Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

NURS 402: Lecture > Health Assessment > Flashcards

Health Assessment Flashcards

1
Q

What type of data do you collect, validate and analyze during health assessment?

A
  1. Subjective
  2. Objective
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Subjective Data

A

Information based on patient experiences and perceptions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Objective

A

Measurable and directly observed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Health assessment includes two components:

A
  1. Health History
  2. Physical Assessment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Health history

A

collection of subjective information about the patient’s health status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Physical assessment

A

collection of objective data about changes in the patient’s body systems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Types of Health Assessments- 4 types

A
  1. Comprehensive
  2. Ongoing Partial
  3. Focused
  4. Emergency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Comprehensive Health Assessment

A

Conducted upon admission to health care facility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Ongoing Partial Health Assessment

A

Conducted at regular intervals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Focused Health Assessment

A

Conducted to assess a specific problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Emergency Health Assessment

A

Conducted to determine life threatening or unstable conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Considerations When Performing Health Assessment:

A
  1. Lifespan considerations
  2. Cultural Considerations and Sensitivity
  3. Patient Preparation
  4. Environmental Preparations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Factors to Assess During a Health History

A
  1. Biographical data
  2. Reason for seeking health care
  3. History of present health concern
  4. Past Health History
  5. Family Health History
  6. Functional Health
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Preparing the Environment for Physical Assessment:

A
  1. Hand Hygiene
  2. Prepare the Examination Table
  3. Provide a gown and drape for the patient
  4. Are there any precautions beside standard
  5. Gather the supplies and instruments needed
  6. Provide a curtain or screen if the area is open to others
  7. Provide a comfortable room temp.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Equipment Used During a Physical Examination:

A
  1. Thermometer
  2. Sphygmomanometer
  3. Scale
  4. Flashlight or penlight
  5. Stethoscope
  6. Metric tape measure and ruler
  7. Eye chart
  8. Watch with a second hand
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Positions used during Physical Assessment: There are eight

A
  1. Standing
  2. Sitting
  3. Supine
  4. Dorsal Recumbent
  5. Sim’s
  6. Prone
  7. Lithotomy
  8. Knee-chest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Techniques used during a Physical Assessment (say in order)

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Ausculation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Inspection Assesses

A

size
color
shape
position
symmetry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Palpation Assesses:

A

temperature
turgor
texture
moisture
vibrations
shape

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Percussion assesses

A

location
shape
size
density of tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Auscultation assesses

A

the four characteristics of sound:

pitch
loudness
quality
duration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

General survey includes

A

General appearance
vital signs
height, weight, waist circumference
calculating BMI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Physical Assessment includes: 10 things

A
  1. Integument
  2. Head and Neck
  3. Thorax and lungs
  4. Cardiovascular and peripheral vascular systems
  5. Breasts and axillae
  6. Abdomen
  7. Female and male genitalia
  8. Anus, rectum, prostate
  9. Musculoskeletal system
  10. Neurologic system
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Integument (Skin) Assessment Subjective data includes:

A

History of rashes, lesions, bruising, allergies

Exposures to sun, chemicals

Piercings or tattoos

Degree of mobility

Nutritional status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Skin Language Terminology
Erythema Ecchymosis Petechaie Cyanosis Jaundice Pallor Diaphoresis Turgor Edema
26
Erythema
redness (pertaining to skin)
27
Ecchymosis
Collection of blood in subcutaneous tissue (pertaining to skin) Medical term for a bruise
28
Petechiae
Hemorrhagic spots/capillary bleeding (pertaining to skin)
29
Cyanosis
bluish or grayish color (pertaining to skin)
30
Jaundice
yellow color (pertaining to skin)
31
Pallor
Paleness (pertaining to skin)
32
Diaphoresis
Excessive perspiration (pertaining to skin)
33
Turgor
Elasticity (pertaining to skin)
34
Edema
excess fluid (pertaining to skin)
35
Two types of skin lesions
1. Primary Lesions 2. Secondary Lesions
36
Primary Lesions - 9 types
1. Macule 2. Papule 3. Vesicle 4. Pustule 5. Bulla 6. Cyst 7. Nodule 8. Plaque 9. Wheal
37
Macule
a flat, circumscribed area; can be brown, red, white, tan Is a primary lesion
38
Papule
An elevated, palpable, firm, circumscribed area generally less than 5 mm in diameter Is a primary lesion
39
Vesicle
an elevated, circumscribed, superficial, fluid- filled blister less than 5 mm in diameter Is a primary lesion
40
Pustule
An elevated, superficial area that is similar to a vesicle but filled with pus Is a primary lesion
41
Bulla
A vesicle greater than 5 mm in diameter Is a primary lesion
42
Cyst
An elevated, circumscribed area of the skin filled with liquid or semisolid fluid Is a primary lesion
43
Nodule
An elevated, firm, circumscribed, and palpable area greater than 5 mm in diameter; can involve all skin layer Is a primary lesion
44
Plaque
An elevated, flat-topped, firm, rough, superficial papule greater than 2 cm in diameter; papules can coalesce to form plaques Is a primary lesion
45
Wheal
An elevated, irregularly shaped area of cutaneous edema; wheals are solid, transient, and changeable, with a variable diameter; can be red, pale pink, or white Is a primary lesion
46
Secondary Lesions include- 4 things
1. Crust 2. Excoriation 3. Lichenification 4. Scale
47
Crust
a slightly elevated area of variable size; consists of dried serum, blood, or purulent exudate Is a secondary lesion
48
Excoriation
Linear scratches that may or may not be denuded Is a secondary lesion
49
Lichenification
Rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching (eg, chronic eczema and lichen simplex) Is a secondary lesion
50
Scale
Heaped-up keratinized cells; flakey exfoliation; irregular; thick or thin; dry or oily; variable size; can be white or tan Is a secondary lesion
51
Skin, Hair and Nails Objective Assessment: when INSPECTING look for
Color, shape Lesions (use descriptive terms) Bruising, lacerations, wounds Distributions Clubbing ABCDE for skin cancer screening
52
Skin, Hair and Nails Assessment Objective: When PALPATING FEEL for
Temperature Texture, moisture Turgor Edema Palpable lesions Capillary lesions Capillary refill (Normal is <3 seconds)
53
ABCDE for Skin Cancer Screening
Asymmetry Border Color Diameter Evolving
54
Assessing for Melanoma: Assymetry
If a line is drawn through a mole, the two halves will not match
55
Assessing for Melanoma: Border
The borders of an early melanoma tend to be uneven The edges may be scalloped or notched
56
Assessing for Melanoma: Color
A number of different shades of brown, tan, or black could appear A melanoma may also become red, white or blue
57
Assessing for Melanoma: Diameter
Melanomas usually are larger in diameter than the size of the eraser on your pencil, but may sometimes be smaller when first detected
58
What does HEENT stand for?
Head Ears Eyes Nose Throat
59
What is SUBJECTIVE data having to do with HEENT
Changes in vision or hearing History of allergies, chronic illnesses Exposure to harmful substances or smoking History of infection or trauma Pain Dental care practices
60
What is OBJECTIVE data having to do with HEENT. *Only Head, Face and Nose for now* Inspection
Shape of head Size of head Symmetric and Proportionate Nasal turbinates Cranial Nerve I: Olfactory
61
Terms to document NORMAL findings of head (size and shape)
Normocephalic, symmetric
62
Terms to document NORMAL findings of nose
Nares moist and darker red than oral mucosa No evidence of swelling, bleeding, or discharge reports sense of smell
63
What is OBJECTIVE data having to do with HEENT. *Only Head, Face and Nose for now* Palpation
Masses, symmetry of head Frontal and maxillary sinuses Nasal patency Cranial Nerve V: Trigeminal nerve Cranial Nerve VII: Facial
64
Cranial Nerve V:
Trigeminal Nerve TMJ assessment (move jaw from side to side clenching teeth and assessing pain and sensation
65
Cranial Nerve VII
Facial Ask pt to smile, frown, puff cheeks, etc, Assessing for symmetry and function
66
Cranial Nerve I
Olfactory Nerve- smell
67
Nasal patency
Ask pt to occlude one nare and blow out the other side "patency" means clear and open
68
Normal findings having to do with Head, Face, Nose Objective Assessment
No pain upon palpation of sinuses No masses Nares patent
69
What is OBJECTIVE data having to do with HEENT. *Only Ear now* Inspection
Inspect external ears for shape, size, lesions, cerumen, foreign bodies Internal inspection: Tympanic Membrane
70
What is OBJECTIVE data having to do with HEENT. *Only Ear now* Palpation
Ear and mastoid process
71
OBJECTIVE Assessment of Ear hearing includes
Whisper Test
72
What happens if pt fails whisper test
If pt fails, utilize Weber and Rinne Test
73
Assessment of Ear with Whisper test assesses what nerve?
Cranial Nerve VIII- Acoustic Nerve
74
Normal findings of Objective Ear Assessment
No evidence of cerumen, foreign bodies, pain Ears are aligned and symmetric TM pearly gray with no erythema Patient passes Whisper Test
75
OBJECTIVE Assessment of Eyes: Inspection
Inspect: Eyelids eyelashes, eyebrows (distribution, symmetry, alignment) Cornea Conjunctiva Sclera Direct and Consensual Light Reflex Extraocular Movements Visual acuity checked with Snellen Chart Convergence
76
Eye Assessment Objective: Acronym
PERRLA Pupils Equal Round Reactive Light Accommodation
77
Direct and Consensual Light Reflex- How to test it?
Direct Light Reflex: Shine light in one eye- does it constrict Consensual Light Reflex: Shine light in the same eye- the other eye should constrict as well
78
What nerve does direct and Consensual Light Reflex test?
Checks Cranial Nerve III Oculomotor Nerve
79
Extraocular movements in Eyes- How do you test it?
Follow finger with eye. Move in six cardinal fields of gaze (box shape and back to center each time)
80
What are you looking for when testing for Extraocular movements and are doing the 6 cardinal fields of gaze?
Nystagmus Looking to see if eyes are moving in parallel to each other Are the eyes moving in the right direction Any pain?
81
Extraocular movements assess what cranial nerves?
Checks Cranial Nerve III (oculomotor) Cranial Nerve IV (Trochlear) Cranial Nerve VI (Abducens)
82
Which nerve does the visual acuity test assess for?
Cranial Nerve II: Optic This test is done with Snellen Chart
83
Normal Findings of Objective Eye Assessment
Clear without erythema Symmetrical No swelling or exudate PERRLA EOMs: Eyes move together, parallel, without evidence of nystagmus
84
Abnormal findings of Objective Eye Assessment:
Glaucoma Cataracts Nystagmus Any of the above not appearing on exam
85
Throat Assessment OBJECTIVE: Inspection:
Ask pt to open mouth and use tongue blade and penlight to look inside mouth Assess lips, gingiva, teeth, oral mucosa, tongue, hard and soft palates for color, moisture, lesions and swelling Make pt go "ahh" Ask pt to stick tongue- note symmetry or deviation from midline
86
What cranial nerves are assessed when a pt goes "ahhh"
This assesses: Cranial Nerve IX Cranial Nerve X
87
When a pt sticks out tongue, what cranial nerve are you assessing for?
Cranial Nerve XII Facial
88
When a pt is sticking their tongue out, what about that should you note? (Not talking about nerve type)
Note symmetry or deviation from midline
89
How to inspect the Thyroid
Inspect the thyroid anteriorly
90
What landmarks should you locate when inspecting the Thyroid during the thyroid assessment?
Locate landmarks of the Thyroid cartilage, and the cricoid cartilage
91
How to observe/palpate the Thyroid during Thyroid Assessment?
Observe/palpate left and right by displacing tissue to midline and repeating for other side; palpate also when patient swallows
92
Subjective Component of Thorax and Lung Assessment:
Dyspnea History of trauma or lung surgery Number of pillows used when sleeping Cough, chest pain, allergies Exposure to chemicals Smoking
93
Thorax and Lung Assessment: Order of technique when doing looking for objective data: know the order!
Inspection Palpation Percussion Ausculation
94
Where should you be doing the techniques (ex; palpate, inspect, etc..) on the body?
Anteriorly and Posteriorly
95
What are we INSPECTING for anteriorly and posteriorly for lungs and thorax?
Work of breathing, accessory muscle use Anterior and Posterior diameter Deformities, rashes, lesions Symmetry
96
When we are PALPATING for thorax and lung assessment, what are we assessing for?
We are palpating anteriorly and posteriorly systematically palpate assessing for moisture, masses, tenderness, vibration, symmetry Respiratory expansion Tactile fremitus
97
Tactile Fremetis
Assessment of vibration If increased, can be pneumonia or mass; decreased can be obesity, fluid, COPD, asthma
98
Thorax and Lung Assessment What is the purpose of Percussion in this assessment?
Percussion differentiates between bone, organs, and tissues. Percussion determines if tissues are filled with air, fluid, or solid.
99
What are the sounds of percussion?
Resonant Flat Dull or thudlike sounds Hyperresonant sounds Tympanic sounds
100
Sounds of Percussion: Resonant
low pitched, hollow heard over normal lung tissue
101
Sounds of Percussion: Flat
heard over solid areas such as bone
102
Sounds of Percussion: Dull or thudlike sounds
Heard over dense areas such as organs
103
When would dullness replace resonance during percussion of thorax and lungs?
Dullness replaces resonance when fluid or solid tissue replaces air containing lung tissue such as pneumonia, pleural effusions, or tumors
104
Sounds of Percussion: Hyperresonant sounds
louder and low pitched
105
Who might have hyperresonant sounds?
children, and very thin adults or persons with hyperinflated lungs - COPD, acute asthma attack. An area of hyperresonance on one side of the chest may indicate pneumothorax
106
Sounds of Percussion: Tympanic Sounds
Hollow, high, drumlike sounds. Normally heard over the stomach. Indicate excessive air in the chest such as in pneumothorax
107
Objective Thorax and Lung Assessment Auscultation
Assessed systematically listening for breath sounds that are equal and clear Determining the different sounds based on location Assessing for adventitious sounds Listen for full ventilation
108
Normal Breath Sounds are also called:
Bronchial Bronchiovesicular Vesicular
109
Abnormal (adventitious) sounds are called:
Wheeze Rhonchi Crackles Stridor Friction rub
110
SUBJECTIVE Information to collect during Cardiovascular Assessment
History of chest pain, palpitation, dizziness Swelling in ankles or feet Medications Personal or family history Type and amount of exercise
111
Objective information to collect during cardiovascular assessment: What are the techniques to follow to collect OBJECTIVE information?
1. Inspection 2. Palpation 3. Auscultation
112
What is part of the Neck Vessel Assessment in the Cardiovascular Assessment? (What techniques do you use)
Inspection Palpation Auscultation
113
How should you inspect patient during neck vessel inspection?
Inspection: Supine with patient at 30-45 degree angle
114
How should you palpate pt during Neck Vessel assessment?
Palpate one carotid at a time
115
How should you be auscultating during neck vessel assessment?
Use bell of stethoscope Normally, you should not hear anything You are listening for bruit
116
During the Cardiovascular Assessment, how should you inspect (not talking about Neck vessels now):
Inspection: With pt in supine position Inspect precordium for contour, pulsations, and lifts or heaves (rise along the border of the sternum with each heart beat) Observe the apical impulse at the 5th intercostal space midclavicular line
117
During the Cardiovascular Assessment, how should you palpate (not talking about Neck vessels now):
Use the palmar surface of hand with four fingers held together Palpate precordium for pulsations Proceed in a systematic manner Palpate the apical impulse in the mitral area (note size, duration, force and location in relationship to the midclavicular line)
118
For Assessment of Peripheral Vascular System, what is the SUBJECTIVE data you should be collecting?
Ask pt: History of swelling Perfusion issues Cardiovascular Disease Smoking Diabetes
119
For Assessment of Peripheral Vascular System, how should you collect OBJECTIVE data?
Inspect Palpate
120
What should you be inspecting for the objective data when assessing the peripheral vascular system?
Inspect extremities, bilaterally for redness (erythema), lesions, hair distribution, edema, varicosities
121
What should you be palpating when collecting objective data while assessing the peripheral vascular system?
Palpate for pulses: Brachial Radial Ulnar Femoral Popliteal Posterior tibial Dorsalis pedis
122
Abdominal Assessment: SUBJECTIVE information to collect
Abdominal pain, indigestion, nausea Nutrition Changes in bowel habits Appetite Alcohol ingestion Menstrual history
123
What is the order to collect OBJECTIVE data during Abdominal Assessment?
1. Inspection 2. Auscultation 3. Percussion 4. Palpation
124
OBJECTIVE information to collect during Abdominal Exam: Inspection
When inspecting note: Skin color Contour Pulsations Umbilicus Lesions Masses
125
OBJECTIVE information to collect during Abdominal Exam: Ausculation
When auscultating note: Bowel sounds- abnormal or normal Vascular sounds: bruits
126
When auscultating during the abdominal exam, what are considered normal sounds
Normal: gurgling every 5-30 seconds
127
When auscultating during the abdominal exam, what are considered ABNORMAL sounds?
Hyperactive Hypoactive Absent
128
When auscultating during the abdominal exam, what are hyperactive sounds?
Is an abnormal bowel sound Hyperactive: diarrhea, early bowel obstruction
129
When auscultating during the abdominal exam, what are hypoactive sounds?
Is an abnormal bowel sound Hypoactive: Post-op or late bowel obstruction
130
When auscultating during the abdominal exam, what are absent sounds?
Is an abnormal bowel sound No bowel sounds for 5 minutes- obstruction
131
OBJECTIVE information to collect during Abdominal Exam: Percussion
Systematically- comparing both sides Gas filled has tympanic sound Fluid and solid have dull sound
132
OBJECTIVE information to collect during Abdominal Exam: Palpation
Light palpation Deep palpation Assess for tenderness, palpable organs , guarding, rebound tenderness
133
Breast assessment: SUBJECTIVE data to collect
Ask about pain Ask if they do self examinations of the breast Lumps Swelling Discharge Menstruation- changes in breasts during this time Hormones Recent mammogram
134
OBJECTIVE data to collect during Breast Assessment
Inspect breasts in different positions Assess for lumps, symmetry. pulling Palpate in clockwise motion using pads of three fingers to assess for masses in breast and axillae
135
Most common place for breast cancer?
Tail of Spence
136
When should women be doing their breast self examinations?
The week after their menstrual periods
137
SUBJECTIVE information to collect during MALE genitalia assessment
History of infections Difficulty with urination Discharge Testicular self exam Erectile dysfunction Sexual History
138
OBJECTIVE information to collect during MALE genitalia assessment
Inspection of anatomy Urinary meatus if uncircumsized, document and retract foreskin Should be erythema, tenderness, masses, tensions
139
When is the best time for men to do their testicular self exam?
Once a month after a warm shower
140
SUBJECTIVE information to collect during FEMALE genitalia assessment:
Menarche, menstrual history, sexual history, infections, pain with intercourse, OB history
141
SUBJECTIVE information to collect during musculoskeletal assessment
Trauma, arthritis, neurologic disorders History of pain or swelling in muscles or joints Frequency and type of exercise Dietary intake of calcium Smoking, exercise, and diet history
141
OBJECTIVE information to collect during FEMALE genitalia assessment:
Inspection of anatomy, should be free of erythema, swelling, lesions, discharge. Internal exams are for advanced practice nurses
142
OBJECTIVE information to collect during musculoskeletal assessment: Inspection
Inspect for: Symmetry of muscles spinal curves (scoliosis, lordosis, kyphosis)
143
OBJECTIVE information to collect during musculoskeletal assessment: Palpation
palpate or tenderness for edema
144
What are the three things you check for during OBJECTIVE data collection of musculoskeletal assessment?
Inspection Palpation Range of Motion
145
What are you checking for range of motion for during musculoskeletal assessment?
Range of motion of major joints Neck Shoulders Elbows Wrists Hip Spine Knees Legs Feet
146
How to grade muscle strength while collecting objective information during musculoskeletal assessment?
Grade muscle strength 0-5
147
What does 0 muscle strength mean
no contraction
148
What does 1 muscle strength mean
muscle flicker
149
What does 2 muscle strength mean
muscle can move, not against gravity
150
What does 3 muscle strength mean
movement possible against gravity, not against resistance
151
What does 4 muscle strength mean
movement possible against gravity and some resistance
152
What does 5 muscle strength mean
muscle contracts normally against full resistance
153
Neurologic Assessment SUBJECTIVE info to collect
History of numbness, tingling, seizures, trembling Headaches or dizziness Trauma to head or spine History of HTN or stroke Changes in vision, hearing, taste, or smell History of diabetes or cardiovascular disease Alcohol and medications
154
Neurologic Assessment OBJECTIVE info to collect
Mental status Cranial nerve function Cerebellar function Motor and Sensory function Deep tendon reflexes
155
What is included in mental status when collecting objective info for neurologic assessment?
Mental status: Level of consciousness, level of awareness, behavior, appearance, memory and language
156
What is included in Cerebellar function when collecting objective information for neurologic assessment?
Cerebellar function: Gait assessment (Walk regular, heels, toes), Romberg
157
What is included in Motor and Sensory function when collecting objective information for neurologic assessment?
Motor and Sensory function: rapid alternating movements; light touch, sharp and dull

NURS 402: Lecture (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions