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Nursing 134 fundamentals > Health Assesment > Flashcards

Health Assesment Flashcards

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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
Q

2+ edema

A

Moderate pitting Adema, 4 mm depression that disappears in 10 to 15 seconds

26
Q

3+ edema

A

Moderately severe pitting Adema, 6 mm depression that may last more than a minute

27
Q

4+ edema

A

Severe pitting Adema, 8 mm depression that can last more than two minutes

28
Q

6 P’s

A

Pulse, perfusion, paresthesia, paralysis, pressure, pain

29
Q

GLASGOW COMA SCALE

eye response

A

4) spontaneous
3) to speech
2) to pain
1) no response

30
Q

GLASGOW COMA SCALE

Verbal

A

5) oriented to time place and person
4) confusion
3) inappropriate words
2) incomprehensible sounds
1) no response

31
Q

GLASGOW COMA SCALE

Motor

A

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
Q

Braden scale

A

10-12 high risk
13-14 moderate risk
15-18 low risk
19-23 not a risk

33
Q

Supine

A

Laying straight down on back

34
Q

Prone

A

Laying straight down on stomach

35
Q

Lithotomy

A

On back with legs like a table top

36
Q

Sims posterior view

A

On stomach and knee out

37
Q

Knee-chest

A

Bent over

38
Q

Dorsal recumbent

A

position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward

39
Q

Petechiate

A

Small hemorrhagic spots caused by capillary bleeding

40
Q

Erythema

A

superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries

41
Q

Pallor

A

unhealthy pale appearance

42
Q

Ecchymosis

A

discoloration of the skin resulting from bleeding underneath, typically caused by bruising

43
Q

Jaundice

A

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
Q

Cyanosis

A

bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

45
Q

Level of consciousness

A

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
Q

Bronchial breathing sounds

A

Heard over trachea
Loud, high pitched
Expiration longer than inspiration

47
Q

Bronchovesicular breathing sounds

A

Heard in 1st and 2nd intercostal space
Medium pitch, blowing sounds
Equal inspiration and expiration

48
Q

Vesicular breathing sounds

A

Most of the lung
Soft, low pitched breezy sounds
Inspiration longer than expiration

49
Q

Wheezing

A

High pitched, continuous
Inspiration and expiration
Narrow airway

50
Q

Rhohchi

A

Course “snoring quality”
Low pitched continuous
Inspiration and expiration
Air passing through fluid

51
Q

Crackles

A

Bubbling, cracking, popping
Low pitched, discontinuous
Passing through fluid

52
Q

Spridor

A

Harsh, loud, high pitched

Presence of foreign body

53
Q

Friction rub

A

Rubbing, grating

Inflamed pleura

54
Q

APE to Man

A

Aortic, pulmonic, Erbs point, tricuspid, mitral

55
Q

S1

A

Closure of tricuspid and mitral
Fourth intercostal space
Ventricle contraction

56
Q

S2

A

occurs at the termination of systole in corresponds to the onset of ventricular diastole

57
Q

Lordosis

A

Increased/exaggerated lumbar curvature

58
Q

Kyphosis

A

Increase/exaggerated the thoracic spinal curvature

59
Q

Scoliosis

A

Increase Lateral curvature of the spine

Nursing 134 fundamentals (31 decks)

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