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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
Erythema | skin
redness
25
Hyperhidrosis | skin
excessive perspiration
26
Bromhidrosis | skin
foul smelling perspiration
27
Texture | skin
- smooth, soft, flexible - older adult skin is wrinkled, leather
28
Peripheral Artery Disease (PAD) | vascularity
- pallor - cool skin - absent leg hair - no edema - pins and needles sensation - pulse weakened - pain worsens with elevation - dry wound
29
Causes of PAD
- smoking - atherosclerosis - high cholesterol - obesity - HTN
30
Chronic Venous Insufficiency (CVI) | vascularity
- 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
31
Causes of CVI
- age - obesity - pregnancy - blood clots - smoking
32
Ecchymosis | vascularity
bruise
33
Petechiae | vascularity
small bruise patches
34
What is good skin turgor?
- instant, shows no dehydration
35
Edema
- fluid buildup in tissues, direct trauma or venous return impairment
36
1+ | edema
2mm
37
2+ | edema
4mm
38
3+ | edema
6mm
39
4+ | edema
8mm
40
Primary lesions
- macule (flat, altered color) - papule (elevated, solid) - pustule (acne) - vesicle (varicella) - nodule - tumor - wheal (allergy)
41
Secondary lesions
- scar - keloid - crust (secondary to vesicle) - fissure - erosion - excoriation
42
Skin Cancer
**A**symmetry *unevenness* **B**order *irregularity* **C**olor *black to bluish brown* **D**iameter *>6mm* **E**volution *change in size, shape, color*
43
What is brisk capillary refill?
< 3 seconds
44
What does sluggish capillary refill indicate?
poor circulation
45
Assessing the head
- **palpate** cranial bones - **inspect** facial features - **inspect** scalp - **palpate** front and maxillary sinuses - **palpate** TMJ
46
CN V | cranial nerves
TRIGEMINAL
47
Function of Trigeminal (V) | cranial nerves
sensory: nerve to skin of face motor: muscle of jaw, temporalis, masseter, pterygoid
48
CN VII
Facial
49
Function of Facial (VII) | cranial nerves
motor: muscle of **facial expression** sensory: sense of **taste**
50
CN II
Optic
51
Function of Optic (II) | cranial nerves
visual acuity visual field
52
CN III | cranial nerves
Oculomotor
53
Function of Oculomotor (III) | cranial nerves
- visual field (check for eye fundus with opthamaloscope) - raising of upper eyelid
54
Ptosis
abnormal drooping of upper eyelid over the pupil *impairment of cranial nerve III*
55
CN IV | cranial nerves
Trochlear
56
Function of Trochlear (IV) | cranial nerves
- superior oblique muscle - looking down
57
CN VI | cranial nerves
Abducens
58
Function of Abducens (VI) | cranial nerves
- lateral rectus muscle - lateral eye movement
59
CN VIII | cranial nerves
Auditory
60
Function of Auditory (VIII) | cranial nerves
*only sensory* whisper test romberg test (balance)
61
CN I | cranial nerves
Olfactory
62
Function of Olfactory (I) | cranial nerves
*only sensory* occlude each nostril, let pt identify odor
63
CN IX | cranial nerves
glossopharyngeal
64
Function of Glossopharyngeal (IX)
motor: gag reflex sensory: sense of taste (sour or bitter on back of tongue)
65
CN X | cranial nerves
Vagus
66
Function of Vagus (X) | cranial nerves
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
Assessing the neck
- **inspect** thyroid (instruct pt to swallow) - **palpate** thyroid (roll hands laterally toward sternocleidomastoid) - **auscultate** thyroid (listen for bruit if thyroid palpable)
68
What does jugular vein distention indicate?
fluid overload (right sided heart failure)
69
CN XI | cranial nerves
Spinal accessory
70
Function of Spinal Accessory (XI) | cranial nerves
movement of head and shoulder - trapezius muscle - sternocleidomastoid muscle
71
What are abnormal lymph node findings?
- fixed - large - tender - inflamed
72
Lethargic | neuro status
appears drowsy/asleep but makes spontaneous movement; aroused by gentle shaking and saying pts name
73
Stuporous | neuro status
unconscious most of the time, no spontaneous movement, must be shaken or shouted at to rouse, responds to painful stimuli
74
Comatose | neuro status
cannot be aroused by anything
75
CN XII | cranial nerves
hypoglossal
76
Hypoglossal (XII) Function | cranial nerves
*only motor* stick tongue out, move side to side
77
Glasgow Coma Scale
**eye open** - - *spontaneously = score of 4* **best verbal response** - - *oriented = score of 5* **best motor response** - - *obeys command = score of 6*
78
What does 8 or less indicate on GCS?
coma
79
What does a 3 on the GCS indicate?
brain death lowest score
80
Which part of the brain is affected if a pt is aphasic?
**frontal and temporal lobe** - broca's area: expressive - wernicke's area: receptive
81
Which part of the brain controls intellectual function?
frontal lobe
82
Bronchial | normal breath sounds
high pitched, harsh blowing sounds over the trachea
83
Bronchovesicular | normal breath sounds
medium pitched harsh blowing sounds heard over the bronchus
84
Vesicular | normal breath sounds
soft, low pitched whispering sounds heard over most of the lung fields
85
Rhonchi | adventitious breath sounds
course, low pitch, rumbling, snoring sound, cleared by coughing, air passing through fluid
86
Wheezing | adventitious breath sounds
high pitch, musical sound, louder on **expiration**, air passing through narrowed airways
87
Crackles | adventitious breath sounds
crackling, bubbling sound, heard during **inspiration**, not cleared by coughing, air passing through fluid in the airways
88
Stridor | adventitious breath sounds
harsh, loud high pitched, heard over **inspiration**, narrowing of upper airways; presence of foreign body in airway
89
Friction rub | adventitious breath sounds
rubbing, grating, heard over **inspiration** and **expiration** at the lower lateral anterior surface, inflamed pleura rubbing against chest well
90
Systole (S1)
closure of the mitral and tricuspid, causing the first heart sound
91
Diastole (S2)
closure of the aortic and pulmonic, causing the second heart sound
92
S3 | abnormal heart sounds
congested heart *heart failure*
93
S4 | abormal heart sounds
enlarged heart *cardiomyopathy*
94
Mitral Stenosis | abnormal heart sounds
diastolic murmur
95
Mitral regurgitation | abnormal heart sounds
systolic murmur
96
5 | muscle strength
**normal** full ROM against gravity with full resistance
97
4 | muscle strength
**good** full ROM against gravity with moderate resistance
98
3 | muscle strength
**fair** full ROM with gravity
99
2 | muscle strength
**poor** full ROM without gravity (passive motion)
100
1 | muscle strength
**trace** palpable muscle contraction but no movement
101
0 | muscle strength
**zero** no muscle contraction
102
Kyphosis | the spine
abnormal upper back curvature *hunchback/slouching*
103
Scoliosis | the spine
sideway curve of the spine
104
Lordosis | the spine
spine curves significantly inward *exaggerated arch*

Fundamentals Exam 2 (6 decks)

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