Health Assessment Flashcards
Holistic Health Assessment
Comprehensive evaluation of physical, mental, and emotional aspects
Focused Assessment
Specific evaluation targeting a particular health issue
System-specific Assessment
Evaluation focusing on a particular body system
What are types of physical exams?
comprehensive PE
focused PE
system-specific assessment
ongoing assessment
Ongoing Assessment
Continuous evaluation over time to monitor changes
Rapport
Establishing a positive relationship with the client
Order of physical exam techniques to follow
-inspection
-palpation
-percussion
-auscultation
-olfaction
What body system has an exception to the assessment order and what is the order?
the abdomen
-inspection
-auscultation
-percussion
-palpation
what happens during the inspection phase?
use of sight to gather data & eval each system of body
what happens during the palpation phase?
use of touch to gather data
what happens during the percussion phase?
tapping of fingers on skin using short strokes- produces vibrations
what happens during the auscultation phase?
use of hearing to gather data
direct- no equipment
indirect- equipment
what happens during the olfaction phase?
use of smell to gather data
What are component of the general survey?
personal Identity, appearance and behavior, body type, speech, mental state, hygiene, vitals, height and weight
What do we observe the skin for?
Tone
Temperature
Moisture
Texture
Turgor
what is ecchymosis?
bruising
what is petechiae?
Tiny pinpoint red or reddish-purple spots
what it mottling?
Bluish marbling
what are skin lesions?
Variation in pigment or a break in continuous tissue
- always be suspicious of malignancies
ABCDE:
Asymmetry
Border irregularity
Color variation
Diameter >0.5 cm
Elevation above the skin surface
What to assess the hair for?
inspect and palpate for
Color
Texture
Distribution
Alopecia
Hirsutism
Scalp
Pediculosis
is it free of debris?
What to assess the nails for
color, shape, texture
how to assess eyes
Inspect and palpate external eye structures
Assess vision
Examine the internal eye structures
what is visual acuity?
A measure of the eye’s ability to detect the details of an image
Assess distant, near, peripheral, and color vision
How to assess the neck
palpate the tracheal rings, the cricoid, and the thyroid cartilage, cervical lymph nodes, thyroid
how to assess the lungs
Respiratory rate
Rhythm
Depth
Symmetry
Palpate:
Trachea
Chest
Chest excursion (expandability)
what is rhonchi?
snoring during inspiration and expiration
what is friction rub?
high-pitched grating or rubbing sound that may be heard through the resp cycle. loudest over lower lateral anterior field
The female client admitted for an unrelated diagnosis asks the nurse to check her back because “it itches all the time in that one spot.” When the nurse assesses the client’s back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first?
- Notify the HCP to check the lesion on
rounds. - Measure the lesion and note the color.
- Apply lotion to the lesion.
- Instruct the client to make sure the HCP checks the lesion.
2.
The nurse assesses a clients capillary refill. The nurse notes that the capillary refill was > 3 seconds. Is this finding normal or abnormal?
Abnormal
What is the nurse assessing?
Ask the patient to sit or stand about 2 feet away, facing you sitting or standing at eye level with the patient. Ask the patient to hold the head still and follow the movement of your forefinger or a penlight with the eyes. Keeping your finger or light about 1 foot from the patient’s face, move it slowly through the cardinal positions: up and down, left and right, diagonally up and down to the left, diagonally up and down to the right
extra ocular muscles
what test as the PT maintain balance with the eyes closed?
romberg test
what is the first cranial nerve associated with?
olfaction
During the assessment the nurse notes a small lesion on the patients lower gum line. What would be an appropriate follow up question for the client?
Is the area of the lesion painful?
What does your diet consist of?
Do you smoke or use tobacco products?
Do you smoke or use tobacco products?
General Survey
Initial overall assessment of the client’s appearance and behavior
Client Education
Providing information to clients on health assessment and care
Body Systems
Organized approach to examining different physiological systems
Developmental Differences
Considering developmental variations in assessment and care
Direct Auscultation
Listening without using an instrument.
Indirect Auscultation
Listening with the help of a stethoscope
Olfaction
The use of smell to gather data
The General Survey
Overall impression of the client that begins at first contact and continues through the examination, always considering a client’s cultural background
Erythema
Reddened area
Ecchymosis
Bruised (blue/green/yellow) area
Petechiae
Tiny pinpoint red or reddish-purple spots
Mottling
Bluish marbling
Skin Lesions
Variation in pigment or a break in continuous tissue, requiring assessment of size, shape, pattern, color…
Visual Acuity
A measure of the eye’s ability to detect the details of an image, assessed using distant, near, peripheral, and color vision
Capillary refill
It measures how quickly blood returns to the capillaries after they have been compressed and then released. Normal: <3 seconds.
Peripheral pulses
Normal: amplitude +2, regular, strong, equal bilaterally
Peripheral edema
The swelling of tissues in the extremities, such as the hands, arms, legs, and feet, due to the accumulation of excess fluid in the interstitial spaces.
Kyphosis
Abnormal body shape with a rounded back
Lordosis
Abnormal body shape with exaggerated inward curvature of the spine
Deep tendon reflexes (DTRs)
Reflexes elicited by tapping a tendon with a reflex hammer
Superficial reflexes
Reflexes elicited by stimulating the skin
Genitourinary System
Includes reproductive and urinary systems
Bi-manual exam
Internal examination involving the insertion of two fingers into the vagina
