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Health Assessment Flashcards

1
Q

What should you consider before you begin?

A

Age group
Organization of the assessment

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2
Q

What is the single most important near assessment component?

A

Level of consciousness

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3
Q

Level of consciousness is the first clue of

A

Deteriorating condition

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4
Q

Testing level of consciousness categories

A

Alert
Lethargic
Obtunded
Stuporous/Semi Comatose
Comatose

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5
Q

Alert

A

attentive, follows commands, if asleep- wakes promptly and remains attentive

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6
Q

Lethargic

A

drowsy but awakens, slow to respond

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7
Q

Stuporous/Semi-Comatose

A

arouses only to vigorous/noxious stimuli, may only withdraw from pain

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8
Q

Comatose

A

no response to verbal or noxious stimuli, no movement except deep tendon reflex

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9
Q

Cognitive awareness

A

is the patient oriented to person, place, event and time?
also known as mentation

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10
Q

How do you test cognitive awareness? (questions to ask)

A

what is your name and date of birth? (person)
where are you right now? (place)
what year/day is it? (day/time)
what brought you here? (event)

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11
Q

Cranial nerves

A

12 pairs
sensory, motor, or both
not all cranial nerves are always tested

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12
Q

How can you test cranial nerves 3,4,6?

A

pupil responce
cardinal response

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13
Q

How can you test cranial nerve 7?

A

ask patient to smile and show teeth
ask patient to wrinkle forehead or raise eyebrows

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14
Q

How can you test cranial nerve 12?

A

ask patient to touch the roof of mouth with tongue
protrude tongue out of mouth
move tongue from side to side

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15
Q

How can you test cranial nerve 11?

A

place hands lightly on patient’s shoulders
ask patient to shrug shoulders

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16
Q

How can you test motor function?

A

will complete as part of neuro and musculoskeletal assessments
hand grasp and toe wiggle (HGTW)
flexion and extension with resistance
all done bilaterally on BUE and BLE

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17
Q

Neuro components of assessment

A

level of consciousness and orientation
pupil response and cardinal gaze
smile and show teeth, raise eyebrows
tongue to roof of mouth, out, side to side
shoulder strength with resistance
HGTW
flexion/extension BUE and BLE

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18
Q

What do we look for when testing pupil response?

A

equality
round
reactive to light

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19
Q

Cardinal gaze helps us see if eye can

A

track movement

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20
Q

Cardinal gaze

A

use tip of unlit penlight
have patient follow with eyes only
about 9-12” from face, move the end of penlight in an H motion

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21
Q

What is the main component of respiratory specific health assessment components

A

lung sounds

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22
Q

Auscultation of lungs; what are normal lung sounds

A

vesicular
brochovesicular
bronchial

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23
Q

Vesicular

A

periphery of lungs

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24
Q

Brochovesicular

A

closer to the sternum

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25
Bronchial
over trachea
26
Abnormal or adventitious sounds
crackles or rales rhonchi wheezes pleural friction rub
27
Crackles or rales
can be fine or course common cause- fluid
28
Rhonchi
mucus in airway may be cleared with cough
29
Wheezes
"mucus" hear over lung fields common in exhale severe if you can hear upon inhale caused by narrowing of airway
30
Pleural friction rub
number one reason to listen on skin no fluid, rubbing against tissue
31
Abnormal respiratory patterns
bradypnea tachypnea apnea hyperpnea kussmauls cheyne strokes
32
How many lung sounds on front?
7
33
How many lung sounds on the back?
10
34
What side do you start on when listening to patient's pattern of auscultation?
patient's left (your right)
35
What numbers do you take deep breaths on posterior side when looking at pattern of auscultation?
7-10
36
What do you look for when looking at nail shape?
clubbing examine BUE nail shape
37
What can clubbing indicate?
low oxygen in blood
38
Respiratory components of assessment
anterior and posterior lung sounds clubbing
39
Heart sounds
lub dub
40
Lub
systole or S1 and is the sound associated with the closing of the mitral/tricuspid valves
41
Dub
diastole or S2 and is the sound associated with the closing of the aortic/pulmonary valves
42
There are natural pauses between S1 and S2 as well as between S2 and S1, but there should be a longer pause between
S2 and S1
43
What are the 4 heart sounds we listen for?
aortic pulmonic tricuspid mitral (All Party Til Midnight)
44
Aortic
right base second intercostal space to the right of the sternal border
45
Pulmonic
left base second intercostal space to the left of the sternal border
46
Tricuspid
left lateral sternal border fifth intercostal space to the left of sternal border
47
Mitral
apex midclavicular line at the fifth intercostal space
48
Where can pulses be found?
carotid brachial radial ulnar apical femoral popliteal dorsalis pedis
49
What pulses do we assess?
carotid radial apical dorsalis pedis or pedal pulses
50
Carotid
one at a time, bilaterally
51
Radial
bilaterally at the same time testing equality
52
Apical
with stethoscope for 2 beats
53
Dorsalis pedis or pedal pulse
bilaterally at the same time
54
Pulse quality scale
0 absent, nonpalpable 1+ diminished, palpable 2+ strong, normal 3+ full, increased 4+ bounding
55
Assessment via doppler
hand held device most often used for pedal pulse document if used
56
Assessment of extremities
capillary refill edema
57
Capillary refill
press skin of nailed to produce blanching, release pressure and observe time taken for color to return should be less than 2-3 seconds BUE snd BLE
58
Edema
swelling in extremities
59
Dependent edema
most often on feet and ankles, older adults and standing
60
Pitting edema
venous insufficiency or heart failure, fluid in tissues
61
Cardiac components of assessment
heart sounds carotid pulses radial pulses pedal pulses capillary refill assess for edema
62
What body parts do we test ROM
neck shoulders, upper arms, elbows wrists hips knees ankles
63
Neck
move side to side chin to chest extension back
64
Shoulders, upper arms, elbows
arms out side to side (T) arms straight out touch down
65
Wrists
circles
66
Hips, knees, ankles
bilateral hip flexion out bend knees ankle circles
67
Strength
hand grip toe wiggle flexion and extension BUE/BLE
68
Musculoskeletal
neck ROM BUE ROM BLE ROM HGTW flexion/ extension BUE/BLE
69
Assessment of skin; inspect head to toe for
hydration temperature color texture rashes lesions cracking
70
Changes in skin color
pallor- pale erythema- redness jaundice- yellow; impaired liver cyanosis- bluish, decreased circulation or oxygenation of blood
71
Skin characteristics
offer clues to health status temp should be warm, consistent with room temp moisture from diaphoresis or dry from dehydration texture can be dry and coarse or shiny with no hair (impaired circulation) turgor tests elasticity of the skin related to hydration
72
Factors that affect the skin
dampness dehydration nutrition circulation disease jaundice lifestyle
73
Normal changes in older adults (skin)
epidermis- slower healing, risk for skin tears subcutaneous tissue- becomes thinner, decreased protection collagen and elastin fibers- more prone to wrinkles hormones- lack of, can lead to dry and thinning of hair vascular- less of them on surface, leads to cold extremities hair follicles melanocytes- uneven pigment, hair turns grey nails- become thicker and softer skin growth- age spots, warts
74
Pitting Edema 1+
2mm to trace rapid response
75
Pitting Edema 2+
4mm to mild 10-18 sec
76
Pitting Edema 3+
6mm to moderate 1-2 mins
77
Pitting Edema 4+
8mm to severe 2-5 mins
78
Assessment of bony prominences
increased risk for skin breakdown hips, heels, coccyx, shoulders assess for skin integrity non blanching red spots
79
Assessment of nails; we observe for
shape contour cleanliness neatly manicured/trimmed
80
Assessment of nails; should be
transparent smooth rounded convex hygienic
81
Assessment of hair
terminal- scalp, axillae, pubic, beard vellus- soft tiny hairs covering body except on palms and soles quantity- alopecia, hirsutism distribution texture color parasites
82
Assessment of ears; inspect for
symmetry drainage shape hearing defects lesions redness tenderness odor (foul)
83
Assessment of nose; inspect for
position symmetry color swelling deformities discharge flaring patency sinus tenderness
84
Assessment of oral cavity and throat; inspect oral cavity for
lips oral mucosa teeth gums/tongue breath odor
85
Assessment of oral cavity and throat; inspect throat for
lumps ulcers edema white spots redness swelling
86
Assessment of neck
inspect neck for contour and symmetry, midline trachea, jugular vein distension palpate neck for inflamed/enlarged lymph nodes
87
Integument components of assessment
inspect hair and scalp inspect ears inspect nose inspect mouth and throat inspect and palpate neck assess skin turgor inspect skin on back and bony prominences inspect skin of BUE/BLE inspect nails
88
Elimination
excretion of waste products from kidneys and intestines
89
Defecation
process of elimination of waste
90
Feces
semisolid mass of fiber, undigested food, inorganic matter
91
Incontinence
inability to urine or feces
92
Void
to urinate
93
Micturate
to urinate
94
Dysuria
painful or difficult to urinate
95
Hematuria
blood in urine
96
Nocturia
frequent night urination
97
Polyuria
large amounts of urine
98
Urinary frequency
voiding at frequent intervals
99
Urinary urgency
the need to void all at once
100
Proteinuria
presence of large protein in urine
101
Dribbling
leakage of urine despite voluntary control of urination
102
Retention
accumulation of urine in bladder without the ability to completely empty
103
Residual
urine remaining post void >100 mL
104
What is the order in which you assess the abdomen (examination and direction)
inspect (look), auscultation (listen), palpation (feel) RLQ,RUQ,LUQ,LLQ
105
How many mL can a normal bladder hold?
500 mL
106
How many mL can the bladder extend?
1000 mL
107
Turbulent flow
washes urethra free of bacteria
108
Assessment of the urethral meatus and perineal area
inspect orifice for erythema, discharge, swelling, or odor signs of infection, inflammation, or trauma perineal area: color, condition, presence of urine or stool
109
GI/GU components of assessment
examine abdomen (look, listen, feel) ask questions about habits examine of urethral meatus and perineal area
110
Putting it all together: head to toe assessment
created to move from head to toe be methodical be aware of clean to dirty and dirty to clean

M1 (4 decks)

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