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Fundamentals Of Nursing > Health Assessment > Flashcards

Health Assessment Flashcards

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1
Q

What is the purpose of doing a health assessment?

A

To establish nurse/pt relationship, gather data about pt general health, identify strengths, identify actual and potential problems, changes in status, and establishing base

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2
Q

What are the two components of a health assessment?

A

health history (subjective), and physical assessment (objective)

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3
Q

What factors do you assess during health assessment?

A

biographical data, reason for seeking health care, history of present illness, past medical history, lifestyle, expectations of hospital stay, elicit patient values and preferences

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4
Q

Ophthalmoscope

A

visualizes the interior structures of the eye

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5
Q

Otoscope

A

examines the external ear canal and tympanic membrane

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6
Q

Snellen Chart

A

screens for distant vision

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7
Q

Nasal speculum

A

visualizes the lower and middle turbinates of the nose

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8
Q

Vaginal Speculum

A

examines the vaginal canal and cervix

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9
Q

Tuning fork

A

tests auditory function and vibratory perception

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10
Q

Percussion hammer

A

tests deep tendon reflexes and determines tissue density

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11
Q

Sitting

A

used to take vitals

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12
Q

Supine

A

allows relaxation of abdominal muscles

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13
Q

Dorsal recumbent

A

used for patients having difficulty maintaining supine position

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14
Q

Sims

A

assessment of rectum or vagina

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15
Q

Prone

A

assessment of hip joint and posterior thorax

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16
Q

Lithotomy

A

assessment of female rectum and vagina; used for brief period only

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17
Q

Knee-chest

A

assessment of rectal area; used for brief period only

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18
Q

Standing

A

assessment of posture, gait, and balance

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19
Q

Auscultation

A

listening for sounds within the body; assess the four characteristics of sound, that is, pitch loudness, quality, and duration

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20
Q

Inspection

A

purposeful and systematic observation; assess size, color, shape, position and symmetry

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21
Q

Palpation

A

method of examining by feeling a part of the body with the fingers or hand; assess temperature, turgor, texture, moisture, tenderness, and shape

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22
Q

Percussion

A

act of striking one object against the other for the purpose of producing sound; assess location, shape, size, and density of tissue

23
Q

What systems are involved with head-toe-assessment?

A

Neurologic, pulmonary, cardio, genitourinary, gastrointestinal, musculoskeletal, integumentary

24
Q

Neurologic (head to toe assessment)

A

Sensory/Perceptual

25
Q

Pulmonary (head to toe assessment)

A

oxygenation

26
Q

Cardiovascular (head to toe assessment)

A

O2 transport

27
Q

Genitourinary (head to toe assessment)

A

elimination

28
Q

Gastrointestinal (head to toe assessment)

A

elimination

29
Q

Musculoskeletal (head to toe assessment)

A

mobility

30
Q

Integumentary (head to toe assessment)

A

skin integrity

31
Q

Wheezes

A

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)

32
Q

Pleural Friction Rub

A

Grating or rubbing sound caused by inflamed pleura rubbing against the chest wall (sound like rubbing)

33
Q

Rhonchi

A

(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

34
Q

Stridor (crowing)

A

Harsh, loud, high pitched auscultation on inspiration; narrowing of the upper airways (larynx or trachea); presence of foreign body in airway

35
Q

Entropion

A

Eyelid rolled inward against eyeball typically caused by muscle spasm

36
Q

Ectropion

A

Lower lid sags away from eye exposing inner eye surface

37
Q

Convergence test

A

Ask client to follow finger as she slowly moved it towards client nose

38
Q

Extraocular movement

A

Following pencil side to side

39
Q

Oh, Oh, Oh, To Touch And Feel Virgin Girls Vaginas, AH

A

Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal

40
Q

(I) Olfactory

A

Sensory; sense of smell

41
Q

(II) Optic

A

Sensory; sense of vision

42
Q

(III) Oculomotor

A

Motor; pupil constriction, raise eyelids

43
Q

(IV) Trochlear

A

Motor/proprioceptor; downward, inward eye movement

44
Q

(V) Trigeminal

A

Motor; jaw movements like chewing and mastication
Sensory; sensation of the face and neck

45
Q

(VI) Abducens

A

Motor; lateral movement of the eyes

46
Q

(VII) Facial

A

Motor; muscles of the face
Sensory; sense of taste on the anterior two thirds of the tongue

47
Q

(VIII) Vestibulocochlear

A

Sensory; sense of hearing

48
Q

(IX) Glossopharyngeal

A

Motor; pharyngeal movement and swallowing
Sensory; sense of taste on the posterior one third of the tongue

49
Q

(X) Vagus

A

Motor/sensory; swallowing and speaking

50
Q

(XI) Accesory

A

Motor/sensory; movement of shoulder muscle

51
Q

(XII) Hypoglossal

A

Motor; movement of the tongue; strength of tongue

52
Q

Crackles

A

Bubbling or popping type sounds that are usually heard during inspiration (air moving through fluid in the lungs)

53
Q

Bruit

A

occur when artsy is partially obstructed or distended, which prevent blood flow from moving straight through the vessel

Fundamentals Of Nursing (9 decks)

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