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[1] NUR112 | HEALTH ASSESSMENT > General Survey > Flashcards

General Survey Flashcards

1
Q

Includes objective data about the patient’s physical appearance, body structure, mobility, behavior, height, weight, and vital signs. It begins in the interview phase of a comprehensive health assessment

A

GENERAL SURVEY

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2
Q

TRUE OR FALSE:
The general survey begins in the pre-interaction phase of a comprehensive health assessment

A

FALSE
It begins with the INTERVIEW PHASE

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3
Q

TRUE OR FALSE:
While collecting objective data during the health history, the nurse starts observing and developing initial impressions about the individual’s health and formulating strategies for physical assessment

A

FALSE
SUBJECTIVE DATA is collected

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4
Q

Should include what is seen, heard, or smelled during the general survey

A

Initial Impression

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5
Q

TRUE OR FALSE:
The objective data collected during the survey will be used as a guide later on.

A

TRUE

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6
Q

EQUIPMENT TO BE USED
● (1) T - __________
● (2) S - __________
● (3) S - __________
● (4) S - __________
● (5) S - __________
● (6) A - __________

A

(1) Thermometer
(2) Standing Scale
(3) Stretcher Scale
(4) Sphygmomanometer
(5) Stethoscope
(6) Analog Watch

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7
Q

TRUE OR FALSE:
CLIENT PREPARATION
● Conduct the general survey with the client sitiing or standing.
● Ask the client to remove shoes and any heavy outer clothing before you measure height and weight.

A

TRUE

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8
Q

TRUE OR FALSE:
CLIENT PREPARATION
When weighing a hospitalized client, always weigh at a different time of the day, with a different scale, and with the client wearing different clothing.

A

FALSE
The client must be weighed at the SAME TIME OF DAY, with the SAME SCALE, and with the SAME CLOTHING

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9
Q

● A general survey is an overall review or first impression a nurse has of a person’s well being.

A

GENERAL OBSERVATION

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10
Q

TRUE OR FALSE:
GENERAL OBSERVATION
● Appearance
● Body Structure/ mobility
● Behavior
● Observe physical and sexual development
● Compare client’s stated age with her apparent age and development stage
● Observe skin condition and color
● Observe dress
● Observe hygiene
● Observe posture
● Observe body build as well as muscle mass and fat distribution

A

TRUE

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11
Q

Assesses the following:
o Client’s LOC (Level of Consciousness)
o Posture and body movements
o Dress, grooming, & hygiene
o Facial expression
o Speech
o Mood, feelings & expressions
o Thought processes and perceptions
o Cognitive abilities

A

MENTAL STATUS ASSESSMENT

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12
Q

● If a client has experienced a change in weight:
o Determine the (1) __________
o Assess the (2) __________ over which the weight change occurred
o Determine (3) __________ for weight loss or weight gain

A

(1) amount
(2) period of time
(3) possible causes

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13
Q

● Weigh clients using a (1) __________
● Use a (2) __________ for clients who are unable to bear weight

A

(1) standing scale
(2) stretcher scale

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14
Q

TRUE OR FALSE
HEIGHT AND WEIGHT
o Calibrate the scale by setting the weight to one
o Have client stand on the platform scale and remain still
o Adjust scale weight on the balance beam until the tip of the beam registers
in the middle of the mark.

A

FALSE
The scale must be set to ZERO

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15
Q

TRUE OR FALSE:
HEIGHT AND WEIGHT
● With the client standing erect on a scale, raise the metal rod attached to the scale up and over the client’s head.
● The rod should be placed level horizontally at a 45-degree angle to the measuring stick

A

FALSE
The rod should be placed horizontally at a 90-DEGREE ANGLE to the measuring stick

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16
Q

TRUE OR FALSE:
HEIGHT AND WEIGHT
● Height is measured in inches or centimeters.

A

TRUE

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17
Q

TRUE OR FALSE:
● Measurement of height is needed in adults to make an accurate assessment of weight status.

A

TRUE

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18
Q

● In children, height is monitored on a ___________ to assess growth and, indirectly, nutritional status.

A

continuum

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19
Q

● A weight gain of (1) __________ in a (2) __________ period is a useful marker in determining issues related to fluid retention, edema, or dehydration, which may indicate conditions such as congestive heart failure or renal disease.

A

(1) 3 pounds or more
(2) 1-week

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20
Q

● In contrast, unintentional weight loss of (1) __________ of body weight over a month or __________ over (2) __________ is considered clinically significant and warrants attention.

A

(1) 5% or more / 10% or more
(2) 6 months

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21
Q

_________________________ = % WEIGHT CHANGE

A

PRIOR WEIGHT - CURRENT WEIGHT / PRIOR WEIGHT X 100

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22
Q

Is widely used to assess appropriate weight for height

A

BODY MASS INDEX (BMI)

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23
Q

______________________________ = BMI

A

WEIGHT (kg) / HEIGHT^2 (meters)

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24
Q

WHO (BMI): <18.5
Asia-Pacfic (BMI): <18.5

A

UNDERWEIGHT

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25
Q

WHO (BMI): 18.5 - 24.9
Asia-Pacfic (BMI): 18.5 - 22.9

A

NORMAL

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26
Q

WHO (BMI): 25 - 29.9
Asia-Pacfic (BMI): 23 - 24.9

A

OVERWEIGHT

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27
Q

WHO (BMI): >= 30
Asia-Pacfic (BMI): >= 25

A

OBESE

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28
Q

● Include body temperature, pulse, respiratory rate, and blood pressure.
● Measurement of oxygen saturation and pain assessmet.

A

VITAL SIGNS MEASUREMENT

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29
Q

● Nurses measure vital signs to obtain (1) __________, to detect or monitor a change in the patient’s (2) __________, and to monitor patients at risk for (3) __________

A

(1) baseline data
(2) health status
(3) alterations in health

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30
Q

● __________ occurs because the heat loss mechanisms are unable to keep pace with excess heat production

A

Hyperthermia

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31
Q

Fahrenheit: 97.6 - 99.6
Celsius: 36.5 - 37.4

A

ORAL

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32
Q

Fahrenheit: 98.6 - 100.6
Celsius: 37.0 - 38.1

A

RECTAL

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33
Q

Fahrenheit: 96.6 - 98.6
Celsius: 36.0 - 37.0

A

AXILLARY

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34
Q

Fahrenheit: 98.6 - 100.6
Celsius: 37.0 - 38.1

A

TYMPANIC

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35
Q

● The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.

A

Intermittent

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36
Q

● A wide range of temperature fluctuations (more than 2°C [3.6° F]) which occurs over the 24-hour period, all of which are above normal.

A

Remittent

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37
Q

● Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.

A

Relapsing

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38
Q

● Body temperature fluctuates minimally but always remains above normal

A

Constant

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39
Q

PHASES OF FEBRILE EPISODES
● Body’s heat producing mechanism attempt to increase the core body temperature
● Feeling of being cold and shivering
● Skin also appears pale and cool due to vasoconstriction

A
  1. Chill Phase
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40
Q

PHASES OF FEBRILE EPISODES
● Occurs when the fever reaches the new higher set point
● The client’s skin feels warm to touch and appears flushed because of vasodilation
● Complaints of general malaise, weakness and aching muscles

A
  1. Fever Phase
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41
Q

PHASES OF FEBRILE EPISODES
● Febrile episode
● Client’s experiences profuse diaphoresis, decrease shivering and possible fluid volume deficit

A
  1. Flush or Crisis phase
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42
Q

PULSE RATE
● Normal Rate = (1) __________
● Mean / Average = (2) __________

A

(1) 60 – 100 bpm
(2) 80 bpm

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43
Q

TRUE OR FALSE:
PULSE RATE
● May be as low as 60 bpm in healthy athletes

A

FALSE
50 BPM

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44
Q

TRUE OR FALSE:
PULSE RATE
● Equal bilaterally in strength / amplitude

A

TRUE

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45
Q

Pulse Rate Amplitude can be quantified as follows
1+ __________ (easy to obliterate)
2+ __________ (obliterate with moderate pressure)
3+ __________ (unable to obliterate or requires very firm pressure)

A

(1) thready or weak
(2) normal
(3) bounding

46
Q

DEVIATIONS FROM NORMAL PULSE RATE
● > 100 bpm = _____________
o Anxiety, fear, nervousness

A

TACHYCARDIA

47
Q

DEVIATIONS FROM NORMAL PULSE RATE
● < 60 bpm = _______________
o Prolonged sitting or standing

A

BRADYCARDIA

48
Q

DEVIATIONS FROM NORMAL PULSE RATE
● ______________
o Difference between the apical and the radial pulse

A

PULSE DEFICIT

49
Q

RESPIRATORY RATE
● Normal Rate = (1) ___________
● Regular and spontaneous rhythm
● Equal bilateral chest expansion of (2) ___________

A

(1) 12 – 20 cpm
(2) 1 – 2 inches

50
Q

TYPES OF RESPIRATIONS
● 12-20 cpm and regular

A

NORMAL / EUPNEA

51
Q

TYPES OF RESPIRATIONS
● Absence of respiration

A

APNEA

52
Q

TYPES OF RESPIRATIONS
● Slow, shallow respiration

A

BRADYPNEA

53
Q

TYPES OF RESPIRATIONS
● More than 20 cpm and regular

A

TACHYPNEA

54
Q

TYPES OF RESPIRATIONS
● Increased rate and depth

A

HYPERVENTILATION

55
Q

TYPES OF RESPIRATIONS
● Decreased rate and depth

A

HYPOVENTILATION

56
Q

TYPES OF RESPIRATIONS
● Periods of apnea and hyperventilation

A

CHEYNE - STROKES

57
Q

TYPES OF RESPIRATIONS
● Very deep with normal bleeding

A

KUSSMAUL

58
Q

★ (1) __________ – occurs with patients with diabetes
○ (2) __________ - excess Ketones

A

(1) Kussmaul
(2) DKa (Diabetic Ketoacidosis)

59
Q

Systolic BP (SBP): <120
AND
Diastolic BP (DBP): <80

A

NORMAL BP

60
Q

Systolic BP (SBP): 120-129
AND
Diastolic BP (DBP): <80

A

PREHYPERTENSION

61
Q

Systolic BP (SBP): 130-139
OR
Diastolic BP (DBP): 80-89

A

PREHYPERTENSION

62
Q

Systolic BP (SBP): 140-159
OR
Diastolic BP (DBP): 90-99

A

STAGE 1 HYPERTENSION

63
Q

Systolic BP (SBP): >=160
OR
Diastolic BP (DBP): >=100

A

STAGE 2 HYPERTENSION

64
Q

● An unpleasant sensory and emotional experience, which is primarily associated with tissue damage or describes it in terms of such damage, or both.
o Pain comes from the greek word poinē meaning “Penalty”

A

PAIN ASSESSMENT

65
Q

BROAD CLASSIFICATION OF PAIN
● Acute
● Chronic pain

A

TEMPORAL

66
Q

BROAD CLASSIFICATION OF PAIN
● Malignant
● Nonmalignant

A

ETIOLOGIC

67
Q

BROAD CLASSIFICATION OF PAIN
● Nociceptive
● Neuropathic
● Psychogenic

A

PHYSIOLOGICAL

68
Q

A type of pain caused by damage to body tissue; receptors that transmit pain are called nociceptors.

A

NOCICEPTIVE

69
Q

Type of pain which is the result of current or past damage to the peripheral or central nervous system and may not have stimulus; tissue or nerve damage; long lasting, unpleasant. Burning dull, or aching.

A

NEUROPATHIC

70
Q

A pain disorder associated with psychological factors

A

PSYCHOGENIC

71
Q

PAIN ASSESSMENT
(1) __________ – “Are you hurting today?”
(2) __________ - “What words describe your pain?” (Sharp, burning, tingling…)
(3) __________ - “Where is your pain? Does it shoot or radiate anywhere else?”
(4) __________ - “Give me a number between 0-10 for your pain.”
(5) __________ - “How long have you had this pain? How long does it last when the pain comes?”

A

(1) P – Presence of pain
(2) Q – Quality
(3) R – Radiation/Location
(4) S – Severity
(5) T – Timing

72
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Moaning, Groaning, Crying, Yelling, Sighing, Blowing

A

Vocalization

73
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Grimacing, Fearful, Sad, Withdrawn, Tense, Frowning

A

Facial Expression

74
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Bracing, Guarding, Walking, Sitting, Stiff Gait/Movements

A

Body Position

75
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Rocking, Pulling, Rubbing, Sleeping, Hyper-alert, Responsive, Fidgeting, Distracted, Withdrawn

A

Activity Patterns

76
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Immobilization, Purposeless movement, Protective movement, Rhythmic Movement

A

Body Movement

77
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Angry, Sad, Withdrawn, Aggressive, Passive, Irritable

A

Mood Changes

78
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Less able to assist in care, Actively resists care

A

Resistance to Care

79
Q

NONVERBAL PAIN DESCRIPTION GUIDE
Diminished, Loss of interest in food

A

Appetite

80
Q

● Does anyone in your family experience pain?
● How does pain affect your family?

A

FAMILY HISTORY

81
Q

● What are your concerns about pain?
● How does your pain interfere with the following?
o General activity
o Mood/ emotions
o Concentration
o Physical Ability
o Work
o Relations with other people o Sleep
o Appetite
o Enjoyment of life

A

LIFESTYLE AND HEALTH PRACTICES

82
Q

● Client is seated in a quiet, comfortable, and calm environment.
● Explain to the client that the interview will entail questions to clarify the picture of the pain experienced.

A

PREPARING THE CLIENT

83
Q

KEY POINTS TO REMEMBER DURING A PHYSICAL EXAMINATION
● Choose an assessment tool that is reliable and valid to the client’s __________.

A

culture

84
Q
  • Suitable tool for those aged 3 years and over to determine pain scale, but may be unsuitable for those with severe cognitive impairment.
A

WONG-BAKER FACES PAIN RATING SCALE

85
Q

PAIN ASSESSMENT TOOL FOR 0-1 Y.O.

A

NEONATAL/INFANT PAIN SCALE (NIPS)

86
Q

PAIN ASSESSMENT TOOL FOR 1-3 Y.O.

A

FACE, LEGS, ACTIVITY, CRY, CONSOLABILITY (FLACC)

87
Q

PAIN ASSESSMENT TOOL FOR AGES 3 AND ABOVE

A

WONG AND BAKER FACES PAIN RATING SCALE

88
Q

PAIN ASSESSMENT TOOL FOR ADULTS

A

NUMERIC RATING SCALE
VISUAL ANALOGUE SCALE

89
Q

PAIN ASSESSMENT TOOL FOR NON-VERBAL ADULT

A

CRITICAL CARE PAIN OBSERVATION TOOL (CCPOT)
ASSESSMENT IN ADVANCED DEMENTIA (PAINAD)

90
Q

TRUE OR FALSE:
ASSESSING PAIN
● Understand that different cultures express pain differently and maintain different thresholds and expectations.

A

TRUE

91
Q

TRUE OR FALSE
8 BEHAVIORAL INDICATORS OF DISCOMFORT
1. Noisy breathing
2. Negative vocalization
3. Sad facial expression
4. Frightened facial expression
5. Frown
6. Tense body language
7. Fidgeting
8. Physical Violence

A

FALSE
There are only 7 BEHAVIORAL INDICATORS OF DISCOMFORT; physical violence is NOT INCLUDED

92
Q

● Received patient leaning on her daughter
● With difficulty of seating down on the chair
● Posture is not upright
● Unable to concentrate and continue an idea
● (+) facial grimace
● (+) frowning
● (+) irritability
● (+) guarding behavior
● With vital signs of:
o PR=108bpm
o RR=22cpm
o BP = 140/90 mmHg

A

SAMPLE OBJECTIVE DATA

93
Q

● Readiness for enhanced spiritual well-being related to coping with prolonged physical pain
● Readiness for enhanced comfort level
● Health-Seeking behaviors related to desire and request to learn more about health promotion

A

WELLNESS DIAGNOSIS

94
Q

RISK DIAGNOSIS
● Risk for __________ related to chronic pain and immobility

A

activity intolerance

95
Q

RISK DIAGNOSIS
● Risk for __________ related to non-steroidal anti-inflammatory agents or opiates intake or poor eating habits

A

constipation

96
Q

RISK DIAGNOSIS
● Risk for __________ related to anxiety, pain, life change, and chronic illness

A

spiritual distress

97
Q

RISK DIAGNOSIS
● Risk for __________, related to chronic pain, healthcare environment, pain treatment-related regimen

A

powerlessness

98
Q

RISK DIAGNOSIS
● Risk for __________ related to depression, suicidal tendencies, developmental crisis, lack of support systems, loss of significant others, poor coping mechanisms and behaviors

A

self-directed violence

99
Q

ACTUAL DIAGNOSIS
● __________ related to injury agents (biological, chemical, physical, or psychological)

A

Acute pain

100
Q

ACTUAL DIAGNOSIS
● __________ related to chronic inflammatory process of rheumatoid arthritis

A

Chronic pain

101
Q

ACTUAL DIAGNOSIS
● __________ related to abdominal pain and anxiety

A

Ineffective breathing pattern

102
Q

ACTUAL DIAGNOSIS
● __________ related to pain and anxiety

A

Disturbed energy field

103
Q

ACTUAL DIAGNOSIS
● __________ related to stress of handling chronic pain

A

Fatigue

104
Q

ACTUAL DIAGNOSIS
● Impaired ___________ related to chronic pain

A

physical mobility

105
Q

ACTUAL DIAGNOSIS
● ___________ self-care deficit related to severe pain (specify)

A

Bathing/Hygiene self-care deficit

106
Q

ACTUAL DIAGNOSIS
● ____________ related to hearing loss

A

Impaired verbal communication

107
Q

ACTUAL DIAGNOSIS
● ___________ - impaired verbal communication related to inability to clearly express self or understand others

A

Aphasia

108
Q

ACTUAL DIAGNOSIS
● _______________ related to aphasia, a psychological impairment, or organic brain disorder

A

Impaired verbal communication

109
Q

ACTUAL DIAGNOSIS
● __________ self-care deficit related to impaired upper extremity mobility and lack of resources

A

Dressing/Grooming self-care deficit

110
Q

ACTUAL DIAGNOSIS
● ___________ self-care deficit related to inability to wash body parts or inability to obtain water

A

Bathing/Hygiene self-care deficit

111
Q

ACTUAL DIAGNOSIS
● __________ related to alcohol or drug abuse, psychotic disorder, or organic brain dysfunction.

A

Disturbed thought processes

112
Q

● Posture is erect and gait is smooth
● Neatly dressed in light weight clothes appropriate for the summer season.
● Clean nails, well-groomed.
● Well-developed body built for age with even distribution of fat and firm muscle
● Client is alert, friendly, cooperative, and answers questions with good eye contact
● With height of 5’4” and weight of 60 kilos
● With vital signs of
o T = 37.2 ̊C
o PR = 84 bpm, regular, bilateral, equally strong and resilient
o RR = 16 cpm, regular, equal bilateral chest expansion
o BP = 120/80 mmHg, bilateral arms

A

Sample of Objective Data

[1] NUR112 | HEALTH ASSESSMENT (11 decks)

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