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Fundamentals Health Assessment > Fundamentals Health Assessment > Flashcards

Fundamentals Health Assessment Flashcards

1
Q

What is a Brief General Assessment

A

10 minute assessment, concise, timely, and realistic head to toe assessment.

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2
Q

What is Ongoing/Follow-up Assessment?

A

assessment done at regular intervals

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3
Q

What is a Focused Assessment

A

In depth assessment of a specific health issue, usually involves 1 or more body system.
Used to address the immediate concerns.

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4
Q

What is a Comprehensive Assessment?

A

Provides a holistic information, an overall information of body systems and functional abilities, emotional status, cultural + spiritual beliefs, psychosocial situation, family + community dynamics.
Done during admission (initial) assessment
Includes collection of subjective data, complete vital signs

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5
Q

What is Emergency Assessment

A

Focused on ABC’s
Performed mostly in acute settings ( ED, ICU)

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6
Q

Enviromental needs as a patient

A

Privacy and adequate draping (hospital gown)
Room temperature should be comfortable
Warm blankets if needed

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7
Q

Enviromental needs as a Nurse

A

Soundproof room with adequate lighting
Easy to maneuver examination table
Equipment arranges for easy use

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8
Q

Fowler’s Position

A

High Fowler’s (80o - 90o)
Fowler’s (45o – 60o)
Semi Fowler’s (30o - 45o)
Low Fowler’s (15o - 30o)

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9
Q

Trendelenburg Position

A

Trendelenburg (Lower extremities higher than the head)
Reverse (Lower extremities lower than the head)
Modified (Lower extremities & head are above the heart)

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10
Q

What is Biographical Data

A

note preffered language and any cultural barriers

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11
Q

Reason for Seeking Health Care

A

Try to record whatever the patient has to say in the pts exact words
Ex: “I’ve been coughing for 1 week”

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12
Q

History of Present Health Concern

A

Explore the symptoms, let the patient describe and explain their symptoms

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13
Q

Past Health History

A

It includes past diseases, surgeries, hospitalizations, immunizations, list of medications, preventative screenings, these data alert the nurse to certain risk factors
*advise pt of due screenings

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14
Q

Family History

A

Provide info about diseases and conditions for which the patient may be at risk; can provide clues to patient’s current health issues (eg: family members with infectious disease or any environmental hazards at home)

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15
Q

Functional Health Assessment

A

assess pts ADL’S, pt independent ADL’s

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16
Q

Psychosocial and Lifestyle Factors

A

Assess support system (interpersonal relationship and resources), level of activity + exercise, sleep + rest, nutrition, values, beliefs, self esteem, self concept, sexual history and orientation, mental health status + family violence

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17
Q

Review of Systems

A

series of questions about all body systems, maybe incorporated into the physical assessment of each regions

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18
Q

Inspection

A

uses sight, smell, hearing
Use throughout the physical examination
Pay attention to details( color, shape, size, position, symmetry, sounds, odor)

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19
Q

Palpation

A

Uses sense of touch
Types of palpation: Deep, Light
Use sensitive parts of the hand to detect different characteristics

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20
Q

What part of hand to assess for skin temperature

A

Dorsal (back of hand)

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21
Q

What part of hand to assess for vibration on skin?

A

Palm of the hand

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22
Q

What part of hand to assess for masses, size, pulses, tenderness?

A

Pinger pads, and palmar surface

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23
Q

Percussion

A

Uses sense of hearing, sound is produced by fingertip tapping through body tissues

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24
Q

Types of percussion

A

Direct and Indirect

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25
Q

Resonance sound found where?

A

Lung

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26
Q

Flat sound found where?

A

Scapular

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27
Q

Dull sound found where?

A

Liver

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28
Q

Tympanic sounds found where?

A

Stomach

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29
Q

Standing position

A

used to assess posture, balancem and gate

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30
Q

Supine Position

A

facilitates abdominal relaxation
Assesses vital signs, head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses

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31
Q

Sims Position

A

Lies on either side w? the lower arm below the body & upper arm flexed at the shoulder and elbow, both knees are flexed, w/upper leg more acutely flexed.
Assesses rectum or vagina

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32
Q

Lithotomy position

A

pt in dorsal recumbent position with the buttocks at the edge of the examining table + heels in stirrups
Assesses female genitalia and rectum

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33
Q

Sitting

A

Allows visualization of the upper body, facilitates full luung expansion.
Used to assess vital signs, head, neck, anterior + posterior thorax, lungs, heart, breasts, upper extremities,

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34
Q

Dorsal Recumbent Position

A

pt lies on back w legs seperated, knees flexed and soles of feet on bed
Assesses head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses.
** Should NOT be used for abdominal assessment bc it contracts abdominal muscles.

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35
Q

Prone

A

Assesses the hip joint and posterior thorax

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36
Q

Knee-Chest

A

assess anus and rectum

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37
Q

Dull or Thudlike sound

A

normally heard over dense surfaces as heart or liver
Dullness replaces ressonance when fluid or solid tissue replaces air-containing lung tissue, such as pneumonia, pleural effusion, and tumors

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38
Q

Hyperresonant

A

Louder-lower-pitched
Normally heard when percussing the chests of children or thin adults, or in hyperinflated lungs such as COPD, OR DURING ACUTE ASTHMA attack
An area of hyperresonance on one side of the chest may =pneumothorax

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39
Q

Tympanic

A

Hollow, high drumlike sounds
normally heard over stomach, but heard over chest indicates excessive air in the chest, such as in pneumothorax

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40
Q

Auscultation

A

Use sense of hearing, by listening to sounds produced within the body, aided or unaided

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41
Q

Types of Auscultation:

A

Direct and Indirect

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42
Q

General Survery

A

General appearance, behavior, vital signs, height and weight
Ex: how does pt walk? Initial look of pt

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43
Q

How to calculate BMI

A

{wt in lbs x 703/ Ht in Inches ^2}

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44
Q

The Skin (Color)

A

ivory to light pink, brown or olive skin

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45
Q

Pallor

A

Unusual paleness
Easily observe in face, buccal musosa, conjunctivae, nail beds
For dark individual, skin becomes yellowish brown/ashen gray

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46
Q

Cyanosis

A

Bluish Discoloration
Observe in the lips, nail beds, conjunctivase, palms
For dark individual, assess on areas of less pigmentation

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47
Q

Pallor v Cyanosis

A

Pallor= DECREASE in oxygen level in the blood
Cyanosis= INCREASE in amount of deoxygenated blood

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48
Q

Vitiligo

A

Loss of pigmentation

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49
Q

Jaundice

A

Yellowish Tinge
Liver or gallbladder

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50
Q

Erythema

A

Redness
Sign of Inflammation

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51
Q

Hyperhydrosis

A

Excessive perspiration

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52
Q

Bromhidrosis

A

foul-smelling perspiration

53
Q

Stage 1 Pressure ulcer

A

Skin is warm, erythema is NON BLANCHING

54
Q

Texture of skin

A

smooth, soft and flexible
Older = skin is wrinkled and leather

55
Q

Peripheral Artery Disease

A

Pale, cool temp
No leg hair
none to mild edema
changes in sensation
pulse deficit
pain worsens when elevating
regular wound edges
distal
sometimes necrotic

56
Q

Chronic Venous Insufficiency

A

Brown, bronze, warm
may have leg ahir
typical edema
normal sensation
normal pulses
pain improved when elevating
wet wound
irregular wound edges
usually ANKLE

57
Q

Turgor

A

Grasp a fold of skin over the front of chest or under the clavicle, back of forearm, or sternal area and release

58
Q

Normal skin turgor

A

skin lifts easily and snaps back immediately

59
Q

Poor skin turgor

A

2 seconds- some dehydration

60
Q

Tenting

A

> 2 seconds= severe hydration

61
Q

How to assess infant skin turgor

A

abdomen or thigh

62
Q

Edema

A

Fluid buildup in the tissues, direct trauma or venous return impairment

63
Q

How to assess pitting edema

A

press edematous area firmly with the thumb for several seconds and release

64
Q

Primary Lesion

A

macule, papule, pustule, vesicle, nodule, tumor, wheal,

65
Q

Secondary lesions

A

scar, keloid, crust, erosion, excoriation,

66
Q

Skin Cancer Assessment

A

Asymmetry= uneveness
Border=irregularity
Color=black to bluish brown
Diameter= greater than the size of a pencil eraser (>6mm)
Evolution= mole changing in size, shape, or color

67
Q

Nail Blanch Test

A

Capillary refill
apply gentle firm quick pressure with the tumb to nail bed, and observe the return of pink color (perfusion)

68
Q

Brisk Cap Refill

A

<3 seconds

69
Q

Sluggish Cap Refill

A

> 3 seconds

70
Q

Clubbing

A

Change in angle (>180 degrees) between the nail and nail base, normally 160 degrees

71
Q

What does nail clubbing indicate

A

Hypoxia

72
Q

Palpate the crainial bones

A

frontal, parietal, temporal, occipital; note for any deformities

73
Q

Inspect the facial features

A

not for asymmetry by comparing one side to the other

74
Q

Inspect the Scalp

A

seperate the hair into 3 areas with a comb and inspect the scalp for any lesions

75
Q

Hydrocephalus

A

Spinal fluid not draining properly
Infant frontalis is not closed properly
Adult cases= Increase in ICP

76
Q

Acromegly

A

Increase production of growth hormone
Only seen in adults

77
Q

Alopecia

A

Medical term for baldness
Causes= DHT derivative of testosterone

78
Q

Palpate the fronal and maxillary sinuses

A

for frontal sinuses, apply pressure with tumb pushing it up on the bony prominences under the brow
For MAxillary sinuses, apply pressure on zygomatic bone

79
Q

Palpate temporomandibular joint

A

ask pt to open and close his mouth with palpating the TMJ

80
Q

CN V

A

Trigeminal

81
Q

Assess CN V motor

A

clench teeth and relax; open mouth while you push it back as pt holding against resistance.

82
Q

Assess CN V Sensory

A

Wisp cotton on pts face, instruct pt to say now if he felt it
do same w sharp/dull hot/cold items
Assess for corneal reflex as well

83
Q

CN VII

A

Facial

84
Q

Assess CN VII Motor

A

look for asymmetry as pt smile, frown, show teeth, puff out cheeks, raise eyebrows; pt close his eye and attempt to open it but letting patient resist the force

85
Q

Assess CN VII Sensory

A

pt identify salty or sweet on front of tounge (sense of taste)

86
Q

Macular degeneration

A

loss in centeral vision

87
Q

Glaucoma

A

loss of peripheral vision

88
Q

Cataract

A

lens cloudiness/opacity

89
Q

Retinal Detachment

A

retinal falls, like a curtain covering your vision, floaters

90
Q

Myopia

A

image apears in front of the retina
near sited

91
Q

Hyperopia

A

Far sighted
image appears behind the retina

92
Q

Presbyopia

A

for sighted w older adults
result of normal aging

93
Q

Astigmatism

A

cornea lengthens to a football shape

94
Q

Cones

A

daytime vision
colors

95
Q

Rods

A

nighttime vision

96
Q

CN II

A

Optic

97
Q

Assess CN II

A

Visual acuity w snellen chart

98
Q

Assess CN II Visual Field

A

pt cover one eye, follow pen light up, down, side, side

99
Q

CN III

A

Oculomotor

100
Q

Assessing CN III

A

Raising upper eyelid
PERRLA

101
Q

Ptosis

A

abnormal drooping of the eyelid over the pupil is an impairment of the 3rd cranial nerve

102
Q

CN III CN IV CN VI

A

oculomotor
Trochlear
Abducens
6 cardinal field of gaze

103
Q

CN VIII

A

Auditory

104
Q

Whisper Test

A

ask pt to cover his right ear, you whisper on the other 1-2 ft away, let pt repeat what you said

105
Q

CN I

A

Olfactory

106
Q

Assess CN I

A

occlude each nostrol and let pt identify the odor

107
Q

CN IX

A

Glossopharyngea;

108
Q

CN X

A

Vagus

109
Q

Assess CN IX & X (sensory & Motor

A

with a tounge depressor touch the back of pharynx and watch for the palate to rise (gag reflex and swallowing)

110
Q

Assess CN IX & X Motor

A

intruct the pt to say “ah” observe for the palate to rise symmetrically, uvula remains at the middle

111
Q

Assess CN IX sensory

A

instruct the pt to identify if sour or bitter on BACK of tounge (sense of taste)

112
Q

Assess CN X (sensory & motor)

A

listen to pt talking (speech)

113
Q

Sensory X

A

pharynx, larynx, viscera

114
Q

Motor X

A

Larynx

115
Q

The longest and only cranial nerve that wanders from the brain stem to the organs of the neck, thorax & abdomen is

A

CN X vagus nerve

116
Q

CN XII

A

hypoglossal

117
Q

Assess CN XII

A

ask pt to stick tongue out, moe from side to side

118
Q

How to inspect the thyroid gland

A

observe the thyroid gland by instructing pt to swallow

119
Q

How to palpate the thyroid gland

A

place your hands at the midline, palpate by rolling hands laterally towards the SCM

120
Q

Auscultate the thyroid gland

A

listen for bruit if thyroid gland is palpable

121
Q

Awake & Alert

A

fully awake; oriented; responds to all stimuli

122
Q

Lethargic

A

appears drowsy or asleep but makes spontaneous movement; aroused by gentle shaking and saying pts name

123
Q

Stuporous

A

unconscious most of the time,has no spontaneous movement, must be shaken or shouted to arousal; inappropriate verbal response; responds to painful stimuli

124
Q

Comatose

A

cant be aroused, even with use of painful stimuli

125
Q

Glasgow coma scale (GCS)

A

is objectively describe the extent of impaired consciousness in all types of acute mediccal and truma patients

126
Q

Eye open coma scale

A

score of 4 pt is awake and alert

127
Q

Score of 5

A

best verbal response pt is oriented x4

128
Q

Score of 6

A

bbest motor response obeys commands

129
Q
A

Fundamentals Health Assessment (2 decks)

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