • b/t S2 & S1
  • longer than systole
117
Q

S1 heart sounds

A
  • lub
  • loudest over apex
  • when mitral/tricuspid close
  • ctx- systole begins
118
Q

S2 heart sounds

A
  • dub
  • loudest over base
  • aortic/pulmonic close
  • rlx- diastole begins
119
Q

murmur grading

A

•1 barely audible -> 6 loud w/ scope above chest and palpable thrill
*4 when start feeling thrill

120
Q

causes of hypoalbuminemia

A

•renal disorder

121
Q

vertebral curvature

A
  • C & L- concave; lordosis

* T & S- convex; kyphosis

122
Q

older adult musculoskeletal

A
  • decreased height (arm/leg same)
  • osteoporosis
  • muscle atrophy
  • kyphosis
123
Q

consciousness

A
  • level of alertness

* depends on interaction b/t cerebral hemispheres and RAS

124
Q

corticospinal (pyramidal) tract

A
  • motor
  • smooth, delicate, voluntary movement
  • Ex: writing
125
Q

spinothalamic tract

A
  • sensory
  • pain, temp, touch
  • cotton wisp test
126
Q

dorsal (posterior) columns

A
  • sensory
  • position
  • proprioception
  • vibration
  • stereognosis
  • graphesthesia
127
Q

aging adult NS

A 
•neuron atrophy
•slow rxn time
•diminished special senses
•decreased cerebral blood flow -> fall
*no change in mental ability
128
Q

dysarthria

A
  • physical difficulty w/ motor aspect of speech

* slurred and slow or rapid mumbling

129
Q

-osis

A

•abnormal condition

130
Q

-otomy

A
  • to cut into

* TEMPORARY opening

131
Q

-ostomy

A

•to make a PERMANENT opeing

132
Q

stomato

A

•mouth (opening)

133
Q

rhino

134
Q

rhinitis

A

•runny nose

135
Q

aden/o

136
Q

circum

A

•to cut around

137
Q

stasis

A

•to stop

138
Q

hypoxemia

A

•low blood O2

139
Q

dysrhythmia

A

•no heart rhythm

140
Q

hemangioma

A

•tumor of blood vessel

141
Q

cephalgia

A

•headache

142
Q

myelo

A
  • spinal cord

* bone marrow

143
Q

-cele

A

•swelling or hernia

144
Q

-plasia

A
  • development
  • formation
  • growth
145
Q

-plegia

A

•paralysis

146
Q

aphasia

A

•loss of speech

147
Q

-centesis

A

•to puncture

148
Q

-rrhea

A
  • flow

* discharge

149
Q

dysphaGIA

A

•difficulty swallowing

150
Q

tachypena

A

•rapid breathing

151
Q

-ptysis

A
  • coughing

* spitting

152
Q

fibrosis

A

•scarring

153
Q

hydronephrosis

A

•urine regurgitation into kidney

154
Q

pyelo

A

•renal collecting ducts

155
Q

oligo

A

•less than normal

156
Q

-pexy

A

•to surgically reattach

157
Q

enuresis

A

•bed wetting

158
Q

-rrhaphy

A

•to suture

159
Q

-malacia

A

•softening

160
Q

-asthenia

A
  • weakness

* loss of strength

161
Q

-trophy

A
  • development
  • stimulation
  • maintenance
162
Q

-algia/-algesia

163
Q

arthroscopy

A

•entering thru joint and visualizing bone surfaces

164
Q

carcinoma

A
  • most common form of cancer

* develops from epithelial cells

165
Q

sarcoma

A
  • rare form of cancer

* develops from connective tissue (fat, muscle, bone)

166
Q

BBT

A

•basal body temp

167
Q

BRP

A

•bathroom privileges

168
Q

CABG

A

•coronary artery bypass graft

169
Q

CP

A
  • cerebral palsy

* cleft palate

170
Q

DKA

A

•diabetes ketoacidosis

171
Q

DM

A
  • diabetes mellitus

* diastolic murmur

172
Q

DTR

A

•deep tendon reflex

173
Q

fx

A

•fracture

174
Q

IBW

A

•ideal body weight

175
Q

KVO

A

•keep vein open

176
Q

LR

A
  • lactated ringer’s

* isotonic IV sol.

177
Q

NS

A

•normal saline

178
Q

trichotillomania

A

•irresistible urge to pull out hair/eyebrows

179
Q

anisocoria

A
  • unequal diameter of pupils

* CN III issue

180
Q

miosis

A

•constriction of pupils

181
Q

mydriasis

A

•dilated, fixed pupils

182
Q

ectropion

A

•eyelids loosen and roll outward

183
Q

entropion

A

•eyelids roll outward

184
Q

otalgia

A

•earache

185
Q

pleural effusion

A

•FLUID in pleural space

186
Q

pneumothorax

A
  • AIR in pleural space

* absent breath sounds, esp R lat. lobe

187
Q

plethoric

A

•beat red

188
Q

acrocyanosis

A

•blue extremities

189
Q

ototoxic drugs

A

•side effects can cause hearing loss

190
Q

exostosis

A

•abnormal new growth of bone w/in ear

191
Q

furuncle

A

•boil in ear

192
Q

pyrosis

A

•heartburn

193
Q

odynophagia

A

•painful swallowing

194
Q

right main stem bronchi

A
  • more vertical than left

* site of aspiration

195
Q

borborygmia

A
  • hyperactive bowel sounds
  • diarrhea
  • anxiety
  • rxn to food
196
Q

presbycusis

A
  • high freq. hearing loss

* occurs w/ aging

197
Q

how long to wait to take temp after someone drinks/eats

A

•15-20 min

198
Q

75 y/o on new anti-HTN drug and complains of dizziness

A
  • worried about orthostatic HTN

* take BP supine, sitting, standing

199
Q

v.s. older adule

A
  • increased systolic
  • increased pulse pressure
  • arteries stiff -> HTN
200
Q

assessment finding attributed to stiffer arterioles

A

•increased systolic pressure

201
Q

subjective info

A
  • risk factors
  • family history
  • lifestyle habits
202
Q

most important step to obtain accurate data about current physical status

A

•adequate exposure of body areas as they are examined

*NOT therapeutic comm (that’s not part of assessment)

203
Q

what determines strength of pulse

A

•stroke volume

204
Q

what determines BP

A
  • cardiac output

* peripheral vascular resistance

205
Q

reason for estimating systolic

A

•avoid auscultatory gap

206
Q

pt w/ history of falling/injuries

A
  • sign of abuse

* NOT balance problems

207
Q

where does trachea bifurcate

A

•sternal angle

208
Q

quadricep ctx

A

•knee flexion

209
Q

sign of parkinson’s

A

•flat affect

Health Assessment (8 decks)

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