Health Assessment Flashcards
What is the purpose of doing a health assessment?
To establish nurse/pt relationship, gather data about pt general health, identify strengths, identify actual and potential problems, changes in status, and establishing base
What are the two components of a health assessment?
health history (subjective), and physical assessment (objective)
What factors do you assess during health assessment?
biographical data, reason for seeking health care, history of present illness, past medical history, lifestyle, expectations of hospital stay, elicit patient values and preferences
Ophthalmoscope
visualizes the interior structures of the eye
Otoscope
examines the external ear canal and tympanic membrane
Snellen Chart
screens for distant vision
Nasal speculum
visualizes the lower and middle turbinates of the nose
Vaginal Speculum
examines the vaginal canal and cervix
Tuning fork
tests auditory function and vibratory perception
Percussion hammer
tests deep tendon reflexes and determines tissue density
Sitting
used to take vitals
Supine
allows relaxation of abdominal muscles
Dorsal recumbent
used for patients having difficulty maintaining supine position
Sims
assessment of rectum or vagina
Prone
assessment of hip joint and posterior thorax
Lithotomy
assessment of female rectum and vagina; used for brief period only
Knee-chest
assessment of rectal area; used for brief period only
Standing
assessment of posture, gait, and balance
Auscultation
listening for sounds within the body; assess the four characteristics of sound, that is, pitch loudness, quality, and duration
Inspection
purposeful and systematic observation; assess size, color, shape, position and symmetry
Palpation
method of examining by feeling a part of the body with the fingers or hand; assess temperature, turgor, texture, moisture, tenderness, and shape
Percussion
act of striking one object against the other for the purpose of producing sound; assess location, shape, size, and density of tissue
What systems are involved with head-toe-assessment?
Neurologic, pulmonary, cardio, genitourinary, gastrointestinal, musculoskeletal, integumentary
Neurologic (head to toe assessment)
Sensory/Perceptual
Pulmonary (head to toe assessment)
oxygenation
Cardiovascular (head to toe assessment)
O2 transport
Genitourinary (head to toe assessment)
elimination
Gastrointestinal (head to toe assessment)
elimination
Musculoskeletal (head to toe assessment)
mobility
Integumentary (head to toe assessment)
skin integrity
Wheezes
High pitched continuous sounds originating in small air passages that are narrowed by secretions, swelling or tumors; may be inspiratory or expiratory but louder in expiration (sounds like whistle blowing)
Pleural Friction Rub
Grating or rubbing sound caused by inflamed pleura rubbing against the chest wall (sound like rubbing)
Rhonchi
(Sonorous rales congested) = low pitched continuous rumbling, snoring sound produced by narrowing of the LARGER airways due to thick secretions or muscle spasms. May be heard on inspiration and expiration usually expirations. Often clears or changes with coughing; air passing through or around sections
Stridor (crowing)
Harsh, loud, high pitched auscultation on inspiration; narrowing of the upper airways (larynx or trachea); presence of foreign body in airway
Entropion
Eyelid rolled inward against eyeball typically caused by muscle spasm
Ectropion
Lower lid sags away from eye exposing inner eye surface
Convergence test
Ask client to follow finger as she slowly moved it towards client nose
Extraocular movement
Following pencil side to side
Oh, Oh, Oh, To Touch And Feel Virgin Girls Vaginas, AH
Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal
(I) Olfactory
Sensory; sense of smell
(II) Optic
Sensory; sense of vision
(III) Oculomotor
Motor; pupil constriction, raise eyelids
(IV) Trochlear
Motor/proprioceptor; downward, inward eye movement
(V) Trigeminal
Motor; jaw movements like chewing and mastication
Sensory; sensation of the face and neck
(VI) Abducens
Motor; lateral movement of the eyes
(VII) Facial
Motor; muscles of the face
Sensory; sense of taste on the anterior two thirds of the tongue
(VIII) Vestibulocochlear
Sensory; sense of hearing
(IX) Glossopharyngeal
Motor; pharyngeal movement and swallowing
Sensory; sense of taste on the posterior one third of the tongue
(X) Vagus
Motor/sensory; swallowing and speaking
(XI) Accesory
Motor/sensory; movement of shoulder muscle
(XII) Hypoglossal
Motor; movement of the tongue; strength of tongue
Crackles
Bubbling or popping type sounds that are usually heard during inspiration (air moving through fluid in the lungs)
Bruit
occur when artsy is partially obstructed or distended, which prevent blood flow from moving straight through the vessel
