HA LEC Flashcards
Are signs or overt data.Detectable or can be measured or tested. Can be seen, heard, felt, or smelled, and are obtained by observation or Physical Examination (PE).
Objective Data
Example of Objective Data
Body temperature
Blood pressure
Skin discoloration
Heartbeat
Abdominal tenderness
Acetone-like odor
A complete health assessment may be conducted starting at the head and proceeding in a systematic manner downward (head-to-toe assessment. - Cephalo-caudal.
Physical Health Assessment (Cephalo Caudal)
4 primary techniques are used in the Physical Examination
- Inspection
- Palpation
- Percussion
- Auscultation
What is inspection?Give example.
Is the visual examination, which is assessed by using the sense of sight.
General Appearance:
- Situation: A patient arrives in the emergency room after a motor vehicle accident.
- Inspection: The nurse observes the patient’s overall appearance – pale skin, labored breathing, obvious injuries (lacerations, deformities), and anxious demeanor. This initial visual assessment helps prioritize care and identify immediate threats.
What is Palpation? Give examples.
Is the examination of the body using the sense of touch. The pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination. Ex. Radial pulse and Palpating using hands
done with two hands (bimanually) or one hand. In deep bimanual palpation, the nurse extends the dominant hand as for light palpation, then places the finger pads of the nondominant hand on the dorsal surface
Deep Palpation
the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt.
Percussion
the nurse strikes the area to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger. 2,3,4 finger pads, movement from the wrist
Direct Percussion
The most common method of percussion(using pleximeter and pleexor)
Help locate organ borders if an organ is solid or filled with fluid or gas
Indirect Percussion
The long, low hallow sound heard over an intercostal space lying above healthy lung tissue
Resonance
The loud, high pitched, drumlike soubd heard over a gastric air bubble gas filled bowel
Tympany
The soft, high pitched thudding sound normally, such as liver and heart
Dullness
A long loud, low pitched sound
A classic sign of lung hyperinflation which occurs in emphysema
Hyperresonance
Similar to dull sound
May be heard ove pleural fluid
Thickening
Flatness
Percussion sounds
Flatness-soft, high
Dullness-thudlike
Resonance-loud, low
Hyperresonance-very loud, very low
Tympany-loud, high
What is auscultation?
Listening to sound produced by the body
Such as heart, blood vessels, lungs, abdomen
Diaphragm?
Bell?
High picth sounds
Low pitch sounds
4 characteristics of sound:
Pitch-(high and low)
Loudness-(soft to loud)
Quality(gurgling or swishing)
Duration(short, medium, long)
What is primary?
Primary is the client.
Secondary?
Family support or members
What is EXAMINING(PE)
Is a systematic data collection method that uses observation and major method used in Physical Health Assessment
General Survery
Exam begins the minute you first see the patient and continues throughout patient interaction
These are the assessment
-Observe for signs of distress in posture, or facial expression
-Observe body build, height and weight in relation to clients age
-Observe client posture and gait, standing sitting and walking
-Observe client’s overall hygiene and grooming
-Note body and breath odor
Assessmenf of general appearance and mental status is not______?
Delegated
Report significant deviations from expected or normal findings to the
Primary care provider
To resolve a client complain or problem before completing the examination
-A brief review of essential functioning of various body parts or system
Screening Examination(Review of System)
Ulnar side of the hand are used for?
Vibrations
Helps discrimate sign, texture, or the position?
Fingertips
Back lying position with knees flexed and hips externally rotated; small pillow under the head
Dorsal Recumbent
Back lying position with legs extended with or without pillow under the head
Supine(horizontal recumbent)
A seated, position, baci unsupported and legs hanging freely
Sitting
Back lying position with feet supported in stirrups; the hips should be in line with the edge
Lithotomy
Side lying position with low ermost arm behind the body, uppermostbleg flexed at hip and knee
Sim’s position
Lies on abdomen with head turned to side
Prone
Made of paper, cloth, or bed linen.
Provide a degree of privacy
Drapes
To assist viewing of the pharanyx to determine reactions pupils of the eye
Flashlight or penlight
A lighted instrument to visualize the interior of the eye
Ophthalmoscope
Attacted to the otoscope to inspect the nasal cavities
Nasal speculum
A lighted instrument to visualize the eardrum and external auditory canal
Otoscope
An instrument with a rubber head to test reflexes
Reflex Hammer
A two pronged metal instrument used to test hearing acuity and vibratory sense
Tuning fork
To obtain specimens
Cotton applicators
To protect the nurse
Gloves
To depress the tongue during assessment of the mouth and orapharynx
Tongue depressors
Tools that provide information about clients
Laboratory Test
Basic screening as part of wellness check
-confirm a diagnosis
Tests
A capillary blood specimen is taken to measure the current blood glocuse level
It is used for the care of people with diabetes, as monitoring tools
Blood Tests(CBG)
Is the act of “double checking”or verfying data to confirm that is accurate or factual
Validation
Are subjective or objective data that can be directly observed by the nurse.
Cues
Are the nurses interpretation or conclusions made based on the cues
Inferences
Not all data requires?
Validation
Where nurse records client data and data are recorded in a factual manner and not interpreted by the nurse
To increase accuracy, the nurse records subjective data in the client’s own words using quotation marks
Restating increase changing the original meaning.
Documentation
Assessment of general appearance and mental status is not delegated
Assess before, during, after
General Survey
The correspondence (equal in size, form, and arrangement of part on both sides
Symmetry
Solely on one side of the body
Asymmetry
The outermost layer of skin; it provides a waterproof barrier and protects against pathogens.
Epidermis
The layer of skin beneath the epidermis; it contains blood vessels, nerves, hair follicles, and sweat glands.
Dermis
The deepest layer of skin; it consists of fatty tissue, collagen, and fibroblasts.
Subcutaneous Tissue
Use sense of smell to detect unsual skin odors to poor hygiene
Inspection and palpation
Excessive respiration
Hyperhidrosis
Foul smelling perspiration
Bromhidrosis
An area of tissue that has been damaged through injury or disease
Lesions
Those that appear initially in response to some change in external or internal environment
Primary Skin Lesions
Those that do not appear initiallt but result from modifications such as chronicity, trauma, or infection
Secondary Skin Lesions
Forms when a blow breaks blood vessels near skin’s surface
Bruising
Skin redness, warmth, seen in inflammation
Erythema
Chronic skin disease characterized by portions of the skin losing their pigment. It occurs when skin pigment cells die
Vitiligo
Loss of color(pale to ashen without underlying pink)
Pallor
Skin appeared to be blue tinged
Cyanosis
Yellow skin tones, from pale to pumpkin
Jaundice
Presence of excess interstitial fluid
Edema
The escape of blood into the tissues from ruptured blood vessels marked by a livjd black and blue or purple spot or area
Inspect vascularity of the skin
Round spots on the skin as a result of bleeding
Bleeding causes the____to appear red brown or purple
Commonly appear in clusters and may look like a rash.usually flat to toucu, don’t lose color when press
Petechiae
A superficial growth or patch on the skin that differs from the surrounding area is called
skin lesion
A long term skin disease that occuts when hair follicles become clogged with dead skin cells and oil from the skin
Characterized by areas of blackheads
Acne Vulgaris
Are 1mm to 1cm (0.04 to 0.4 in.) in size and circumscribed, flat, non palpable
Freckles
Flat moles
Measles
Petechiae
Patches-larger than 1cm(0.4 in.) and may have an irregular shape
Macule
A solid, raised lesion less than 1cm diameter.can be rough in texture and red, pink, brown in color
Wart
Insect bite
Acne
Pimples
Elevated moles
Papule
Raised, defined, any color greater than 1cm diameter
-psoriasis
Plaque
A reddened, localized collection of edema fluid; irregular in shape. Size varies
Urticaria(hives)
Mosquito bites
Wheal
A solid, elevated lesion, hard lump of matter that extends deeper into the dermis has circumscribed border and are 0.5 to 2cm
-squamous cell carcinoma
Fibroma
Nodule
Are larger than 2cm and may have an irregular border
Malignant melanoma
Hemangioma
Tumor
Circumscribded, superficial skin elevations form by free fluid in a cavity
Vesicle
Bulla
Pustule
A circumscribed, round or oval, thin translucent mass filled with serous fluid or blood are less than 0m5 cm
-herpes simplex, early chicken pox, small burn blister
Vesicle
Are larger than 0.5 cm
Large blister
Second degree burn
Herpes simplex
Bulla
A raided lesion of any size (vesicle or bulla) filled with pus
Pustule
1-cm (0.4 in) or larger, elevated, encapsulated, fluid filled or semisolid mass arising from the subcatenous tissue or dermis
Cyst
