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Module 1 Exam > Health assessment > Flashcards

Health assessment Flashcards

1
Q

Level of Consciousness

A

Single most important neuro assessment component. Often first clue of deteriorating condition

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2
Q

Alert

A

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

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3
Q

Lethargic

A

Drowsy but awakens, slow to respond. (Drunk)

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4
Q

Obtunded

A

Difficult to arouse, needs constant stimulation

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5
Q

Stuporous/Semi-Comatose:

A

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

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6
Q

Comatose:

A

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

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7
Q

Cognitive Awareness

A

Is the patient oriented to person, place, event, and time?
Also known as mentation

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8
Q

Testing Cognitive Awareness questions

A

What is your name and date of birth?
Where are you right now?
What year/day is it?

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9
Q

Cranial Nerves

A

I – Olfactory
II – Optic
III – Oculomotor
IV – Trochlear
V – Trigeminal
VI - Abducens
VII – Facial
VIII – Vestibulocochlear
IX – Glossopharyngeal
X – Vagus
XI – Accessory
XII – Hypoglossal

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10
Q

Testing Cranial Nerves III, IV, and VI

A

Pupil Response.
Cardinal Gaze

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11
Q

Pupil Response

A

Examine size and shape of pupils and compare to scale
Start at ear with penlight and move in toward nose
Note change in size and speed of reaction
With penlight off, move penlight close to and away from pupils

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12
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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13
Q

Testing Cranial Nerve VII

A

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

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14
Q

Testing Cranial Nerve XII

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

Testing Cranial Nerve XI

A

Place hands lightly on patient shoulders
Ask patient to shrug shoulders

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16
Q

Testing 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

Auscultation of the lungs: Vesicular

A

periphery of the lungs. Sounds Soft and breezy

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19
Q

Auscultation of the lungs: Bronchovesicular

A

closer to the sternum. Sounds like blowing

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20
Q

Auscultation of the lungs: Bronchial

A

over trachea. Sounds hollow

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21
Q

Crackles or rales

A

Can be fine or course
Sounds like pouring milk over rice krispies.
Due to fluid collection at basis of lungs

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22
Q

Rhonchi

A

Rumbling, large secretions in airway. May clear with cough. Hear over bronchial and bronchial vesicular

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23
Q

Wheezes

A

High pitched. Musical sounds upon Exhalation.
Can appear in asthma and all lung diseases that have tightened airway

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24
Q

Pleural friction rub

A

Sounds like stethoscope rubbing against clothes. Fluid in pleural cavity no longer there. Empty space where lungs rub against tissue

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25
Q

Abnormal Respiratory Patterns

A

Bradypnea-slow
Tachypnea-fast
Apnea-absent
Hyperpnea-more deeply and faster
Kussmaul’s- deep, labored breathing pattern that indicates that the body or organs have become too acidic.
Cheyne-Stokes- The pattern involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all, called apneas

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26
Q

Nail Shape

A

Examine BUE nail shape
Clubbing

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27
Q

Clubbing

A

Consistently low O2 in blood. Common in High Altitude, COPD, Asthma

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28
Q

Respiratory Components of Assessment

A

Anterior and posterior lung sounds
Clubbing

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29
Q

Heart Sounds

A

Lub, Dub

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30
Q

LUB

A

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

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31
Q

DUB

A

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

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32
Q

There are natural pauses between S1 and S2 as well as

A

as well as between S2 and S1 but there should be a longer pause between S2 and S1

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33
Q

Aortic

A

Right base; Second intercostal space to the right of the sternal border

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34
Q

Pulmonic:

A

Left base; Second intercostal space to the left of the sternal border

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35
Q

Tricuspid:

A

Left lateral sternal border; Fifth intercostal space to the left of the sternal border

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36
Q

Mitral

A

Apex; Midclavicular line at the fifth intercostal space

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37
Q

All party till midnight

A

Acronym for Location of heart sounds

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38
Q

All party till midnight

A

Acronym for Location of heart sounds

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39
Q

Pulses

A

Carotid*
Brachial
Radial*
Ulnar
Apical*
Femoral
Popliteal
Dorsalis pedis*

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40
Q

Asessment of Pulses

A

Carotid-Bilateral
Apical-With Stethescope for two beats
Dorsalis Pedis or Pedal Pulses-Bilaterally at the same time
Radial-Bilaterally at the same time

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41
Q

Pulse Quality Rating

A

0 – Absent, Non-palpable
1+ – Diminished, palpable. Weak and thready
2+ – Strong , normal
3+ – Full, Increased
4+ – Bounding

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42
Q

Assessment via Doppler

A

Hand-held device
Most often used for pedal pulses

43
Q

Capillary refill

A

press skin of nailbed to produce blanching, release pressure and observe time taken for color return, should be less than 2-3 seconds, BUE and BLE

44
Q

Edema

A

Swelling in Extremities

45
Q

Dependent edema:

A

most often on feet and ankles, older adults and standing. Area of accident

46
Q

Pitting edema

A

venous insufficiency or heart failure, fluid in tissues

47
Q

Cardiac Components of Assessment

A

Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for edema

48
Q

Range of Motion ROM

A

Neck
Shoulders, upper arms, & elbows
Upper arms & Elbows
Wrists
Hips
Knees
Ankles

49
Q

Neck ROM

A

Move neck side to side
Chin to chest
Extension back

50
Q

Shoulders, Upper Arms & Elbows

A

Arms out to side
Arms straight up
Touchdown

51
Q

Wrists

A

Wrist circles

52
Q

Hips, Knees, and Ankles

A

Bilateral hip flexion out-frog motion, lift knee, move out to side
Bend knees
Ankle circles

53
Q

Strength

A

Handgrip
Toe wiggle
Flexion and extension of BUE/BLE

54
Q

Musculoskeletal Components of Assessment

A

Neck ROM
BUE ROM
BLE ROM
HGTW
Flexion/Extension BUE and BLE

55
Q

To assess skin you need to Inspect head to toe for:

A

Hydration
Temperature
Color
Texture
Rashes
Lesions
Cracking

56
Q

Changes in skin color:

A

Pallor – pale or ashen gray
Erythema – redness r/t vasodilation
Jaundice – yellow, impaired liver
Cyanosis – bluish, decreased circulation or oxygenation of blood

57
Q

Skin Can offer clues to health status such as

A

Temp should be warm, consistent with room temp
Moisture from diaphoresis or dry from dehydration
Texture can be dry & course (elbows/knees) or shiny with no hair (impaired peripheral circulation)
Turgor tests elasticity of the skin related to hydration

58
Q

Factors Effecting the Skin

A

Dampness
Dehydration
Nutrition
Circulation
Disease
Jaundice
Lifestyle

59
Q

Pitting Edema

A

Caused by kidney or heart failure
Leads to excess fluid collection in tissues

60
Q

Assessment of Bony Prominences

A

Hips, heels, coccyx, shoulders
Assess for skin integrity
Blanching red spots

61
Q

Assessment of Nails Observe for:

A

Shape
Contour
Cleanliness
Neatly manicured/trimmed

62
Q

Nails Should be:

A

Transparent
Smooth
Rounded
Convex
Hygienic

63
Q

Terminal Hair

A

Scalp, axillae, pubic, and beard

64
Q

Vellus Hair

A

Soft tiny hairs covering body except on palms and soles

65
Q

To assess hair you need to look at

A

Terminal Hair
Vellus Hair
Quantity: Alopecia (patchy, hair less), hirsutism (abnormal hair growth)
Distribution
Texture
Color
Parasites

66
Q

To assess ears, Inspect for

A

Symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor

67
Q

Inspect nose for:

A

Position, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness

68
Q

Inspect oral cavity:

A

Lips
Oral mucosa
Teeth
Gums/tongue
Breath odor

69
Q

Inspect throat for:

A

Lumps
Ulcers
Edema
White spots
Redness
Swallowing

70
Q

Inspect neck for:

A

Contour & symmetry, midline trachea, jugular vein distention

71
Q

Palpate neck for:

A

Inflamed/enlarged lymph nodes

72
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 and BLE
Inspect nails

73
Q

Elimination

A

excretion of waste products from kidneys and intestines

74
Q

Defecation

A

process of elimination of waste

75
Q

Feces

A

Semisolid mass of fiber, undigested food, inorganic matter

76
Q

Incontinence

A

inability to control urine or feces

77
Q

Void, Micturate

A

to urinate

78
Q

Dysuria

A

painful or difficult urination

79
Q

Hematuria

A

blood in the urine

80
Q

Nocturia

A

frequent night urination

81
Q

Polyuria

A

large amounts of urine

82
Q

Urinary frequency

A

voiding at frequent intervals

83
Q

Urinary urgency

A

the need to void all at once. Have to go all the time

84
Q

Proteinuria

A

presence of large protein in urine. Shows dysfunction of the kidney

85
Q

Dribbling

A

leakage of urine despite voluntary control of urination. (Age/Birth)

86
Q

Retention

A

accumulation of urine in bladder without the ability to completely empty

87
Q

Residual

A

urine remaining post void >100ml. Pt is holding urine in after voiding

88
Q

Structures of the Gastrointestinal Tract

A

Upper gastrointestinal tract
Small intestine
Large Intestine
Rectum and anus

89
Q

Upper gastrointestinal tract

A

Mouth, Pharynx, Esophagus, Stomach

90
Q

Small Intestine

A

Folded, twisted, and coiled tube from stomach to large intestine
1” in diameter and 20’ long
Most digestion and absorption happens here
Chyme travels via peristalsis
3 segments – duodenum, jejunum, and ileum

91
Q

Chyme

A

Partially digested food mixed with stomach acid

92
Q

Large Intestine

A

AKA – colon
2.5” diameter and 5-6’ long
7 segments – cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus

93
Q

Kidneys

A

Filter and regulate
Remove waste from blood to form urine.
Bilateral, posterior flanks
Size of fists
Primary regulators of fluid and acid-base balance

94
Q

Ureters

A

Transport urine from kidneys to bladder

95
Q

Bladder

A

Reservoir for urine until the urge develops

96
Q

Urethra

A

Urine travels from bladder and exits through urethral meatus

97
Q

Anatomy of Kidney

A

Nephron – functional unit of the kidney
Glomerulus
Bowman’s Capsule
Proximal Convoluted Tubule
Loop of Henle
Distal Tubule
Collecting Duct

98
Q

Ureters

A

Tubule structures that enter the bladder
Urine traveling through ureters is typically sterile
Ureters enter bladder obliquely and posteriorly to prevent reflux
Obstructions cause peristaltic waves severe pain often referred to as renal colic (kidney stones)

99
Q

Bladder

A

Hollow, distensible, muscular organ
In men – bladder lies against anterior wall of rectum
In women – bladder rest against anterior walls of uterus and vagina
When bladder is full, it extends above symphysis pubis
Normal bladder – 500ml
Can extend to 1000ml

100
Q

Urethra

A

Turbulent flow washes urethra free of bacteria
Descends through pelvic floor muscles
Contraction of pelvic floor muscles can prevent flow of urine
In women – urethra is short (1 ½ to 2 ½ in), leads to prevalence of infection
In men – urethra is long (8 in), serves in both GU and reproductive system, three sections: prostatic, membranous, and penile

101
Q

Examine in this order:

A

Abdomen.
Inspection (look) – observe size, shape, contour, skin integrity
Auscultation (listen) – bowel sounds, four quadrants
Normal hypoactive, hyperactive
Palpation (feel) – palpate for tenderness, pain, masses

102
Q

Assessment of the Abdomen. Ask:

A

Normal bowel and urine patterns
Appearance
Changes
History of problems

103
Q

Assessment of Urethral Meatus and Perineal Area

A

Inspect urethral orifice for erythema, discharge, swelling, or odor
Signs of infection, inflammation, or trauma
Perineal area: color, condition, presence of urine or stool

104
Q

GI/GU Components of Assessment

A

Examination of abdomen – look, listen, feel
Ask questions about habits
Examination of urethral meatus and perineal area

Module 1 Exam (6 decks)

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