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Fundamentals Exam 2 > Health Assessment > Flashcards

Health Assessment Flashcards

1
Q

How do you prepare a patient for a health assessment?

A
  • provide privacy and adequate draping (gown)
  • comfortable room temp
  • warm blankets
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1
Q

How do you prepare the environment for an assessment?

A
  • organized equipment
  • soundproof room with adequate lighting
  • easy to manuever exam table/bed
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2
Q

High Fowler’s

A

80-90 degrees
(sitting upright)

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3
Q

Semi Fowler’s

A

30-45 degrees

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4
Q

Fowler’s

A

45-60 degrees
(used for improved breathing)

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5
Q

Low Fowler’s

A

15-30 degrees

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6
Q

Trendelenburg Position

A

lower extremities higher than the head
used during abdominal surgeries

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7
Q

Reverse Trendelenburg

A

lower extremeties lower than the head
helps relieve intracranial pressure

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8
Q

Modified Trendelenburg

A

lower extremeties and head above the heart
helps with venous return

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9
Q

Health History

A
  • biograhical data
  • reason for seeking health care
  • history of present health concern
  • past health history
  • family history
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10
Q

Functional Health Assesment

A
  • assess ADLs (bathing, dressing, toileting)
  • assess independent ADLs (meal prep, transportation, housekeeping)
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11
Q

Lifestyle Factors

A
  • support system
  • activity/exercise
  • sleep/rest
  • nutrition
  • values/beliefs
  • coping/stress
  • substance use
  • sexual history/orientation
  • mental health status
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12
Q

What is the dorsal surface of hand used to assess?

A

Temperature

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13
Q

Which part of the hand is used to assess for masses, size, tenderness, pulses, and texture?

A

finger pads/palmar surface

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14
Q

Which part of the hand is used to assess vibration?

A

palm

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15
Q

What type will the lungs be?

types of sound during percussion

A

resonance

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16
Q

What will the scapula sound like?

types of sound during percussion

A

flat

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17
Q

What will the liver sound like?

types of sound during percussion

A

dull

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18
Q

What type of noise will the stomach make?

types of sound during percussion

A

tympanic

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19
Q

What is included in a general survey?

A
  • general appearance and behavior
  • vitals
  • height and weight
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20
Q

Pallor

skin

A
  • unusual paleness
  • reduced level of oxygen in blood
  • observe in face, buccal mucosa, nail beds
  • for darker individual: skin becomes yellowish brown/ashen gray
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21
Q

Cyanosis

skin

A
  • bluish tint
  • increase in deoxygenated blood
  • observe in lips, nail beds, conjunctivae, palms
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22
Q

Vitiligo

skin

A

loss of pigmentation

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23
Q

Jaundice

skin

A

yellowish tinge
indicates liver problem

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24
Q

Erythema

skin

A

redness

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25
Q

Hyperhidrosis

skin

A

excessive perspiration

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26
Q

Bromhidrosis

skin

A

foul smelling perspiration

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27
Q

Texture

skin

A
  • smooth, soft, flexible
  • older adult skin is wrinkled, leather
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28
Q

Peripheral Artery Disease (PAD)

vascularity

A
  • pallor
  • cool skin
  • absent leg hair
  • no edema
  • pins and needles sensation
  • pulse weakened
  • pain worsens with elevation
  • dry wound
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29
Q

Causes of PAD

A
  • smoking
  • atherosclerosis
  • high cholesterol
  • obesity
  • HTN
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30
Q

Chronic Venous Insufficiency (CVI)

vascularity

A
  • bronze/brown color (iron in HMG)
  • warm to touch
  • normal leg hair
  • edema (pooling of blood)
  • normal sensation
  • normal pulses
  • improved pain upon eleation
  • wet wound
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31
Q

Causes of CVI

A
  • age
  • obesity
  • pregnancy
  • blood clots
  • smoking
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32
Q

Ecchymosis

vascularity

A

bruise

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33
Q

Petechiae

vascularity

A

small bruise patches

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34
Q

What is good skin turgor?

A
  • instant, shows no dehydration
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35
Q

Edema

A
  • fluid buildup in tissues, direct trauma or venous return impairment
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36
Q

1+

edema

A

2mm

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37
Q

2+

edema

A

4mm

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38
Q

3+

edema

A

6mm

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39
Q

4+

edema

A

8mm

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40
Q

Primary lesions

A
  • macule (flat, altered color)
  • papule (elevated, solid)
  • pustule (acne)
  • vesicle (varicella)
  • nodule
  • tumor
  • wheal (allergy)
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41
Q

Secondary lesions

A
  • scar
  • keloid
  • crust (secondary to vesicle)
  • fissure
  • erosion
  • excoriation
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42
Q

Skin Cancer

A

Asymmetry unevenness
Border irregularity
Color black to bluish brown
Diameter >6mm
Evolution change in size, shape, color

43
Q

What is brisk capillary refill?

A

< 3 seconds

44
Q

What does sluggish capillary refill indicate?

A

poor circulation

45
Q

Assessing the head

A
  • palpate cranial bones
  • inspect facial features
  • inspect scalp
  • palpate front and maxillary sinuses
  • palpate TMJ
46
Q

CN V

cranial nerves

A

TRIGEMINAL

47
Q

Function of Trigeminal (V)

cranial nerves

A

sensory: nerve to skin of face
motor: muscle of jaw, temporalis, masseter, pterygoid

48
Q

CN VII

49
Q

Function of Facial (VII)

cranial nerves

A

motor: muscle of facial expression
sensory: sense of taste

50
Q

CN II

51
Q

Function of Optic (II)

cranial nerves

A

visual acuity
visual field

52
Q

CN III

cranial nerves

A

Oculomotor

53
Q

Function of Oculomotor (III)

cranial nerves

A
  • visual field (check for eye fundus with opthamaloscope)
  • raising of upper eyelid
54
Q

Ptosis

A

abnormal drooping of upper eyelid over the pupil
impairment of cranial nerve III

55
Q

CN IV

cranial nerves

56
Q

Function of Trochlear (IV)

cranial nerves

A
  • superior oblique muscle
  • looking down
57
Q

CN VI

cranial nerves

58
Q

Function of Abducens (VI)

cranial nerves

A
  • lateral rectus muscle
  • lateral eye movement
59
Q

CN VIII

cranial nerves

60
Q

Function of Auditory (VIII)

cranial nerves

A

only sensory
whisper test
romberg test (balance)

61
Q

CN I

cranial nerves

62
Q

Function of Olfactory (I)

cranial nerves

A

only sensory
occlude each nostril, let pt identify odor

63
Q

CN IX

cranial nerves

A

glossopharyngeal

64
Q

Function of Glossopharyngeal (IX)

A

motor: gag reflex
sensory: sense of taste (sour or bitter on back of tongue)

65
Q

CN X

cranial nerves

66
Q

Function of Vagus (X)

cranial nerves

A

sensory and motor: speech
sensory: phsrynx, larynx, viscera
motor: larynx
longest and only CN that goes from brain stem to organs of neck, thorax, abdomen

67
Q

Assessing the neck

A
  • inspect thyroid (instruct pt to swallow)
  • palpate thyroid (roll hands laterally toward sternocleidomastoid)
  • auscultate thyroid (listen for bruit if thyroid palpable)
68
Q

What does jugular vein distention indicate?

A

fluid overload (right sided heart failure)

69
Q

CN XI

cranial nerves

A

Spinal accessory

70
Q

Function of Spinal Accessory (XI)

cranial nerves

A

movement of head and shoulder
- trapezius muscle
- sternocleidomastoid muscle

71
Q

What are abnormal lymph node findings?

A
  • fixed
  • large
  • tender
  • inflamed
72
Q

Lethargic

neuro status

A

appears drowsy/asleep but makes spontaneous movement; aroused by gentle shaking and saying pts name

73
Q

Stuporous

neuro status

A

unconscious most of the time, no spontaneous movement, must be shaken or shouted at to rouse, responds to painful stimuli

74
Q

Comatose

neuro status

A

cannot be aroused by anything

75
Q

CN XII

cranial nerves

A

hypoglossal

76
Q

Hypoglossal (XII) Function

cranial nerves

A

only motor
stick tongue out, move side to side

77
Q

Glasgow Coma Scale

A

eye open
- - spontaneously = score of 4

best verbal response
- - oriented = score of 5

best motor response
- - obeys command = score of 6

78
Q

What does 8 or less indicate on GCS?

79
Q

What does a 3 on the GCS indicate?

A

brain death
lowest score

80
Q

Which part of the brain is affected if a pt is aphasic?

A

frontal and temporal lobe
- broca’s area: expressive
- wernicke’s area: receptive

81
Q

Which part of the brain controls intellectual function?

A

frontal lobe

82
Q

Bronchial

normal breath sounds

A

high pitched, harsh blowing sounds over the trachea

83
Q

Bronchovesicular

normal breath sounds

A

medium pitched harsh blowing sounds heard over the bronchus

84
Q

Vesicular

normal breath sounds

A

soft, low pitched whispering sounds heard over most of the lung fields

85
Q

Rhonchi

adventitious breath sounds

A

course, low pitch, rumbling, snoring sound, cleared by coughing, air passing through fluid

86
Q

Wheezing

adventitious breath sounds

A

high pitch, musical sound, louder on expiration, air passing through narrowed airways

87
Q

Crackles

adventitious breath sounds

A

crackling, bubbling sound, heard during inspiration, not cleared by coughing, air passing through fluid in the airways

88
Q

Stridor

adventitious breath sounds

A

harsh, loud high pitched, heard over inspiration, narrowing of upper airways; presence of foreign body in airway

89
Q

Friction rub

adventitious breath sounds

A

rubbing, grating, heard over inspiration and expiration at the lower lateral anterior surface, inflamed pleura rubbing against chest well

90
Q

Systole (S1)

A

closure of the mitral and tricuspid, causing the first heart sound

91
Q

Diastole (S2)

A

closure of the aortic and pulmonic, causing the second heart sound

92
Q

S3

abnormal heart sounds

A

congested heart
heart failure

93
Q

S4

abormal heart sounds

A

enlarged heart
cardiomyopathy

94
Q

Mitral Stenosis

abnormal heart sounds

A

diastolic murmur

95
Q

Mitral regurgitation

abnormal heart sounds

A

systolic murmur

96
Q

5

muscle strength

A

normal
full ROM against gravity with full resistance

97
Q

4

muscle strength

A

good
full ROM against gravity with moderate resistance

98
Q

3

muscle strength

A

fair
full ROM with gravity

99
Q

2

muscle strength

A

poor
full ROM without gravity (passive motion)

100
Q

1

muscle strength

A

trace
palpable muscle contraction but no movement

101
Q

0

muscle strength

A

zero
no muscle contraction

102
Q

Kyphosis

the spine

A

abnormal upper back curvature
hunchback/slouching

103
Q

Scoliosis

the spine

A

sideway curve of the spine

104
Q

Lordosis

the spine

A

spine curves significantly inward
exaggerated arch

Fundamentals Exam 2 (6 decks)

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