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Module 1 (Intro To Basics) > Health Assessment > Flashcards

Health Assessment Flashcards

1
Q

List the Procedure and Order of Health Assessment exactly!!

A

Intro, wash hands, gloves
- Full name, DOB, current date, current location, and event
- Hair
- Eyes, Ears, Nose, Mouth, and Throat
- Smile, tongue mvmt, raise eyebrows
- Carotid pulse
- Neck ROM (side-to-side, back, and forward)
- Shrug shoulders
- Pinch the clavicle for turgor
Inspect, Palpate, Auscultate
- Heart sounds (4- APTM) for 2 cycles
- Anterior lung sounds (7) LEFT - RIGHT
Only ab: AUSCULTATE BEFORE PALPATING
- Abdomen (4-20 secs starting at RLQ clockwise)
=Ask about bowel and urinary output
- Posterior lung sounds (10 sounds Left to right)
BUE
- out to the side, up, circles, touchdown
- wrist circles
- hand grasps
- radial pulses both
- clubbing
- capillary refill
BLE
-lift, knee bend, side
- ankle circles, flexion and extension
- toe wiggle
- palpate pedal pulses
- capillary refill
Inspect perineal area if needed
Hand hygiene and document

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2
Q

Purpose of Physical Assessment

A

baseline data
supplement, confirm, or refute previous data
confirm or identify nursing diagnosis
clinical judgements
evaluate physiological outcomes of care

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3
Q

Subjective data

A

verbal description from pt (statement)

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4
Q

Objective data

A

observable by a nurse (fact, measurable)

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5
Q

Primary source of data

A

Patient (not always reliable)

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6
Q

Secondary source of data

A

Family, friends, medical records, and previous physicians

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7
Q

Considerations for Assessment

A

cultural sensitivity
infection control
environment
equipment

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8
Q

Data collecting can be done through what methods

A

interviews
health history
physical exams
diagnostic and lab results

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9
Q

Laboratory diagnostic tests

A

ABGs
CBC
Sputum

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10
Q

Radiological studies tests

A

Xrays
CT
V/Q
Pet Scans

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11
Q

The following are all different types of physical assessments what do they have in common?
-Comprehensive
-Focused
-System specific
-Ongoing

A

Head to Toe

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12
Q

During an examination, what process do you follow except for the abdomen?

A

Inspect, palpate, auscultate

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13
Q

After the nurse is done with their assessment, planning, and evaluation means the nurse is ?

A

Accountable for documenting and checking up on the outcome

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14
Q

All senses are tested during an examination except for?

A

taste

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15
Q

The back of the hand or dorsum is used to check what on a patient?

A

Temperature

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16
Q

Light palpations are about ___ cm deep.
Deep palpations are about ___ cm deep

A

1
4

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17
Q

When are deep palpations used in physical assessment?

A

abdomen

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18
Q

T/F:
Auscultating needs to happen directly on the skin.

A

True

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19
Q

The bell of the stethoscope is used for what sounds and when is it used?

A

Low sounds
vascular and heart sounds

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20
Q

The diaphragm of a stethoscope is used for what sounds and when is it used?

A

High sounds
bowel and abnormal lung sounds

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21
Q

What are some special considerations for young and elderly patients?

A

recognize limitations (adjust positions, more time, and more space)

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22
Q

What are the signs of abuse? Mandatory

A

inconsistency between injury and statement
bruises, burns, lacerations, and bites
Xrays show fractures in various stages of healing (especially not reported)
behavior issues, insomnia, anxiety, isolation

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23
Q

What do you need when you notice signs of abuse?

A

Consent
-Ask about them, but they might lie

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24
Q

Level of Consciousness is the 1st clue of what?

A

deteriorating condition

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25
Q

What are the 5 levels of consciousness?

A

1) Alert
2) Lethargic
3) Obtunded
4) Stuporous/Semi-comatose
5) Comatose

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26
Q

Alert (1)

A

attentive, follow commands
If asleep, they awaken promptly and attentive

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27
Q

Lethargic (2)

A

drowsy but awakens, slow response

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28
Q

Obtunded (3)

A

difficult to arouse, needs constant stimuli

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29
Q

Stuporous / Semi-comatose (4)

A

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

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30
Q

Comatose (5)

A

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

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31
Q

How is cognitive awareness tested?

A

Orientation of person, place, time, and event
Cranial nerves tested (sensory, motor, or both)

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32
Q

How many cranial nerves are there?

A

12

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33
Q

What is ICU sycosis?

A

days blend together (time is messed up)

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34
Q

What are cranial nerves tested when examining pupil responses (size, shape)?
-Dilation of pupils with a penlight
-Penlight off near and far sidedness

A

CN 3,4,6

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35
Q

What cranial nerves are tested when smiling with teeth and wrinkling forehead or raising eyebrows?

A

CN 7

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36
Q

What cranial nerves are tested when moving the tongue up, out, and side to side?

A

CN 12

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37
Q

How do you test the cardinal gaze?

A

tip of a penlight to and from the face
H movement with eyes only

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38
Q

What cranial nerves are tested when shrugging against resistance?

A

CN 11

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39
Q

What motions tests the cranial motor functions?

A

hand grasp and toe wiggle
flexion and extension with resistance
bilaterally with upper and lower extremities

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40
Q

What are the areas of the lungs from medial to lateral?

A

Bronchial (over trachea)
Bronchovesicular (closer to sternum)
Vesicular (peripheral lobes)

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41
Q

Crackles or rales
Sounds
Common location
Common cause

A

Rice krispies high pitch
base of lungs
fluid

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42
Q

Rhonchi
Sounds
Common location
Common cause

A

rumbling core sounds
trachea
mucous plug
(usually clear with cough)

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43
Q

Wheezes
Sounds
Common location
Common cause

A

high pitch musical note
all lung fields during exhalation
narrowing of airways due to asthma, COPD

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44
Q

Pleural Friction Rub
Sounds
Common location
Common cause

A

stethoscope rubbing on clothes
any location where there is no fluid in the lung sac
lung is rubbing on tissue

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45
Q

Bradypnea

A

slow breathing

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46
Q

Tachypnea

A

rapid breathing

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47
Q

apnea

A

no breathing

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48
Q

Hyperpnea

A

breathing deeper and faster

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49
Q

Kussmaul’s

A

deep and labored associated with DKA

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50
Q

Cheyne-stokes breathing

A

cyclical episodes of hyperpnea and apnea

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51
Q

For lung auscultation, what side do you start on for both anterior and posterior?

A

left side

52
Q

On the posterior lung sounds, what expiration and inspiration do you tell them to take a deep breath?

A

7,8,9,10

53
Q

What lung has an extra lobe?

A

right

54
Q

What does clubbing look like?

A

when putting your fingers together, there is a wide-angle and no gap under fingernails

55
Q

When do people have clubbing in their nails?

A

low O2 for long periods of time (altitude sickness, asthma)

56
Q

What is the route of deoxygenated to oxygenated blood through the heart?

A

Superior and inferior vena cava - right atrium - bicuspid valve - right ventricle - pulmonary valve - pulmonary artery - lungs
lungs - pulmonary veins - left atrium - tricuspid valve - left ventricle - aortic valve - aorta

57
Q

LUB sound is

A

systole (S1)
associated with the closing of the mitral and tricuspid valve

58
Q

DUB sound is

A

diastole (S2)
associated with closing of aortic and pulmonary valves

59
Q

SA node is known as the

A

pacemaker

60
Q

What is the order and location of the 4 heart valves?

A

Aortic: right 2nd intercostal space next to the sternum
Pulmonic: left 2nd intercostal space next to the sternum
Tricuspid: left lateral sternal border, 5th intercostal space
Mitral: apex, midclavicular line at 5th intercostal

61
Q

What pulse site do you not palpate at the same time?

A

carotid

62
Q

Pulses that are analyzed during the physical assessment

A

Carotid
Radial
Apical
Dorsalis pedis

63
Q

What number of pulse point is normal?

A

2+

64
Q

What does a pulse point of 0 mean?

A

absent

65
Q

What does a pulse point of 1+ mean?

A

diminished

66
Q

What does a pulse point of 3+ mean?

A

full and increasing

67
Q

What does a pulse point of 4+ mean?

A

bounding

68
Q

What is a doppler device?

A

handheld device with ultrasound gel
used for pedal pulses

69
Q

How long normally does it take for a capillary refill?

A

2-3 seconds (bleaching to red)

70
Q

Dependent edema

A

gravity related swelling of feet and ankles
mainly on older adults when standing

71
Q

Pitting edema

A

Severe swelling in the feet up to 4-8 mm of depth with no bounce back after 5 minutes
venous insufficiency, kidney disease, or heart failure
excess fluid in tissues throughout the body

72
Q

Neck ROM

A

side to side
chin to chest
head backward
rotation in circles

73
Q

BUE ROM

A

arms out
straight up
touchdown
wrist circles

74
Q

BLE ROM

A

knee to chest
hip flexion out
ankle circles

75
Q

What to inspect on the skin when doing inspection?

A

skin breakdown
hydration
temp
color
texture
rashes
lesions
cracking

76
Q

Pallor

A

pale or ash gray

77
Q

erythema

A

redness of vasodilation

78
Q

jaundice

A

yellow, impaired liver

79
Q

cyanosis

A

bluish, decreased circulation of oxygen to the blood

80
Q

How do you test turgor on a pt?

A

pinch the clavicle
-elasticity of skin related to hydration

81
Q

Healthy skin temperature on inspection

A

warm and consistent with room temperature

82
Q

Healthy skin moisture on inspection

A

diaphoresis or hydrated

83
Q

Healthy skin texture on inspection

A

hydrated with hair

84
Q

Abnormal skin texture on inspection

A

shiny with no hair = impaired peripheral circulation

85
Q

What are some factors affecting skin?

A

dampness
dehydration
nutrition
circulation
disease
jaundice
lifestyle

86
Q

Normal skin changes in elderly people

A

collagen and elastic fibers decrease
hormones decrease
vascularity decreases leading to hypertension and atherosclerosis disease
hair follicles and melanocytes decrease (uneven and gray hair)
nails become thick
skin growth of warts and liver spots

87
Q

Pitting edema response rate when pressed against

A

1+ 2mm trace rapid
2+ 4mm mild 10-18 secs
3+ 6mm moderate 1-2 minutes
4+ 8mm severe 2-5 minutes

88
Q

What bony prominences are highest for skin breakdown?

A

hips, heels, coccyx, shoulders

89
Q

Nails should look like

A

transparent
smooth
rounded
convex
hygenic

90
Q

Terminal hair is located where

A

scalp, axillae, pubic, and beard

91
Q

Vellus hair is located where

A

soft tiny hairs covering the body except on palms and soles

92
Q

Alopecia

A

partial or complete absence of hair on the body (baldness)

93
Q

Hirsutism

A

abnormal growth of hair on the face or body especially for women

94
Q

Where does mastication begin?

A

myophayrnx
esophagus
stomach

95
Q

Elimination

A

excretion of waste products from kidneys and intestines

96
Q

Defecation

A

process of eliminiation of waste

97
Q

Feces

A

semisolid mass of fiber, undigested food, and inorganic matter

98
Q

Incontinence

A

inability to control urine or feces

99
Q

Void

A

to urinate

100
Q

Micturate

A

to urinate

101
Q

Dysuria

A

painful or difficult urination

102
Q

Hematuria

A

blood in the urine

103
Q

Nocturia

A

frequent night urination

104
Q

Polyuria

A

large amounts of urine

105
Q

Urinary frequency

A

voiding at frequent intervals

106
Q

Urinary urgency

A

the need to void all at once

107
Q

Proteinuria

A

presence of large protein in urine

108
Q

Dribbling

A

leakage of urine despite voluntary control of urination

109
Q

Rentention

A

accumulation of urine in the bladder without the ability to completely empty

110
Q

Residual

A

urine remaining post void greater than 100 mL

111
Q

Structures of the Gastrointestinal Tract

A

upper gastric intestinal tract
small intestine
large intestine
rectum and anus

112
Q

Small intestine
-shaped
-how long
-3 segments

A

folded, twisted, and coiled tube from stomach to LG intestine
20 feet long
duodenum, jejunum, and ileum

113
Q

Large intestine - COLON
-shaped
-how long
-7 segments

A

flat
5-6 ft long
cecum, ascending, transverse, descending, sigmoid colon, rectum, anus

114
Q

Where are most of the digestion and absorption happen?

A

small intestine

115
Q

Chyme travels via

A

peristalsis

116
Q

Kidney functions

A

filter and regulate
remove waste from blood to form urine
primary regulators of fluid and acid-base balance

117
Q

Ureter

A

transport urine from kidneys to bladder
usually sterile
obstructions cause peristaltic waves severe pain = renal colic

118
Q

Bladder

A

reservoir for urine until the urge develops
In women, located anterior walls of the uterus and vagina
In men, anterior wall of rectum

119
Q

urethra

A

urine travels from bladder and exits through urethral meatus

120
Q

What size is a kidney related to?

A

size of fists

121
Q

What is a functional unit of a kidney?

A

nephron

122
Q

Normal bladder volume =
can extend to =

A

500mL
1000mL

123
Q

In women, the urethra is ____ leads to a number of UTIs.

A

short (1 1/2 to 2 1/2 inches)

124
Q

In men, the urethra is ____ and serves in both GU and the reproductive system, prostatic, membraneous, and penile

A

long (8 inches)

125
Q

Name some of the parts of the kidney.

A

glomerulus, bowman’s capsule, PCT, loop of Henle, DT, collecting duct

Module 1 (Intro To Basics) (32 decks)

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