Health Assesment Flashcards
What is a health assessment
- first step in nursing process
What does a health assessment include
- health history
- physical assignment
Health history includes
-health status including any problems
In a physical assessment what techniques do you use
Collect objective data about patient using your senses including
- inspection
- palpation
- percussion
- auscultation
Macule
Primary lesion less than 1 cm flat nonpalpable change in skin color
Ex: petechia or freakle
Patch
Primary skin lesion greater than 1 cm flat nonpalpable change in skin color
Ex: vitiligo
Papule
Primary skin lesion mass less than .5 cm palpable and elevated
Ex: mole
Plaque
Primary skin lesion mass greater than .5 cm palpable and elevated
Nodule
Primary lesion mass .5 cm to 2 cm palpable elevated firmer than papule
Ex: wart
Tumor
Primary skin lesion mass greater than 2 cm palpable and elevated
Wheal
Primary skin lesion irregular superficial area of localized skin Edema
Ex: hives, mosquito bites
Vesicles
Primary lesion less than .5 cm filled with serious fluid
Ex: herpes simplex
Bulla
Primary skin lesion greater than .5 cm filled with serious fluid
Ex: second-degree burn
Pustule
Primary skin lesion filled with pus
Ex: acne or impetigo
Scales
Secondary lesion flakes of skin layer
Crust
Secondary skin lesion dried exudate skin
Fissure
Secondary skin lesion cracks in the skin example athletes foot
Ulcer
Secondary skin lesion area of destruction of entire epidermidis, example pressure sore
Scar
Secondary lesion, surgical healing, excess collagen production after injury
Atrophy
Secondary skin lesion, loss of some portion of the skin
Keloid
Secondary skin lesion, racecar after injury has healed
Erosion
Secondary lesion, lots of part or all of epidermidis that does not extend into the dermis
Lichenification
Secondary skin lesion, skin becomes thick and leathery
1+ edema
Mild pitting edema, 2 mm depression that disappears rapidly
2+ edema
Moderate pitting Adema, 4 mm depression that disappears in 10 to 15 seconds
3+ edema
Moderately severe pitting Adema, 6 mm depression that may last more than a minute
4+ edema
Severe pitting Adema, 8 mm depression that can last more than two minutes
6 P’s
Pulse, perfusion, paresthesia, paralysis, pressure, pain
GLASGOW COMA SCALE
eye response
4) spontaneous
3) to speech
2) to pain
1) no response
GLASGOW COMA SCALE
Verbal
5) oriented to time place and person
4) confusion
3) inappropriate words
2) incomprehensible sounds
1) no response
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
Braden scale
10-12 high risk
13-14 moderate risk
15-18 low risk
19-23 not a risk
Supine
Laying straight down on back
Prone
Laying straight down on stomach
Lithotomy
On back with legs like a table top
Sims posterior view
On stomach and knee out
Knee-chest
Bent over
Dorsal recumbent
position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward
Petechiate
Small hemorrhagic spots caused by capillary bleeding
Erythema
superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries
Pallor
unhealthy pale appearance
Ecchymosis
discoloration of the skin resulting from bleeding underneath, typically caused by bruising
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.
Cyanosis
bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
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
Bronchial breathing sounds
Heard over trachea
Loud, high pitched
Expiration longer than inspiration
Bronchovesicular breathing sounds
Heard in 1st and 2nd intercostal space
Medium pitch, blowing sounds
Equal inspiration and expiration
Vesicular breathing sounds
Most of the lung
Soft, low pitched breezy sounds
Inspiration longer than expiration
Wheezing
High pitched, continuous
Inspiration and expiration
Narrow airway
Rhohchi
Course “snoring quality”
Low pitched continuous
Inspiration and expiration
Air passing through fluid
Crackles
Bubbling, cracking, popping
Low pitched, discontinuous
Passing through fluid
Spridor
Harsh, loud, high pitched
Presence of foreign body
Friction rub
Rubbing, grating
Inflamed pleura
APE to Man
Aortic, pulmonic, Erbs point, tricuspid, mitral
S1
Closure of tricuspid and mitral
Fourth intercostal space
Ventricle contraction
S2
occurs at the termination of systole in corresponds to the onset of ventricular diastole
Lordosis
Increased/exaggerated lumbar curvature
Kyphosis
Increase/exaggerated the thoracic spinal curvature
Scoliosis
Increase Lateral curvature of the spine
