Health Assessment Flashcards
List the Procedure and Order of Health Assessment exactly!!
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
Purpose of Physical Assessment
baseline data
supplement, confirm, or refute previous data
confirm or identify nursing diagnosis
clinical judgements
evaluate physiological outcomes of care
Subjective data
verbal description from pt (statement)
Objective data
observable by a nurse (fact, measurable)
Primary source of data
Patient (not always reliable)
Secondary source of data
Family, friends, medical records, and previous physicians
Considerations for Assessment
cultural sensitivity
infection control
environment
equipment
Data collecting can be done through what methods
interviews
health history
physical exams
diagnostic and lab results
Laboratory diagnostic tests
ABGs
CBC
Sputum
Radiological studies tests
Xrays
CT
V/Q
Pet Scans
The following are all different types of physical assessments what do they have in common?
-Comprehensive
-Focused
-System specific
-Ongoing
Head to Toe
During an examination, what process do you follow except for the abdomen?
Inspect, palpate, auscultate
After the nurse is done with their assessment, planning, and evaluation means the nurse is ?
Accountable for documenting and checking up on the outcome
All senses are tested during an examination except for?
taste
The back of the hand or dorsum is used to check what on a patient?
Temperature
Light palpations are about ___ cm deep.
Deep palpations are about ___ cm deep
1
4
When are deep palpations used in physical assessment?
abdomen
T/F:
Auscultating needs to happen directly on the skin.
True
The bell of the stethoscope is used for what sounds and when is it used?
Low sounds
vascular and heart sounds
The diaphragm of a stethoscope is used for what sounds and when is it used?
High sounds
bowel and abnormal lung sounds
What are some special considerations for young and elderly patients?
recognize limitations (adjust positions, more time, and more space)
What are the signs of abuse? Mandatory
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
What do you need when you notice signs of abuse?
Consent
-Ask about them, but they might lie
Level of Consciousness is the 1st clue of what?
deteriorating condition
What are the 5 levels of consciousness?
1) Alert
2) Lethargic
3) Obtunded
4) Stuporous/Semi-comatose
5) Comatose
Alert (1)
attentive, follow commands
If asleep, they awaken promptly and attentive
Lethargic (2)
drowsy but awakens, slow response
Obtunded (3)
difficult to arouse, needs constant stimuli
Stuporous / Semi-comatose (4)
arouses only with vigorous/noxious stimuli, may only withdraw from pain
Comatose (5)
no response to verbal or noxious stimuli, no movement except for deep tendon reflex
How is cognitive awareness tested?
Orientation of person, place, time, and event
Cranial nerves tested (sensory, motor, or both)
How many cranial nerves are there?
12
What is ICU sycosis?
days blend together (time is messed up)
What are cranial nerves tested when examining pupil responses (size, shape)?
-Dilation of pupils with a penlight
-Penlight off near and far sidedness
CN 3,4,6
What cranial nerves are tested when smiling with teeth and wrinkling forehead or raising eyebrows?
CN 7
What cranial nerves are tested when moving the tongue up, out, and side to side?
CN 12
How do you test the cardinal gaze?
tip of a penlight to and from the face
H movement with eyes only
What cranial nerves are tested when shrugging against resistance?
CN 11
What motions tests the cranial motor functions?
hand grasp and toe wiggle
flexion and extension with resistance
bilaterally with upper and lower extremities
What are the areas of the lungs from medial to lateral?
Bronchial (over trachea)
Bronchovesicular (closer to sternum)
Vesicular (peripheral lobes)
Crackles or rales
Sounds
Common location
Common cause
Rice krispies high pitch
base of lungs
fluid
Rhonchi
Sounds
Common location
Common cause
rumbling core sounds
trachea
mucous plug
(usually clear with cough)
Wheezes
Sounds
Common location
Common cause
high pitch musical note
all lung fields during exhalation
narrowing of airways due to asthma, COPD
Pleural Friction Rub
Sounds
Common location
Common cause
stethoscope rubbing on clothes
any location where there is no fluid in the lung sac
lung is rubbing on tissue
Bradypnea
slow breathing
Tachypnea
rapid breathing
apnea
no breathing
Hyperpnea
breathing deeper and faster
Kussmaul’s
deep and labored associated with DKA
Cheyne-stokes breathing
cyclical episodes of hyperpnea and apnea
For lung auscultation, what side do you start on for both anterior and posterior?
left side
On the posterior lung sounds, what expiration and inspiration do you tell them to take a deep breath?
7,8,9,10
What lung has an extra lobe?
right
What does clubbing look like?
when putting your fingers together, there is a wide-angle and no gap under fingernails
When do people have clubbing in their nails?
low O2 for long periods of time (altitude sickness, asthma)
What is the route of deoxygenated to oxygenated blood through the heart?
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
LUB sound is
systole (S1)
associated with the closing of the mitral and tricuspid valve
DUB sound is
diastole (S2)
associated with closing of aortic and pulmonary valves
SA node is known as the
pacemaker
What is the order and location of the 4 heart valves?
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
What pulse site do you not palpate at the same time?
carotid
Pulses that are analyzed during the physical assessment
Carotid
Radial
Apical
Dorsalis pedis
What number of pulse point is normal?
2+
What does a pulse point of 0 mean?
absent
What does a pulse point of 1+ mean?
diminished
What does a pulse point of 3+ mean?
full and increasing
What does a pulse point of 4+ mean?
bounding
What is a doppler device?
handheld device with ultrasound gel
used for pedal pulses
How long normally does it take for a capillary refill?
2-3 seconds (bleaching to red)
Dependent edema
gravity related swelling of feet and ankles
mainly on older adults when standing
Pitting edema
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
Neck ROM
side to side
chin to chest
head backward
rotation in circles
BUE ROM
arms out
straight up
touchdown
wrist circles
BLE ROM
knee to chest
hip flexion out
ankle circles
What to inspect on the skin when doing inspection?
skin breakdown
hydration
temp
color
texture
rashes
lesions
cracking
Pallor
pale or ash gray
erythema
redness of vasodilation
jaundice
yellow, impaired liver
cyanosis
bluish, decreased circulation of oxygen to the blood
How do you test turgor on a pt?
pinch the clavicle
-elasticity of skin related to hydration
Healthy skin temperature on inspection
warm and consistent with room temperature
Healthy skin moisture on inspection
diaphoresis or hydrated
Healthy skin texture on inspection
hydrated with hair
Abnormal skin texture on inspection
shiny with no hair = impaired peripheral circulation
What are some factors affecting skin?
dampness
dehydration
nutrition
circulation
disease
jaundice
lifestyle
Normal skin changes in elderly people
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
Pitting edema response rate when pressed against
1+ 2mm trace rapid
2+ 4mm mild 10-18 secs
3+ 6mm moderate 1-2 minutes
4+ 8mm severe 2-5 minutes
What bony prominences are highest for skin breakdown?
hips, heels, coccyx, shoulders
Nails should look like
transparent
smooth
rounded
convex
hygenic
Terminal hair is located where
scalp, axillae, pubic, and beard
Vellus hair is located where
soft tiny hairs covering the body except on palms and soles
Alopecia
partial or complete absence of hair on the body (baldness)
Hirsutism
abnormal growth of hair on the face or body especially for women
Where does mastication begin?
myophayrnx
esophagus
stomach
Elimination
excretion of waste products from kidneys and intestines
Defecation
process of eliminiation of waste
Feces
semisolid mass of fiber, undigested food, and inorganic matter
Incontinence
inability to control urine or feces
Void
to urinate
Micturate
to urinate
Dysuria
painful or difficult urination
Hematuria
blood in the urine
Nocturia
frequent night urination
Polyuria
large amounts of urine
Urinary frequency
voiding at frequent intervals
Urinary urgency
the need to void all at once
Proteinuria
presence of large protein in urine
Dribbling
leakage of urine despite voluntary control of urination
Rentention
accumulation of urine in the bladder without the ability to completely empty
Residual
urine remaining post void greater than 100 mL
Structures of the Gastrointestinal Tract
upper gastric intestinal tract
small intestine
large intestine
rectum and anus
Small intestine
-shaped
-how long
-3 segments
folded, twisted, and coiled tube from stomach to LG intestine
20 feet long
duodenum, jejunum, and ileum
Large intestine - COLON
-shaped
-how long
-7 segments
flat
5-6 ft long
cecum, ascending, transverse, descending, sigmoid colon, rectum, anus
Where are most of the digestion and absorption happen?
small intestine
Chyme travels via
peristalsis
Kidney functions
filter and regulate
remove waste from blood to form urine
primary regulators of fluid and acid-base balance
Ureter
transport urine from kidneys to bladder
usually sterile
obstructions cause peristaltic waves severe pain = renal colic
Bladder
reservoir for urine until the urge develops
In women, located anterior walls of the uterus and vagina
In men, anterior wall of rectum
urethra
urine travels from bladder and exits through urethral meatus
What size is a kidney related to?
size of fists
What is a functional unit of a kidney?
nephron
Normal bladder volume =
can extend to =
500mL
1000mL
In women, the urethra is ____ leads to a number of UTIs.
short (1 1/2 to 2 1/2 inches)
In men, the urethra is ____ and serves in both GU and the reproductive system, prostatic, membraneous, and penile
long (8 inches)
Name some of the parts of the kidney.
glomerulus, bowman’s capsule, PCT, loop of Henle, DT, collecting duct
