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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
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2
Q

Subjective Data

A

Information based on patient experiences and perceptions

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3
Q

Objective

A

Measurable and directly observed

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4
Q

Health assessment includes two components:

A
  1. Health History
  2. Physical Assessment
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5
Q

Health history

A

collection of subjective information about the patient’s health status

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6
Q

Physical assessment

A

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

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7
Q

Types of Health Assessments- 4 types

A
  1. Comprehensive
  2. Ongoing Partial
  3. Focused
  4. Emergency
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8
Q

Comprehensive Health Assessment

A

Conducted upon admission to health care facility

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9
Q

Ongoing Partial Health Assessment

A

Conducted at regular intervals

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10
Q

Focused Health Assessment

A

Conducted to assess a specific problem

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11
Q

Emergency Health Assessment

A

Conducted to determine life threatening or unstable conditions

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12
Q

Considerations When Performing Health Assessment:

A
  1. Lifespan considerations
  2. Cultural Considerations and Sensitivity
  3. Patient Preparation
  4. Environmental Preparations
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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
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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.
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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
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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
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17
Q

Techniques used during a Physical Assessment (say in order)

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Ausculation
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18
Q

Inspection Assesses

A

size
color
shape
position
symmetry

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19
Q

Palpation Assesses:

A

temperature
turgor
texture
moisture
vibrations
shape

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20
Q

Percussion assesses

A

location
shape
size
density of tissues

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21
Q

Auscultation assesses

A

the four characteristics of sound:

pitch
loudness
quality
duration

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22
Q

General survey includes

A

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

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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
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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

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25
Q

Skin Language Terminology

A

Erythema

Ecchymosis

Petechaie

Cyanosis

Jaundice

Pallor

Diaphoresis

Turgor

Edema

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26
Q

Erythema

A

redness (pertaining to skin)

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27
Q

Ecchymosis

A

Collection of blood in
subcutaneous tissue (pertaining to skin)

Medical term for a bruise

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28
Q

Petechiae

A

Hemorrhagic spots/capillary
bleeding (pertaining to skin)

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29
Q

Cyanosis

A

bluish or grayish color (pertaining to skin)

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30
Q

Jaundice

A

yellow color (pertaining to skin)

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31
Q

Pallor

A

Paleness (pertaining to skin)

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32
Q

Diaphoresis

A

Excessive perspiration (pertaining to skin)

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33
Q

Turgor

A

Elasticity (pertaining to skin)

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34
Q

Edema

A

excess fluid (pertaining to skin)

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35
Q

Two types of skin lesions

A
  1. Primary Lesions
  2. Secondary Lesions
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36
Q

Primary Lesions - 9 types

A
  1. Macule
  2. Papule
  3. Vesicle
  4. Pustule
  5. Bulla
  6. Cyst
  7. Nodule
  8. Plaque
  9. Wheal
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37
Q

Macule

A

a flat, circumscribed area; can be brown, red, white, tan

Is a primary lesion

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38
Q

Papule

A

An elevated, palpable, firm, circumscribed area generally less than 5 mm in diameter

Is a primary lesion

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39
Q

Vesicle

A

an elevated, circumscribed, superficial, fluid-
filled blister less than 5 mm in diameter

Is a primary lesion

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40
Q

Pustule

A

An elevated, superficial area that is similar to a
vesicle but filled with pus

Is a primary lesion

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41
Q

Bulla

A

A vesicle greater than 5
mm in diameter

Is a primary lesion

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42
Q

Cyst

A

An elevated, circumscribed area of the skin filled
with liquid or semisolid fluid

Is a primary lesion

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43
Q

Nodule

A

An elevated, firm, circumscribed, and palpable
area greater than 5 mm in diameter; can involve all skin layer

Is a primary lesion

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44
Q

Plaque

A

An elevated, flat-topped, firm, rough, superficial papule greater than 2 cm in diameter; papules can coalesce to form plaques

Is a primary lesion

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45
Q

Wheal

A

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

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46
Q

Secondary Lesions include- 4 things

A
  1. Crust
  2. Excoriation
  3. Lichenification
  4. Scale
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47
Q

Crust

A

a slightly elevated area of variable size; consists of dried
serum, blood, or purulent exudate

Is a secondary lesion

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48
Q

Excoriation

A

Linear scratches that may or may not be denuded

Is a secondary lesion

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49
Q

Lichenification

A

Rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching (eg, chronic eczema and lichen simplex)

Is a secondary lesion

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50
Q

Scale

A

Heaped-up keratinized cells; flakey exfoliation; irregular;
thick or thin; dry or oily; variable size; can be white or tan

Is a secondary lesion

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51
Q

Skin, Hair and Nails Objective Assessment: when INSPECTING look for

A

Color, shape

Lesions (use descriptive terms)

Bruising, lacerations, wounds

Distributions

Clubbing

ABCDE for skin cancer screening

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52
Q

Skin, Hair and Nails Assessment Objective: When PALPATING FEEL for

A

Temperature

Texture, moisture

Turgor

Edema

Palpable lesions

Capillary lesions

Capillary refill (Normal is <3 seconds)

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53
Q

ABCDE for Skin Cancer Screening

A

Asymmetry

Border

Color

Diameter

Evolving

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54
Q

Assessing for Melanoma: Assymetry

A

If a line is drawn through a mole, the two halves will not match

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55
Q

Assessing for Melanoma: Border

A

The borders of an early melanoma tend to be uneven

The edges may be scalloped or notched

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56
Q

Assessing for Melanoma: Color

A

A number of different shades of brown, tan, or black could appear

A melanoma may also become red, white or blue

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57
Q

Assessing for Melanoma: Diameter

A

Melanomas usually are larger in diameter than the size of the eraser on your pencil, but may sometimes be smaller when first detected

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58
Q

What does HEENT stand for?

A

Head
Ears
Eyes
Nose
Throat

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59
Q

What is SUBJECTIVE data having to do with HEENT

A

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

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60
Q

What is OBJECTIVE data having to do with HEENT.
Only Head, Face and Nose for now

Inspection

A

Shape of head

Size of head

Symmetric and Proportionate

Nasal turbinates

Cranial Nerve I: Olfactory

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61
Q

Terms to document NORMAL findings of head (size and shape)

A

Normocephalic, symmetric

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62
Q

Terms to document NORMAL findings of nose

A

Nares moist and darker red than oral mucosa

No evidence of swelling, bleeding, or discharge

reports sense of smell

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63
Q

What is OBJECTIVE data having to do with HEENT.
Only Head, Face and Nose for now

Palpation

A

Masses, symmetry of head

Frontal and maxillary sinuses

Nasal patency

Cranial Nerve V: Trigeminal nerve

Cranial Nerve VII: Facial

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64
Q

Cranial Nerve V:

A

Trigeminal Nerve

TMJ assessment (move jaw from side to side clenching teeth and assessing pain and sensation

65
Q

Cranial Nerve VII

A

Facial

Ask pt to smile, frown, puff cheeks, etc,

Assessing for symmetry and function

66
Q

Cranial Nerve I

A

Olfactory Nerve- smell

67
Q

Nasal patency

A

Ask pt to occlude one nare and blow out the other side

“patency” means clear and open

68
Q

Normal findings having to do with Head, Face, Nose Objective Assessment

A

No pain upon palpation of sinuses

No masses

Nares patent

69
Q

What is OBJECTIVE data having to do with HEENT.
Only Ear now

Inspection

A

Inspect external ears for shape, size, lesions, cerumen, foreign bodies

Internal inspection: Tympanic Membrane

70
Q

What is OBJECTIVE data having to do with HEENT.
Only Ear now

Palpation

A

Ear and mastoid process

71
Q

OBJECTIVE Assessment of Ear hearing includes

A

Whisper Test

72
Q

What happens if pt fails whisper test

A

If pt fails, utilize Weber and Rinne Test

73
Q

Assessment of Ear with Whisper test assesses what nerve?

A

Cranial Nerve VIII- Acoustic Nerve

74
Q

Normal findings of Objective Ear Assessment

A

No evidence of cerumen, foreign bodies, pain

Ears are aligned and symmetric

TM pearly gray with no erythema

Patient passes Whisper Test

75
Q

OBJECTIVE Assessment of Eyes: Inspection

A

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
Q

Eye Assessment Objective: Acronym

A

PERRLA

Pupils
Equal
Round
Reactive
Light
Accommodation

77
Q

Direct and Consensual Light Reflex- How to test it?

A

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
Q

What nerve does direct and Consensual Light Reflex test?

A

Checks Cranial Nerve III Oculomotor Nerve

79
Q

Extraocular movements in Eyes- How do you test it?

A

Follow finger with eye.

Move in six cardinal fields of gaze

(box shape and back to center each time)

80
Q

What are you looking for when testing for Extraocular movements and are doing the 6 cardinal fields of gaze?

A

Nystagmus

Looking to see if eyes are moving in parallel to each other

Are the eyes moving in the right direction

Any pain?

81
Q

Extraocular movements assess what cranial nerves?

A

Checks

Cranial Nerve III (oculomotor)

Cranial Nerve IV (Trochlear)

Cranial Nerve VI (Abducens)

82
Q

Which nerve does the visual acuity test assess for?

A

Cranial Nerve II: Optic

This test is done with Snellen Chart

83
Q

Normal Findings of Objective Eye Assessment

A

Clear without erythema

Symmetrical

No swelling or exudate

PERRLA

EOMs: Eyes move together, parallel, without evidence of nystagmus

84
Q

Abnormal findings of Objective Eye Assessment:

A

Glaucoma

Cataracts
Nystagmus

Any of the above not appearing on exam

85
Q

Throat Assessment OBJECTIVE:

Inspection:

A

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
Q

What cranial nerves are assessed when a pt goes “ahhh”

A

This assesses:

Cranial Nerve IX
Cranial Nerve X

87
Q

When a pt sticks out tongue, what cranial nerve are you assessing for?

A

Cranial Nerve XII Facial

88
Q

When a pt is sticking their tongue out, what about that should you note? (Not talking about nerve type)

A

Note symmetry or deviation from midline

89
Q

How to inspect the Thyroid

A

Inspect the thyroid anteriorly

90
Q

What landmarks should you locate when inspecting the Thyroid during the thyroid assessment?

A

Locate landmarks of the Thyroid cartilage, and the cricoid cartilage

91
Q

How to observe/palpate the Thyroid during Thyroid Assessment?

A

Observe/palpate left and right by displacing tissue to midline and repeating for other side;

palpate also when patient swallows

92
Q

Subjective Component of Thorax and Lung Assessment:

A

Dyspnea

History of trauma or lung surgery

Number of pillows used when sleeping

Cough, chest pain, allergies

Exposure to chemicals

Smoking

93
Q

Thorax and Lung Assessment:
Order of technique when doing looking for objective data: know the order!

A

Inspection

Palpation

Percussion

Ausculation

94
Q

Where should you be doing the techniques (ex; palpate, inspect, etc..) on the body?

A

Anteriorly and Posteriorly

95
Q

What are we INSPECTING for anteriorly and posteriorly for lungs and thorax?

A

Work of breathing, accessory muscle use

Anterior and Posterior diameter

Deformities, rashes, lesions

Symmetry

96
Q

When we are PALPATING for thorax and lung assessment, what are we assessing for?

A

We are palpating anteriorly and posteriorly

systematically palpate assessing for moisture, masses, tenderness, vibration, symmetry

Respiratory expansion

Tactile fremitus

97
Q

Tactile Fremetis

A

Assessment of vibration

If increased, can be pneumonia or mass; decreased can be obesity, fluid, COPD, asthma

98
Q

Thorax and Lung Assessment

What is the purpose of Percussion in this assessment?

A

Percussion differentiates between bone, organs, and tissues.

Percussion determines if tissues are filled with air, fluid, or solid.

99
Q

What are the sounds of percussion?

A

Resonant

Flat

Dull or thudlike sounds

Hyperresonant sounds

Tympanic sounds

100
Q

Sounds of Percussion: Resonant

A

low pitched, hollow heard over normal lung tissue

101
Q

Sounds of Percussion: Flat

A

heard over solid areas such as bone

102
Q

Sounds of Percussion: Dull or thudlike sounds

A

Heard over dense areas such as organs

103
Q

When would dullness replace resonance during percussion of thorax and lungs?

A

Dullness replaces resonance when fluid or solid tissue replaces air containing lung tissue such as pneumonia, pleural effusions, or tumors

104
Q

Sounds of Percussion: Hyperresonant sounds

A

louder and low pitched

105
Q

Who might have hyperresonant sounds?

A

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
Q

Sounds of Percussion: Tympanic Sounds

A

Hollow, high, drumlike sounds.

Normally heard over the stomach. Indicate excessive air in the chest such as in pneumothorax

107
Q

Objective Thorax and Lung Assessment

Auscultation

A

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
Q

Normal Breath Sounds are also called:

A

Bronchial

Bronchiovesicular

Vesicular

109
Q

Abnormal (adventitious) sounds are called:

A

Wheeze

Rhonchi

Crackles

Stridor

Friction rub

110
Q

SUBJECTIVE Information to collect during Cardiovascular Assessment

A

History of chest pain, palpitation, dizziness

Swelling in ankles or feet

Medications

Personal or family history

Type and amount of exercise

111
Q

Objective information to collect during cardiovascular assessment: What are the techniques to follow to collect OBJECTIVE information?

A
  1. Inspection
  2. Palpation
  3. Auscultation
112
Q

What is part of the Neck Vessel Assessment in the Cardiovascular Assessment? (What techniques do you use)

A

Inspection

Palpation

Auscultation

113
Q

How should you inspect patient during neck vessel inspection?

A

Inspection:
Supine with patient at 30-45 degree angle

114
Q

How should you palpate pt during Neck Vessel assessment?

A

Palpate one carotid at a time

115
Q

How should you be auscultating during neck vessel assessment?

A

Use bell of stethoscope

Normally, you should not hear anything

You are listening for bruit

116
Q

During the Cardiovascular Assessment, how should you inspect (not talking about Neck vessels now):

A

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
Q

During the Cardiovascular Assessment, how should you palpate (not talking about Neck vessels now):

A

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
Q

For Assessment of Peripheral Vascular System, what is the SUBJECTIVE data you should be collecting?

A

Ask pt:

History of swelling
Perfusion issues
Cardiovascular Disease
Smoking
Diabetes

119
Q

For Assessment of Peripheral Vascular System, how should you collect OBJECTIVE data?

A

Inspect
Palpate

120
Q

What should you be inspecting for the objective data when assessing the peripheral vascular system?

A

Inspect extremities, bilaterally for redness (erythema), lesions, hair distribution, edema, varicosities

121
Q

What should you be palpating when collecting objective data while assessing the peripheral vascular system?

A

Palpate for pulses:

Brachial
Radial
Ulnar
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

122
Q

Abdominal Assessment: SUBJECTIVE information to collect

A

Abdominal pain, indigestion, nausea

Nutrition

Changes in bowel habits

Appetite

Alcohol ingestion

Menstrual history

123
Q

What is the order to collect OBJECTIVE data during Abdominal Assessment?

A
  1. Inspection
  2. Auscultation
  3. Percussion
  4. Palpation
124
Q

OBJECTIVE information to collect during Abdominal Exam: Inspection

A

When inspecting note:

Skin color

Contour

Pulsations

Umbilicus

Lesions

Masses

125
Q

OBJECTIVE information to collect during Abdominal Exam: Ausculation

A

When auscultating note:

Bowel sounds- abnormal or normal

Vascular sounds: bruits

126
Q

When auscultating during the abdominal exam, what are considered normal sounds

A

Normal: gurgling every 5-30 seconds

127
Q

When auscultating during the abdominal exam, what are considered ABNORMAL sounds?

A

Hyperactive

Hypoactive

Absent

128
Q

When auscultating during the abdominal exam, what are hyperactive sounds?

A

Is an abnormal bowel sound

Hyperactive: diarrhea, early bowel obstruction

129
Q

When auscultating during the abdominal exam, what are hypoactive sounds?

A

Is an abnormal bowel sound

Hypoactive: Post-op or late bowel obstruction

130
Q

When auscultating during the abdominal exam, what are absent sounds?

A

Is an abnormal bowel sound

No bowel sounds for 5 minutes- obstruction

131
Q

OBJECTIVE information to collect during Abdominal Exam: Percussion

A

Systematically- comparing both sides

Gas filled has tympanic sound

Fluid and solid have dull sound

132
Q

OBJECTIVE information to collect during Abdominal Exam: Palpation

A

Light palpation

Deep palpation

Assess for tenderness, palpable organs , guarding, rebound tenderness

133
Q

Breast assessment: SUBJECTIVE data to collect

A

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
Q

OBJECTIVE data to collect during Breast Assessment

A

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
Q

Most common place for breast cancer?

A

Tail of Spence

136
Q

When should women be doing their breast self examinations?

A

The week after their menstrual periods

137
Q

SUBJECTIVE information to collect during MALE genitalia assessment

A

History of infections

Difficulty with urination

Discharge

Testicular self exam

Erectile dysfunction

Sexual History

138
Q

OBJECTIVE information to collect during MALE genitalia assessment

A

Inspection of anatomy

Urinary meatus

if uncircumsized, document and retract foreskin

Should be erythema, tenderness, masses, tensions

139
Q

When is the best time for men to do their testicular self exam?

A

Once a month after a warm shower

140
Q

SUBJECTIVE information to collect during FEMALE genitalia assessment:

A

Menarche, menstrual history, sexual history, infections, pain with intercourse, OB history

141
Q

SUBJECTIVE information to collect during musculoskeletal assessment

A

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
Q

OBJECTIVE information to collect during FEMALE genitalia assessment:

A

Inspection of anatomy, should be free of erythema, swelling, lesions, discharge.

Internal exams are for advanced practice nurses

142
Q

OBJECTIVE information to collect during musculoskeletal assessment: Inspection

A

Inspect for:

Symmetry of muscles

spinal curves (scoliosis, lordosis, kyphosis)

143
Q

OBJECTIVE information to collect during musculoskeletal assessment:
Palpation

A

palpate or tenderness for edema

144
Q

What are the three things you check for during OBJECTIVE data collection of musculoskeletal assessment?

A

Inspection

Palpation

Range of Motion

145
Q

What are you checking for range of motion for during musculoskeletal assessment?

A

Range of motion of major joints

Neck
Shoulders
Elbows
Wrists
Hip
Spine
Knees
Legs
Feet

146
Q

How to grade muscle strength while collecting objective information during musculoskeletal assessment?

A

Grade muscle strength 0-5

147
Q

What does 0 muscle strength mean

A

no contraction

148
Q

What does 1 muscle strength mean

A

muscle flicker

149
Q

What does 2 muscle strength mean

A

muscle can move, not against gravity

150
Q

What does 3 muscle strength mean

A

movement possible against gravity, not against resistance

151
Q

What does 4 muscle strength mean

A

movement possible against gravity and some resistance

152
Q

What does 5 muscle strength mean

A

muscle contracts normally against full resistance

153
Q

Neurologic Assessment SUBJECTIVE info to collect

A

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
Q

Neurologic Assessment OBJECTIVE info to collect

A

Mental status

Cranial nerve function

Cerebellar function

Motor and Sensory function

Deep tendon reflexes

155
Q

What is included in mental status when collecting objective info for neurologic assessment?

A

Mental status: Level of consciousness, level of awareness, behavior, appearance, memory and language

156
Q

What is included in Cerebellar function when collecting objective information for neurologic assessment?

A

Cerebellar function: Gait assessment (Walk regular, heels, toes), Romberg

157
Q

What is included in Motor and Sensory function when collecting objective information for neurologic assessment?

A

Motor and Sensory function: rapid alternating movements; light touch, sharp and dull

NURS 402: Lecture (17 decks)

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