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Module 1 > Health Assesment > Flashcards

Health Assesment Flashcards

1
Q

Before you begin

A

Age group considerations
Organization of the assessment is a must if you go from dirty to clean always clean stethascope and wash hands

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2
Q

Neuro specific health assessment components

A

Level of consciousness and orientation
Pupil response and cardinal age
Smile and show teeth, raise eyebrows
Tongue to roof of the mouth out side to side
Shoulder strength with resistance
HGTW
FLEXION AND EXTENSION BUE AND BLE

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3
Q

Level of consciousness

A

Single most important part of the assessment
Clue to see of deteriorating condition
Alert, lethargic, obtunded, stuporous/ semi-comatose, comatose
Name and date of birth, where are you, and what brought you to the hospital

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4
Q

Alert

A

Attentive, follows commands, if asleep wakes promptly remains attentive

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5
Q

Lethargic

A

Drowsy slow to respond

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6
Q

Obtunded

A

Difficult to arouse needs constant stimulation

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7
Q

Stuporous/semicomatouse

A

Arouses only to vigorous stimuli like pain

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8
Q

Comatose

A

No response to verbal or nonverbal or noxious stimuli no movement except deep tendon reflex

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9
Q

Cranial nerves

A

12 pairs
Sensory motor or both
Not all of the cranial nerves are always tested
Listed in order of testing not numerical value

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10
Q

Testing cranial nerves iii IV AND VI

A

Pupil response with pen light to see pupils dialate
Use tip of pen and have patient follow with their eyes and with an H motion

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11
Q

Testing cranial nerve VII

A

Ask patient to smile and show teeth
Wrinkle forehead

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12
Q

Testing cranial number 12 `

A

Put tongue on the roof of mouth
Stick tongue out and move it from side to side

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13
Q

Testing cranial nerve XI

A

Place hands on shoulders and ask patient to shrug them up and down

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14
Q

Testing motor function

A

Hand grasp and toe wiggle
FLEXION and extension with resistance
All done bilaterally BUE BLE
Done to make sure everything is working properly

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15
Q

Respiratory components of assessment

A

Anterior and posterior lung sounds
Clubbing

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16
Q

Auscultation of the lungs

A

Vesicular
Bronchovesicular
Bronchial

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17
Q

Vesicular

A

Periphery of the lungs Soft and breezy sounds

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18
Q

Bronchovesicular

A

Closer to the sternum is like a blowing sounds

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19
Q

Bronchial

A

Over the trachea largest and loud and high pitched

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20
Q

Abnormal or adventitious sounds

A

Crackles or rales
Rhonchi
Wheezes
Pleural friction rub

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21
Q

Crackles or rales

A

Can be fine or coursed
Call them crackles because they sound like rice crisps
They are caused by fluid
Can be cleared with a cough

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22
Q

Rhonchi

A

Due to large secretions in the air way sounds like flapping
Can be cleared with a cough so the airway will be cleared

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23
Q

Wheezes

A

High pitched musical sounds so we can hear them over all of the lungs commonly heard in the exhale but in severe cases can be heard inhale
Can be caused by respiratory illness

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24
Q

Pleural friction rub

A

Sounds like stehascope rubbing against cloth
Why we use stethascope on skin
No fluid and something could be rubbing against tissue
It is very painful

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25
Q

Abnormal respiratory patterns

A

Bradypnea
Tachypnea
Apnea
Hyperpnea
Kussmauls
Cheyne strokes

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26
Q

Bradypnea

A

Slow breathing

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27
Q

Tachypnea

A

Breathing fast

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28
Q

Hyperpnea

A

Breathing more deeply and faster than usual

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29
Q

Kussmaul breathing

A

Fast and deep breaths that occur in response to metabolic acidosis

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30
Q

Cheyne-strokes

A

Breathing disorder characterized by cyclical episodes of apnea and hyperventilation

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31
Q

Pattern of auscultation

A

1 starting on the left

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32
Q

Clubbing of the nails

A

Can occur when the blood is consistently low oxygen in the blood. Also people who live in places with high elevations this can happen

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33
Q

Cardiac specific health assessment components

A

Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for Edema

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34
Q

Heart sounds

A

LUB S1
DUB S2

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35
Q

LUB

A

Systole or s1 and is the sounds associated with the mitral and tricuspid valves

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36
Q

DUB

A

S2 or diastole and is the sounds associated with the aortic and the pulmonic valves closing

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37
Q

Pauses between heart sounds

A

There are natural pauses between s1 and s2 but the pauses between s2 and s1 is longer

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38
Q

Location of heart sounds

A

Aortic
Pulmonic
Tricuspid
Mitral

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39
Q

Aortic

A

Right base and the second intercostal space to the right of the eternal border

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40
Q

Pulmonic

A

Left bases and second intercostal space to the left of the eternal border

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41
Q

Tricuspid

A

Left lateral sternal border and fifth intercostal space to the left of the sternal border

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42
Q

Mitral

A

Apex and midclavicular line at the fifth intercostal space

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43
Q

Pulses

A

Carotid
Brachial
Radial
Ulnar
Apical
Femoral
Popliteal
Dorsalis pedis

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44
Q

Assessment of pulses

A

Carotid
Radial
Apical
Dorsalis pedis

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45
Q

Carotid

A

One at a time bilaterally

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46
Q

Radial

A

Bilaterally at the same time

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47
Q

Apical

A

With a stethoscope for two beats

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48
Q

Dorsalis pedis

A

Bilaterally at the same time

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49
Q

Pulse points

A

0,1+,2+,3+,4+

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50
Q

0 pulse point

A

Absent non palpable

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51
Q

1+ pulse point

A

Diminished palpable very weak

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52
Q

2+ pulse point

A

Strong normal

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53
Q

3+ pulse point

A

Full increased

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54
Q

4+

A

Bounding can feel it very strongly

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55
Q

Doppler

A

Hand held device
Most often used for pedal pulses If we can not feel it by hand
If we use the Doppler make sure to document it every time

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56
Q

Assessment of extremities

A

Capillary refill
Edema

57
Q

Edema

A

Swelling in the extremities
Dependent and pitting edema

58
Q

Dependent edema

A

Most often on feet and ankles older adults and standing

59
Q

Pitting edema

A

Venous insufficiency or heart failure fluid tissues

60
Q

Musculoskeletal specific health assessment components

A

Neck ROM
BUE ROM
BLE ROM
HGTW
FLEXION AND EXTENSION BUE AND BLE

61
Q

RANGE OF MOTION ROM

A

Neck
Shoulders,upper arms and elbows
Upper arms and elbows
Wrist
Hips
Knees
Ankles

62
Q

NECK ROM

A

Move neck side to side
Chin to chest
Extension back

63
Q

Shoulders upper arms and elbows

A

Arms out to the side
Straight up
Touch down

64
Q

Wrist

A

Wrist circles

65
Q

Hips knees and ankles

A

Bilateral hip FLEXION out
Bend knees
Ankle circles

66
Q

Strength

A

Hand grip
Toe wiggle
FLEXION and extension of BBUE/BLE

67
Q

Integumentary specific health assessment

A

Hair and scalp
Inspect ears
Inspect nose
Mouth and throat
Inspect and palpate neck
Assess skin turbot
Inspect skin on back and bony prominences
Inspect skin of BUE AND BLE
Nails

68
Q

Assessment of skin

A

Inspect head to toe for
Hydration
The pasture
Color
Texture
Rashes
Lesions
Cracking

69
Q

Changes in skin color

A

Pallor
Erythema
Jaundice
Cyanosis

70
Q

Pallor

A

Pale or ashen gray

71
Q

Erythema

A

Redness r/t vasodilation

72
Q

Jaundice

A

Yellow impaired liver

73
Q

Cyanosis

A

Bluish, decreased circulation of oxygenation of blood

74
Q

Skin characteristics

A

Temp should be warm consistent with room temp
Moisture from diapers is or dry from dehydration
Texture can be dry and course (elbows/knees) or shiny with no hair (impaired peripheral circulation)
Turgor tests elasticity of the skin related to hydration

75
Q

Factors of effecting skin

A

Dampness
Dehydration
Nutrition circulation
Disease
Jaundice
Lifestyle

76
Q

Normal skin changes in older adults

A

Epidermis
Subcutaneous tissue
Collagen and elastin fibers
Hormones
Vascularity
Hair follicles
Melanocytes
Nails
Skin growths

77
Q

Epidermis

A

As we get older it becomes thinner translucent and older adults are more prone to skin tearing

78
Q

Subcutaneous tissue

A

This becomes thinner as well which is decreased protection which is why older adults get cold faster

79
Q

Collagen and elastin fibers

A

When we start losing collagen we get wrinkles and skin doesn’t return the way when it was pulled

80
Q

Hormones

A

Lack of hormones can lead to dry and thinning of the hair

81
Q

Vascularity

A

As we get older some of the smaller microcapillaries on the skin decrease on cooler areas on the skin

82
Q

Hair follicles

A

Slower growing over time

83
Q

Melanocytes

A

Gives our skin pigmentation so it decreases over time which causes pigment to become uneven and causes hair to turn gray

84
Q

Nails

A

Nails become thicker and softer or thick and hard

85
Q

Skin growths

A

Wartz or liver and age spots which should limit sun exposure

86
Q

Pitting edema

A

Caused by kidney failure
Leads to excess fluid collection in tissues

87
Q

Four point scale 1+

A

2mm to trace (rapid response)

88
Q

Four point scale 2+

A

4mm to mild 10-18 seconds

89
Q

Four point scale 3+

A

6mm to moderate 1-2 minutes

90
Q

Four point scale 4+

A

8mm to severe 2-5 minutes

91
Q

Assessment of bony prominence

A

Hips heels coccyx shoulders
Assess for skin integrity
Non blanching red spots

92
Q

Assessment of nails

A

Shape contour cleanliness
Nearly manicured

Should be transparent, smooth, rounded, convex, hygienic

93
Q

Assessment of hair

A

Terminal hair
Vellum hair
Quantity - alopecia hirutism
Distribution
Texture
Color
Parasites

94
Q

Terminal hair

A

Scalp, axillae, pubic, and beard

95
Q

Vellum hair

A

Soft tiny hairs covering body except on palms and soles (what makes humans to be considered mammals)

96
Q

Alopecia

A

Abnormal hair loss

97
Q

Hiritusm

A

Abnormal growth of hair on a persons face and body especially if a woman

98
Q

Assessment of ears

A

Symmetry, drainage, shape, hearing defects, lesions, redness, tenderness or odor

Could odor or if it is green it can indicate of a possible infection

99
Q

Assessment of the nose

A

Inspect nose for position, symmetry, color, swelling, deformities, discharge, flaring, latency and sinus tenderness

100
Q

Assessment of oral cavity and throat

A

Lips oral mucosa
Teeth
Gums/tongue
Breath order

Throat: lumps
Ulcers
Edema
White spots
Redness
Swallowing

101
Q

Assessment of neck

A

Contour and symmetry,
Midline trachea
Jugular vein

Palpate the neck for enlarged lymph nodes

102
Q

Elimination

A

Excretion of waste products from kidneys and intestines

103
Q

Defamation

A

Process of elimination of waste

104
Q

Feces

A

Semisolid mass of five, undirected food, inorganic matter

105
Q

Urinary elimination vocab

A

Incontinence
Void
Micturate
Dysuria
Hematuria
Nocturnal
Polyuria
Urinary frequency
Urinary urgency
Protienuria
Dribbling
Retention
Residual

106
Q

Incontinence

A

Inability to control urine or feces

107
Q

Void

A

To urinate

108
Q

Micturate

A

To urinate

109
Q

Dysuria

A

Painful or difficult urination

110
Q

Hematuria

A

Blood in the urine

111
Q

Nocturia

A

Frequent night urination

112
Q

Polyuria

A

Large amounts of urine

113
Q

Urinary frequency

114
Q

Urinary frequency

A

Voiding at frequent intervals
Holding it till a later time

115
Q

Urinary urgency

A

The need to void all at once
“I have to go and i have to go now”

116
Q

Protienuria

A

Protienuria in the urine

117
Q

Dribbling

A

Leakage of urine despite voluntary control of urination

118
Q

Retention

A

Accumulation of urine in bladder without the ability to completely empty

119
Q

Residual

A

Urine remaking post void >100ml
Anything that what we would consider that is left in the bladder and it is known through a bladder scan

120
Q

Structures of the gastrointestinal tract

A

Upper gastrointestinal tract
Small intestine
Large intestine
Rectum and anus
Mouth
pharynx
Stomach

121
Q

Small intestine

A

Folded, twisted and coupled tube from stomach to large intestine
1” in diameter and 20’ long
Most digestion and absorption takes place here
Chyme travels via peristalsis
3 segments duodenum, jejunum and ileum

122
Q

Chyme

A

Food mixed with stomach acids it is chyme once it leaves the stomach

123
Q

Large intestine

A

Aka colon
2.4” diameter and 5-6’ long
7 segments cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum and anus

124
Q

Organs of urinary elimination

A

Kidneys
Ureters
Bladder
Urethra

125
Q

Kidneys

A

Filter and regulate
Remove waste from blood to form urine

126
Q

Ureters

A

Transport urine from kidneys to bladder
Enter the bladder posteriorly and obliquely into the bladder to prevent reflux

127
Q

Bladder

A

Resvoir for urine until urge develops

128
Q

Urethra

A

Urine travels from bladder and exits through urethral meatus

129
Q

Kidneys

A

Bilateral posterior flanks
Size of fists
Primary regulators of fluid and acid base balance

130
Q

Kidneys

A

Nephron- functional unit of the kidney
Glomerulus
Bowman’s capsule
Proximal consulates tubule
Loop of henle
Distal tubule
Collecting duct

131
Q

Ureters

A

Tubule structures that enter the bladder
Urine traveling through the Exeter’s is typically sterile
Ureters enter bladder obliquely and posterior lay to prevent reflux
Obstructions cause peristaltic waves severe pain often referred to as renal colic

132
Q

Bladder

A

Hollow, distensible,muscular organ
In men- bladder lies against anterior walls of rectum
In women- bladder rest against anterior walls of uterus and vagina
When bladder is full it extends above symphysis pubis

133
Q

Normal bladder

A

500 ml but can extend to 1000 ml

134
Q

Urethra

A

Turbulent flow washes urethra free of bacteria
Descends through pelvic floor muscles can prevent flow of urine
In someone- urethra is short(1 1/2 to 2 1/2 in) leads to prevalence of infection
In men urethra is long (8 in) serves in both GU and reproductive system three sections- prostatic membranous, and penil

135
Q

Assessment of the abdomen

A

Look listen and feel
When you listen listen for digestion for 5-20 seconds
When you feel ask if any pain or tenderness and feel for masses
Ask “have you had a bowl movement today? How are your bowl movements and what are your urinary patterns?”

136
Q

Assessment of urethral meatus and perineal area

A

Inspect urethral or if ace for erythema, discharge swelling or odor
Signs of infection, inflammation or trauma
Perineal areas -color, condition, presence of urine or stool

137
Q

GI/GU components

A

Examination of abdomen- look listen and feel
Ask questions and habits
Examination of urethral meatus and perineal area

138
Q

Head to toe assessment

A

Created to move from head to toe
Be methodical
Be aware of clean to dirt and dirty to clean

Module 1 (18 decks)

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