Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is Ongoing/Follow-up Assessment?

A

assessment done at regular intervals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is Emergency Assessment

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Enviromental needs as a patient

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Enviromental needs as a Nurse

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is Biographical Data

A

note preffered language and any cultural barriers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

History of Present Health Concern

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Functional Health Assessment

A

assess pts ADL’S, pt independent ADL’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Review of Systems

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Inspection

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Palpation

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What part of hand to assess for skin temperature

A

Dorsal (back of hand)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What part of hand to assess for vibration on skin?

A

Palm of the hand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

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

A

Pinger pads, and palmar surface

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Percussion

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Types of percussion

A

Direct and Indirect

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Resonance sound found where?
Lung
26
Flat sound found where?
Scapular
27
Dull sound found where?
Liver
28
Tympanic sounds found where?
Stomach
29
Standing position
used to assess posture, balancem and gate
30
Supine Position
facilitates abdominal relaxation Assesses vital signs, head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses
31
Sims Position
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
32
Lithotomy position
pt in dorsal recumbent position with the buttocks at the edge of the examining table + heels in stirrups Assesses female genitalia and rectum
33
Sitting
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,
34
Dorsal Recumbent Position
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.
35
Prone
Assesses the hip joint and posterior thorax
36
Knee-Chest
assess anus and rectum
37
Dull or Thudlike sound
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
38
Hyperresonant
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
39
Tympanic
Hollow, high drumlike sounds normally heard over stomach, but heard over chest indicates excessive air in the chest, such as in pneumothorax
40
Auscultation
Use sense of hearing, by listening to sounds produced within the body, aided or unaided
41
Types of Auscultation:
Direct and Indirect
42
General Survery
General appearance, behavior, vital signs, height and weight Ex: how does pt walk? Initial look of pt
43
How to calculate BMI
{wt in lbs x 703/ Ht in Inches ^2}
44
The Skin (Color)
ivory to light pink, brown or olive skin
45
Pallor
Unusual paleness Easily observe in face, buccal musosa, conjunctivae, nail beds For dark individual, skin becomes yellowish brown/ashen gray
46
Cyanosis
Bluish Discoloration Observe in the lips, nail beds, conjunctivase, palms For dark individual, assess on areas of less pigmentation
47
Pallor v Cyanosis
Pallor= DECREASE in oxygen level in the blood Cyanosis= INCREASE in amount of deoxygenated blood
48
Vitiligo
Loss of pigmentation
49
Jaundice
Yellowish Tinge Liver or gallbladder
50
Erythema
Redness Sign of Inflammation
51
Hyperhydrosis
Excessive perspiration
52
Bromhidrosis
foul-smelling perspiration
53
Stage 1 Pressure ulcer
Skin is warm, erythema is NON BLANCHING
54
Texture of skin
smooth, soft and flexible Older = skin is wrinkled and leather
55
Peripheral Artery Disease
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
Chronic Venous Insufficiency
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
Turgor
Grasp a fold of skin over the front of chest or under the clavicle, back of forearm, or sternal area and release
58
Normal skin turgor
skin lifts easily and snaps back immediately
59
Poor skin turgor
2 seconds- some dehydration
60
Tenting
>2 seconds= severe hydration
61
How to assess infant skin turgor
abdomen or thigh
62
Edema
Fluid buildup in the tissues, direct trauma or venous return impairment
63
How to assess pitting edema
press edematous area firmly with the thumb for several seconds and release
64
Primary Lesion
macule, papule, pustule, vesicle, nodule, tumor, wheal,
65
Secondary lesions
scar, keloid, crust, erosion, excoriation,
66
Skin Cancer Assessment
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
Nail Blanch Test
Capillary refill apply gentle firm quick pressure with the tumb to nail bed, and observe the return of pink color (perfusion)
68
Brisk Cap Refill
<3 seconds
69
Sluggish Cap Refill
>3 seconds
70
Clubbing
Change in angle (>180 degrees) between the nail and nail base, normally 160 degrees
71
What does nail clubbing indicate
Hypoxia
72
Palpate the crainial bones
frontal, parietal, temporal, occipital; note for any deformities
73
Inspect the facial features
not for asymmetry by comparing one side to the other
74
Inspect the Scalp
seperate the hair into 3 areas with a comb and inspect the scalp for any lesions
75
Hydrocephalus
Spinal fluid not draining properly Infant frontalis is not closed properly Adult cases= Increase in ICP
76
Acromegly
Increase production of growth hormone Only seen in adults
77
Alopecia
Medical term for baldness Causes= DHT derivative of testosterone
78
Palpate the fronal and maxillary sinuses
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
Palpate temporomandibular joint
ask pt to open and close his mouth with palpating the TMJ
80
CN V
Trigeminal
81
Assess CN V motor
clench teeth and relax; open mouth while you push it back as pt holding against resistance.
82
Assess CN V Sensory
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
CN VII
Facial
84
Assess CN VII Motor
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
Assess CN VII Sensory
pt identify salty or sweet on front of tounge (sense of taste)
86
Macular degeneration
loss in centeral vision
87
Glaucoma
loss of peripheral vision
88
Cataract
lens cloudiness/opacity
89
Retinal Detachment
retinal falls, like a curtain covering your vision, floaters
90
Myopia
image apears in front of the retina near sited
91
Hyperopia
Far sighted image appears behind the retina
92
Presbyopia
for sighted w older adults result of normal aging
93
Astigmatism
cornea lengthens to a football shape
94
Cones
daytime vision colors
95
Rods
nighttime vision
96
CN II
Optic
97
Assess CN II
Visual acuity w snellen chart
98
Assess CN II Visual Field
pt cover one eye, follow pen light up, down, side, side
99
CN III
Oculomotor
100
Assessing CN III
Raising upper eyelid PERRLA
101
Ptosis
abnormal drooping of the eyelid over the pupil is an impairment of the 3rd cranial nerve
102
CN III CN IV CN VI
oculomotor Trochlear Abducens 6 cardinal field of gaze
103
CN VIII
Auditory
104
Whisper Test
ask pt to cover his right ear, you whisper on the other 1-2 ft away, let pt repeat what you said
105
CN I
Olfactory
106
Assess CN I
occlude each nostrol and let pt identify the odor
107
CN IX
Glossopharyngea;
108
CN X
Vagus
109
Assess CN IX & X (sensory & Motor
with a tounge depressor touch the back of pharynx and watch for the palate to rise (gag reflex and swallowing)
110
Assess CN IX & X Motor
intruct the pt to say "ah" observe for the palate to rise symmetrically, uvula remains at the middle
111
Assess CN IX sensory
instruct the pt to identify if sour or bitter on BACK of tounge (sense of taste)
112
Assess CN X (sensory & motor)
listen to pt talking (speech)
113
Sensory X
pharynx, larynx, viscera
114
Motor X
Larynx
115
The longest and only cranial nerve that wanders from the brain stem to the organs of the neck, thorax & abdomen is
CN X vagus nerve
116
CN XII
hypoglossal
117
Assess CN XII
ask pt to stick tongue out, moe from side to side
118
How to inspect the thyroid gland
observe the thyroid gland by instructing pt to swallow
119
How to palpate the thyroid gland
place your hands at the midline, palpate by rolling hands laterally towards the SCM
120
Auscultate the thyroid gland
listen for bruit if thyroid gland is palpable
121
Awake & Alert
fully awake; oriented; responds to all stimuli
122
Lethargic
appears drowsy or asleep but makes spontaneous movement; aroused by gentle shaking and saying pts name
123
Stuporous
unconscious most of the time,has no spontaneous movement, must be shaken or shouted to arousal; inappropriate verbal response; responds to painful stimuli
124
Comatose
cant be aroused, even with use of painful stimuli
125
Glasgow coma scale (GCS)
is objectively describe the extent of impaired consciousness in all types of acute mediccal and truma patients
126
Eye open coma scale
score of 4 pt is awake and alert
127
Score of 5
best verbal response pt is oriented x4
128
Score of 6
bbest motor response obeys commands
129

Fundamentals Health Assessment (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions