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M1 > Health Assessment > Flashcards

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
Q

Bronchial

A

over trachea

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26
Q

Abnormal or adventitious sounds

A

crackles or rales
rhonchi
wheezes
pleural friction rub

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27
Q

Crackles or rales

A

can be fine or course
common cause- fluid

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28
Q

Rhonchi

A

mucus in airway
may be cleared with cough

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29
Q

Wheezes

A

“mucus”
hear over lung fields
common in exhale
severe if you can hear upon inhale
caused by narrowing of airway

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30
Q

Pleural friction rub

A

number one reason to listen on skin
no fluid, rubbing against tissue

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31
Q

Abnormal respiratory patterns

A

bradypnea
tachypnea
apnea
hyperpnea
kussmauls
cheyne strokes

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32
Q

How many lung sounds on front?

A

7

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33
Q

How many lung sounds on the back?

A

10

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34
Q

What side do you start on when listening to patient’s pattern of auscultation?

A

patient’s left (your right)

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35
Q

What numbers do you take deep breaths on posterior side when looking at pattern of auscultation?

A

7-10

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36
Q

What do you look for when looking at nail shape?

A

clubbing
examine BUE nail shape

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37
Q

What can clubbing indicate?

A

low oxygen in blood

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38
Q

Respiratory components of assessment

A

anterior and posterior lung sounds
clubbing

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39
Q

Heart sounds

A

lub
dub

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40
Q

Lub

A

systole or S1 and is the sound associated with the closing of the mitral/tricuspid valves

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41
Q

Dub

A

diastole or S2 and is the sound associated with the closing of the aortic/pulmonary valves

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42
Q

There are natural pauses between S1 and S2 as well as between S2 and S1, but there should be a longer pause between

A

S2 and S1

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43
Q

What are the 4 heart sounds we listen for?

A

aortic
pulmonic
tricuspid
mitral
(All Party Til Midnight)

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44
Q

Aortic

A

right base
second intercostal space to the right of the sternal border

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45
Q

Pulmonic

A

left base
second intercostal space to the left of the sternal border

46
Q

Tricuspid

A

left lateral sternal border
fifth intercostal space to the left of sternal border

47
Q

Mitral

A

apex
midclavicular line at the fifth intercostal space

48
Q

Where can pulses be found?

A

carotid
brachial
radial
ulnar
apical
femoral
popliteal
dorsalis pedis

49
Q

What pulses do we assess?

A

carotid
radial
apical
dorsalis pedis or pedal pulses

50
Q

Carotid

A

one at a time, bilaterally

51
Q

Radial

A

bilaterally at the same time
testing equality

52
Q

Apical

A

with stethoscope for 2 beats

53
Q

Dorsalis pedis or pedal pulse

A

bilaterally at the same time

54
Q

Pulse quality scale

A

0 absent, nonpalpable
1+ diminished, palpable
2+ strong, normal
3+ full, increased
4+ bounding

55
Q

Assessment via doppler

A

hand held device
most often used for pedal pulse
document if used

56
Q

Assessment of extremities

A

capillary refill
edema

57
Q

Capillary refill

A

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
Q

Edema

A

swelling in extremities

59
Q

Dependent edema

A

most often on feet and ankles, older adults and standing

60
Q

Pitting edema

A

venous insufficiency or heart failure, fluid in tissues

61
Q

Cardiac components of assessment

A

heart sounds
carotid pulses
radial pulses
pedal pulses
capillary refill
assess for edema

62
Q

What body parts do we test ROM

A

neck
shoulders, upper arms, elbows
wrists
hips
knees
ankles

63
Q

Neck

A

move side to side
chin to chest
extension back

64
Q

Shoulders, upper arms, elbows

A

arms out side to side (T)
arms straight out
touch down

65
Q

Wrists

A

circles

66
Q

Hips, knees, ankles

A

bilateral hip flexion out
bend knees
ankle circles

67
Q

Strength

A

hand grip
toe wiggle
flexion and extension BUE/BLE

68
Q

Musculoskeletal

A

neck ROM
BUE ROM
BLE ROM
HGTW
flexion/ extension BUE/BLE

69
Q

Assessment of skin; inspect head to toe for

A

hydration
temperature
color
texture
rashes
lesions
cracking

70
Q

Changes in skin color

A

pallor- pale
erythema- redness
jaundice- yellow; impaired liver
cyanosis- bluish, decreased circulation or oxygenation of blood

71
Q

Skin characteristics

A

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
Q

Factors that affect the skin

A

dampness
dehydration
nutrition
circulation
disease
jaundice
lifestyle

73
Q

Normal changes in older adults (skin)

A

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
Q

Pitting Edema 1+

A

2mm to trace
rapid response

75
Q

Pitting Edema 2+

A

4mm to mild
10-18 sec

76
Q

Pitting Edema 3+

A

6mm to moderate
1-2 mins

77
Q

Pitting Edema 4+

A

8mm to severe
2-5 mins

78
Q

Assessment of bony prominences

A

increased risk for skin breakdown
hips, heels, coccyx, shoulders
assess for skin integrity
non blanching red spots

79
Q

Assessment of nails; we observe for

A

shape
contour
cleanliness
neatly manicured/trimmed

80
Q

Assessment of nails; should be

A

transparent
smooth
rounded
convex
hygienic

81
Q

Assessment of hair

A

terminal- scalp, axillae, pubic, beard
vellus- soft tiny hairs covering body except on palms and soles
quantity- alopecia, hirsutism
distribution
texture
color
parasites

82
Q

Assessment of ears; inspect for

A

symmetry
drainage
shape
hearing defects
lesions
redness
tenderness
odor (foul)

83
Q

Assessment of nose; inspect for

A

position
symmetry
color
swelling
deformities
discharge
flaring
patency
sinus tenderness

84
Q

Assessment of oral cavity and throat; inspect oral cavity for

A

lips
oral mucosa
teeth
gums/tongue
breath odor

85
Q

Assessment of oral cavity and throat; inspect throat for

A

lumps
ulcers
edema
white spots
redness
swelling

86
Q

Assessment of neck

A

inspect neck for contour and symmetry, midline trachea, jugular vein distension
palpate neck for inflamed/enlarged lymph nodes

87
Q

Integument components of assessment

A

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
Q

Elimination

A

excretion of waste products from kidneys and intestines

89
Q

Defecation

A

process of elimination of waste

90
Q

Feces

A

semisolid mass of fiber, undigested food, inorganic matter

91
Q

Incontinence

A

inability to urine or feces

92
Q

Void

A

to urinate

93
Q

Micturate

A

to urinate

94
Q

Dysuria

A

painful or difficult to urinate

95
Q

Hematuria

A

blood in urine

96
Q

Nocturia

A

frequent night urination

97
Q

Polyuria

A

large amounts of urine

98
Q

Urinary frequency

A

voiding at frequent intervals

99
Q

Urinary urgency

A

the need to void all at once

100
Q

Proteinuria

A

presence of large protein in urine

101
Q

Dribbling

A

leakage of urine despite voluntary control of urination

102
Q

Retention

A

accumulation of urine in bladder without the ability to completely empty

103
Q

Residual

A

urine remaining post void >100 mL

104
Q

What is the order in which you assess the abdomen (examination and direction)

A

inspect (look), auscultation (listen), palpation (feel)
RLQ,RUQ,LUQ,LLQ

105
Q

How many mL can a normal bladder hold?

A

500 mL

106
Q

How many mL can the bladder extend?

A

1000 mL

107
Q

Turbulent flow

A

washes urethra free of bacteria

108
Q

Assessment of the urethral meatus and perineal area

A

inspect orifice for erythema, discharge, swelling, or odor
signs of infection, inflammation, or trauma
perineal area: color, condition, presence of urine or stool

109
Q

GI/GU components of assessment

A

examine abdomen (look, listen, feel)
ask questions about habits
examine of urethral meatus and perineal area

110
Q

Putting it all together: head to toe assessment

A

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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