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Nursing 134 fundamentals > Health Assesment > Flashcards

Health Assesment Flashcards

1
Q

What is a health assessment

A
  • first step in nursing process
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2
Q

What does a health assessment include

A
  • health history

- physical assignment

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3
Q

Health history includes

A

-health status including any problems

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4
Q

In a physical assessment what techniques do you use

A

Collect objective data about patient using your senses including

  • inspection
  • palpation
  • percussion
  • auscultation
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5
Q

Macule

A

Primary lesion less than 1 cm flat nonpalpable change in skin color
Ex: petechia or freakle

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6
Q

Patch

A

Primary skin lesion greater than 1 cm flat nonpalpable change in skin color
Ex: vitiligo

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7
Q

Papule

A

Primary skin lesion mass less than .5 cm palpable and elevated
Ex: mole

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8
Q

Plaque

A

Primary skin lesion mass greater than .5 cm palpable and elevated

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9
Q

Nodule

A

Primary lesion mass .5 cm to 2 cm palpable elevated firmer than papule
Ex: wart

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10
Q

Tumor

A

Primary skin lesion mass greater than 2 cm palpable and elevated

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11
Q

Wheal

A

Primary skin lesion irregular superficial area of localized skin Edema
Ex: hives, mosquito bites

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12
Q

Vesicles

A

Primary lesion less than .5 cm filled with serious fluid

Ex: herpes simplex

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13
Q

Bulla

A

Primary skin lesion greater than .5 cm filled with serious fluid
Ex: second-degree burn

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14
Q

Pustule

A

Primary skin lesion filled with pus

Ex: acne or impetigo

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15
Q

Scales

A

Secondary lesion flakes of skin layer

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16
Q

Crust

A

Secondary skin lesion dried exudate skin

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17
Q

Fissure

A

Secondary skin lesion cracks in the skin example athletes foot

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18
Q

Ulcer

A

Secondary skin lesion area of destruction of entire epidermidis, example pressure sore

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19
Q

Scar

A

Secondary lesion, surgical healing, excess collagen production after injury

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20
Q

Atrophy

A

Secondary skin lesion, loss of some portion of the skin

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21
Q

Keloid

A

Secondary skin lesion, racecar after injury has healed

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22
Q

Erosion

A

Secondary lesion, lots of part or all of epidermidis that does not extend into the dermis

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23
Q

Lichenification

A

Secondary skin lesion, skin becomes thick and leathery

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24
Q

1+ edema

A

Mild pitting edema, 2 mm depression that disappears rapidly

25
2+ edema
Moderate pitting Adema, 4 mm depression that disappears in 10 to 15 seconds
26
3+ edema
Moderately severe pitting Adema, 6 mm depression that may last more than a minute
27
4+ edema
Severe pitting Adema, 8 mm depression that can last more than two minutes
28
6 P’s
Pulse, perfusion, paresthesia, paralysis, pressure, pain
29
GLASGOW COMA SCALE | eye response
4) spontaneous 3) to speech 2) to pain 1) no response
30
GLASGOW COMA SCALE | Verbal
5) oriented to time place and person 4) confusion 3) inappropriate words 2) incomprehensible sounds 1) no response
31
GLASGOW COMA SCALE | Motor
6) obeys command 5) moves to localized pain 4) flex ion to withdraw from pain 3) abnormal flexion 2) abnormal extension 1) no response
32
Braden scale
10-12 high risk 13-14 moderate risk 15-18 low risk 19-23 not a risk
33
Supine
Laying straight down on back
34
Prone
Laying straight down on stomach
35
Lithotomy
On back with legs like a table top
36
Sims posterior view
On stomach and knee out
37
Knee-chest
Bent over
38
Dorsal recumbent
position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward
39
Petechiate
Small hemorrhagic spots caused by capillary bleeding
40
Erythema
superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries
41
Pallor
unhealthy pale appearance
42
Ecchymosis
discoloration of the skin resulting from bleeding underneath, typically caused by bruising
43
Jaundice
yellowing of the skin or whites of the eyes, arising from excess of the pigment bilirubin and typically caused by obstruction of the bile duct, by liver disease, or by excessive breakdown of red blood cells.
44
Cyanosis
bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
45
Level of consciousness
Alert=attend to environment, responds appropriately Lethargic= drowsy, needs gentle verbal/touch stimulation to initiate response Obtunded/stuporous= responds slowly to external stimulation, Must Be Shaken or shouted at, response to painful stimuli Comatose= can’t be aroused even with painful stimuli, gag reflex may be present
46
Bronchial breathing sounds
Heard over trachea Loud, high pitched Expiration longer than inspiration
47
Bronchovesicular breathing sounds
Heard in 1st and 2nd intercostal space Medium pitch, blowing sounds Equal inspiration and expiration
48
Vesicular breathing sounds
Most of the lung Soft, low pitched breezy sounds Inspiration longer than expiration
49
Wheezing
High pitched, continuous Inspiration and expiration Narrow airway
50
Rhohchi
Course “snoring quality” Low pitched continuous Inspiration and expiration Air passing through fluid
51
Crackles
Bubbling, cracking, popping Low pitched, discontinuous Passing through fluid
52
Spridor
Harsh, loud, high pitched | Presence of foreign body
53
Friction rub
Rubbing, grating | Inflamed pleura
54
APE to Man
Aortic, pulmonic, Erbs point, tricuspid, mitral
55
S1
Closure of tricuspid and mitral Fourth intercostal space Ventricle contraction
56
S2
occurs at the termination of systole in corresponds to the onset of ventricular diastole
57
Lordosis
Increased/exaggerated lumbar curvature
58
Kyphosis
Increase/exaggerated the thoracic spinal curvature
59
Scoliosis
Increase Lateral curvature of the spine

Nursing 134 fundamentals (31 decks)

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