Health Assessment 2220 Exam 1 Flashcards
1
Q
What does health assessment include?
A
encompasses the entire person such as physical, intellectual, spiritual, environmental, sociocultural, and emotional
2
Q
How to conduct health assessment
A
gathering information about health status of pt current and past history, health history subjective, and physical assessment objective
3
Q
types of health assessments
A
initial/comprehensive, focused/episodic, emergency, and time lapsed
4
Q
initial/comprehensive assessment
A
full head to toes exam conducted on admission
5
Q
focused/episodic assessment
A
specific to injury/complain of pt and is conducted after comprehensive exam focused on pt chief complaint (ex: ABD pain requires ABD exam)
6
Q
Emergency Assessment
A
life threatening problems need to be noted and solved immediately; focused on ABCs then secondary complaints; rapid head to toe exam/trauma assessment conducted (ex: stabbings, anaphylaxis, SOB)
7
Q
Time lapsed
A
interval assessment such as taking vital signs every 4 hours or every so many days a pt requires a check up
8
Q
Types of assessment techniques in order
A
Inspection, palpation, percussion, and auscultation
9
Q
Order of assessment for abdominal exam
A
Inspection, auscultation, percussion, palpation (palpating prior to auscultation can create abnormal bowel sounds)
10
Q
inspection assessment
A
what do you see, hear, smell? what size, color, shape, position, symmetrical?
11
Q
palpation assessment
A
feeling of the pt body using palmar surface and fingers for sensitivity, ulnar surface for vibration, dorsal surface for temperature; whats the temp., skin turgor, texture, moisture, vibration, shape?
12
Q
light palpation
A
1cm (0.5”)
13
Q
moderate palpation
A
1cm-2cm (0.5-0.75”)
14
Q
deep palpation
A
2cm (1”)
15
Q
percussion assessment
A
tapping of pt body listening for different sounds that are produced (hollow vs. dense)
16
Q
direct percussion
A
directly tapping on surface of pt
17
Q
blunt percussion
A
using the ulnar surface of fist and thumping your own other hand against pt
18
Q
indirect percussion
A
tapping finger on own other finger/hand against pt
19
Q
auscultation assessment
A
listening to pt organs and bodily systems with stethoscope
20
Q
use for diaphragm
A
to hear higher pitched sounds such as lung sounds, bowel sounds, and normal heart sounds
21
Q
use for bell
A
listen to lower pitched sounds such as murmurs or bruits
22
Q
is bell pressed lightly or firmly when auscultating
A
lightly
23
Q
diaphragm pressed lightly or firmly when auscultating?
A
firmly
24
Q
what are you listening for when auscultating?
A
quality of sounds such as pitch (high or low), loudness (soft or loud), duration (short,medium, or long), quality (description of sound)
25
tips for ausculation
examine from the right of pt, warm stethoscope, close eyes for better attention, auscultate on bare skin
26
general survey importance
begins moment of contact, provides clues to overall health, first impression give cues for what needs attention, establishes pt baseline, includes vitals, H&W
27
What to observe for in general survey
(11) 1. signs of distress, 2. stature/build, 3. speech patterns, 4. Significant others accompanying, 5. Dressing/grooming, 6. posture/gait/coordination, 7. LOC, 8. Eye contact, 9. vision/hearing problems, 10. nutritional state, 11. affect
28
example general survey
pt is 56 Y male construction worker appears healthy and stated age
pt AOx4, cooperative and shwoing no signs of distress
HT 6'1" Wt 202lbs
T- 97.6 P-82bpm RR 16/min BP 122/78 R arm sitting
29
The importance of an interview
establishes trust
30
Health history
biographical data, reason for seeking care, present health or history of present illness, past health, family history, functional assessment & ADLs/psychosocial
31
chief complaint
reason pt is seeking care in their own words
32
present health or HPI
location, character/quality, severity/quantity, timing, setting, aggravating/relieving factors, associated/radiating factors, pt perception; OPQRSTI
33
Past health
childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, OB history, immunizations, last exam, allergies, current meds
34
family history
age and health/cause of death of blood relatives; presence of heart disease, cancer, HTN, CVA, diabetes, cancer, blood disorders, obesity, psychiatric
35
subjective data
symptoms that pt describes; clinician cannot see these and relies on pt word (pain, health history
36
objective data
what can be seen through a general survey and physical examination
37
interviewing techniques
(5) validating- validates correctness of what nurse heard, clarifying- using question to decipher the truth or if something is unclear, reflecting- repeating what pt has said or describing feelings to elaborate, sequencing- used to place events in chronological order to identify cause and effect, directing- obtain more information or introduce something new
38
open ended questions
used to start conversation and obtain information (ex; what concerns do you have about treatment?)
39
close-ended questions
helpful for seeking specific information or clarification (ex: how many times do you take this medication?)
40
communicating with children
be responsive to nonverbal communication, get at eye level, be gentle and calm, use understandable language, use structured play
41
communicating with critically ill
assume they can hear you, explain what you are doing and provide cues about day/night, call bell within reach
42
sources for assessment
reviewing medical records, patient interview, family interview, other providers
43
phases of interview
introduction-purpose of interview, how long it will take, expectations, ensure confidentiality, working- open-ended questions for obtaining info and close-ended for direct questions, closing- summary of the interview
44
functional assessment
self esteem/self-concept: personal identity, body image, role-performance, activity: are they active or sedentary, sleep/rest: adequate sleep, nutrition/elim.: good diet and bowels, stress/adaptations: stressors in life d/t job or family and what coping skills, intimate partner violence: safe at home or stating domestic violence
45
older adult assessment tool
SPICES: sleep disorders, problems with eating, incontinence, confusion, evidence of falls, skin breakdown
46
non-verbal communication
physical appearance and facial expressions (how you present to the pt), posture (get at eye level), gestures, tone of voice and touch (be careful with touch)
47
equipment used for assessments
opthalmoscope for eyes, odoscope for ears, stethothscope for lungs, hear, BP, heart sounds, bowel sounds, pulse ox for sat
48
when are vital signs taken?
admissions, discharge, change in status, every 1-4-8 hours (depending on floor)
49
normal ranges
BP- 120/80, HR-60-100, RR- 12-20, Sat. 95-100 , Core temp. 35.9-38 C or 96.7-100.4F
50
What can affect vitals
pain
51
most accurate temp.
rectal (98.7-100.5)
52
least accurate temp.
axillary
53
ways to measure core temp
tympanic and rectal (rectal usually 1 degree F higher than oral)
54
how to take BP
using sphygmomanometer and stethescope, aneroid (calibrated 2mmHg), needle at 0
55
incorrect BP readings
too small of cuff = higher reading and too large cuff= lower reading; pt has not rester (5 min), consumption of caffeine, smoked, arm not at heart level, pt not quiet
56
factors affecting temperature
circadian rhythm (lowest temp in AM and peak around 4-8PM), age (older = lower core temp.), sex progesterone during ovulation increases temp. (~0.5-1F), environmental temp or consuming warm drink (wait 15 min), increase in metabolic rate (exercise, stress, illness)
57
oral route temp
most common; blue one for mouth; wait 15-30 minutes after iced or hot drink
58
contraindications to oral temp
kids <5 years, confused/unconscious pt, comatose pt, pt with seizure disorders, pt after oral/nasal surgery, pt receiving O2
59
tympanic membrane route
measures core temp (usually 1F higher than oral), good for young, confused/unconscious pt
60
contraindication for tympanic membrane temp.
pt with ear drainage, external ear infection (middle ear infect. is fine), or scars on tympanic membrane
61
temporal
non-inasive, quick, reliable
62
contraindications to temporal artery route temp.
do not measure over scar tissue, open lesions, or abrasions
63
axillary route
used when both oral and rectal are contraindicated, not used when accuracy required, usually 1 F lower than oral
64
core temp measurements
tympanic membrane and rectal
65
rectal temp. route
measures core temp., the most accurate, 1 degree higher than oral, use lubricant, insert in direction of umbilicus 1.5 inch
66
contraindication of rectal temp
pt with diarrhea, bowel surgery, rectal diseases, heart disease or after cardiac surgery, neutropenic pt, pt with spinal cord injury, throbocytopenia
67
factors that afect respirations
(12 factors) age (d/t lung capacity), sex (males lower RR d/t capacity), altitude (increased elevation = increased RR), stree/anxiety (stimulates SNS increasing R), exercise (increase O2 demand increasing RR), medications (narcs depress Resp. drive and stimulants increase), acid-base balance (hyperventilate to release CO2), brain lesions (cheyne stokes), respiratory disease (can affect rate, depth, pattern), pain (incease RR but decreases depth), anemia (decreased O2 carrying which increases RR), fever (increases metabolic rate which increases RR)
68
when counting respirations
do not announce, count to 15 sec and multiply by 4; if irregular count for 1 minute
69
Pulse factors
W>M, pulse decreases with age (infant pulse varies with breathing), SNS increases HR and PNS decreases HR, fever stress, disease, activity increase HR, beta blocker slow down HR, atropine increase HR
70
pulse sites
superficial temporal (forehead), external maxillary (in front of ear), carotid ( at a time), brachial, ulnar, radial, femoral (groin), popliteal (behind knee), posterior tibial (medial posterior to ankle), dorsalis pedis (top of foot)
71
where to palpate on unresponsive
carotid
72
pulse deficit
difference between apical and pulse rates (femoral or radial); not every beat is generating enough blood flow for peripheral pulse
73
when count pulse for 60 seconds
irregular rhythm
74
factors affecting BP
age (increase with age d/t decreased elasticity; wider pulse pressure with age), circadian rhythm (lowest in AM; varies 5-10), sex (w lower than M until menopause), food intake (increases after food), exercise 9increases during exercise), weight (increased BP with increased weight), emotional state (anxiety, pain, fear, excitement, increases BP by stim. SNS), body position (lower in prone/supine), race (higher in African Americans), meds (diuretics decrease BP, oral contraceptives increase BP)
75
Normal BP
120/80 and below
76
Prehypertension
120-129/80
77
stage 1 HTN
130-139/80-89
78
stage 2 HTN
140+/90+
79
HTN crisis
180+/and or 120+
80
Why is normal BP important
HTN is one of leading causes for cardiovascular disorders like MI, stroke, renal failure,\; end organ damage of brain, heart, kidneys
81
orthostatic hypotension
decrease in SBP of 20 or more and decrease of DBP of 10 or more within 3 minutes of standing compared to supine/sitting; d/t vasodilation (HR compensates by increasing)
82
need for O2
less than or equal to 90%
83
inaccurate sat readings
HGB too low, poor Peripheral circ. movement, CO (higher affinity for binding), thick nails, dark nail polish
84
Valves of heart and location
Tricuspid valve (from right atria to right ventricle, pulmonary valve (right ventricle to right pulmonary artery), mitral valve (left atrium to left ventricle), aortic valve (left ventricle to aorta)
85
auscultate aorta
2nd intercostal space, RSB
86
auscultate pulmonary artery
2nd intercostal space, LSB
87
auscultate Erbs point
3rd intercostal space, LST
88
auscultate tricuspid valve
4th intercostal space, LSB
89
auscultate mitral valve
5th intercostal space, mid clavicular line
90
PMI
point of maximal impulse is 5th intercostal space mid clavicular line; apical pulse
91
S1 sounds
closing of AV valves (mitral and Tricuspid); ventricular systole begins
92
S2 sounds
closing of Semilunar valves (pulmonary and aortic); diastole begins
93
diastole
period between S2 and S1
94
systole
area between S1 and S2
95
what are you feeling at the PMI
ventricular recoil
96
documenting pulses
rate, rhythm, and quality; location; amplitude (0-+3)
97
pulse amplitudes
0- absent pulse, unable to palpate, +1- diminished pulse, +2- brisk, normal pulse, +3- bounding pulse
98
how to find/auscultated weak or difficult pulses
use a doppler
99
pack years documenting
15 years of smoking 2.5 packs a day = 37.5 pack year
100
BMI
ratio of weight to height
101
underweight
less than 18.5 BMI
102
normal weight
18.5-24.9 BMI
103
overweight
25-29.9 BMI
104
obese
30-39.9 BMI
105
extreme obesity
40+ BMI
106
Cardiovascular exam
signs and symptoms, lifestyle habits, medications, family history, smoking history
107
signs and symptoms of CV
fatigue, dyspnea, chest pain, SOB, leg cramping, foot sensation (pins and needles), wound healing (slow), edema, arrythmias or palpitations
108
lifestyle habits for CV
alcohol consumption, smoking, exercise, diet
109
family history for CV
HTN, DM, murmurs, CHD, CVD (cardiovascular disease), dyslipidemia (dysfunctional lipids), obesity, LQTS (long QT syndrome)
110
smoking history
type of tobacco or nicotine, when started and stopped, pack years, smoking cessation
111
risk of lung cancer for former smokers
risk is back to those of non smokers after 15 years
112
HDL vs. LDL
HDL keeps arteries clear of plaques; LDL forms plaques causing hardening and narrowing
113
Lipid lab numbers
triglycerides <150mg/dL
Total CHOL <200mg/dL
LDL <100mg/dL
HDL >60mg/dL
114
Cardiopulmonary Inspection
skin color (general, lips, nailbeds); body position (upright or tripod); finger clubbing (from chronic hypoxia); nasal flaring (hypoxia sign); anxiousness or restlessness
115
Central cyanosis
blue lips and due to low arterial O2, cap refill < 3 sec (normal)
116
peripheral cyanosis
normal arterial O2, prolonged cap refill > 3 sec
117
edema
caused by capillaries leaking fluid; scale is +1-+4 (2mm, 4mm, 6mm, 8mm (pitting))
118
causes for edema
hear failure, kidney failure, liver failure, weakness/damage to veins in legs, inadequate lymphatic system, long term protein deficiency, increased cell membrane permeability
119
skin turgor
hydration status; pinched skin should return to normal otherwise it results in tenting
120
location for turgor test
forearm, sternum, sub-clavicular, abdomen In children (do not use back of hands for older adults)
121
types of pain
acute vs chronic
122
acute pain
last less than 6 months (rapid onset), mild - severe, triggers autonomic nervous system (increase HR, BP, and RR), disappears after underlying cause is resolved
123
chronic pain
lasts beyond normal healing period, minimum of 6 months, can be unrelenting and severe or consistent or comes and goes
124
sources of pain
cutaneous/ superficial (skin wound), somatic (tendon, ligament, nerve, bone, blood), visceral (organ pain), referred pain (originates somewhere but is felt elsewhere), neuropathic (pins and needles; disease/lesion of CNS or PNS), intractable pain (resistant to interventions) psychogenic pain (no reason for pain)
125
pain assessment
COLD ERA and OLDCARTS
126
COLD ERA
character of complaint/ pain, onset of symptoms, location, duration or pain, exacerbated by what, relieved by what, associated symptoms
127
OLDCARTS
onset, location, duration, character, aggravating factors/associated symptoms, relieving factors, treatment, severity
128
pain rating scales
Wong baker (faces), 0-10 distress scale, abbey pain scale, nonverbal pain scales (dementia pain scales), FLACC pain scale (2 months-7 years)
129
medical asepsis
hand hygiene and wearing gloves; reduce number of pathogens; keeping clean
130
types of PPE
gloves, gowns, masks, eyewear
131
gowns
prevent soiling of blood/bodily fluids
132
masks
prevent inhalation of large particle aerosols and small droplet nuclei; discourage touching eyes, nose, mouth
133
eyewear
protect eye membrane from splash contamination
134
N95
filtering facepiece respirator; filters out 95% of particles; needs to be fit-tested, can reuse for 5 days
135
donning PPE
wash hands, put on gown, put on mask, put on goggles/face shield, put on gloves (outside of pt room)
136
doffing PPE
(untie gown ties if fasten in front then...), remove gloves, then goggles/face shield, then gown, then mask, then wash hands
137
HAI
healthcare associated infections
138
Types of HAIs
CAUTI, SSI, VAP, CLABSI, MRSA, C-Diff, VRE, CRE
139
CAUTI
catheter associated UTI
140
SSI
surgical site infections
141
VAP
ventilator associated pneumonia
142
CLABSI
central line associated bloodstream infections
143
MRSA
methicillin resist and staphylococcus aureus
144
C-diff
gram pos. bacillus (anaerobic); diarrhea; contact enteric precautions (gloves and gowns); use soap d/t spores
145
types of precautions
contact (direct or indirect), airborne, droplet
146
types of indirect contact
vector (living creature ex: insect) and fomite (inanimate object)
147
how to create correct precaution measures
standard precautions + transmission based
148
standard precautions
blood, all bodily fluids EXCEPT sweat, non-intact skin, mucous membrane
149
contact/contact enteric (intestines) definition and PPE
gown, gloves, handwashing before, disposable equip or clean with chlorhexidine;
150
contact and contact enteric precautions
private room if possible, dedicated equip., door can be open, disposable cleaning supplies, transport- protect surfaces, instructions to visitors are susceptibility and PPE
151
droplet precautions definition and PPE
mask, gown, gloves; infections spread by large particle droplets (ex: rubella, mumps, diptheria)
152
droplet precautions
private room if possible, dedicated equipment, door can be open, transport of pt- mask and tissue receptacle, instructions of visitors- susceptibility and PPE
153
airborne precautions defintion and PPE
TB, varicells, rubeola; resppirator, gown, and gloves (room may have HEPA
154
airborne precautions
private room (neg. pressure and sealed), dedicated equipment, door closed, pt transport requires mask, instruct visitors susceptibility and PPE
155
Reverse (neutropenic) isolastion
private room, dedicated equip., door closed, no standing water in room, no plants/flowers, healthy providers. transport of pt needs mask, visitors should not visit if sick, where proper PPE
156
5 steps of infection prevention
stop at the source, block portal of exit (cover motuh when cough), interrupt mode of transportation (wash hands), protect portal of entry (mucous mebranes), increase defense (vaccines)
157
infectious agent
BACTERIA, fungi, virus, parasite
158
reservoir/host
natural habitat of organism (human, animal, inanimate object)
159
portal of exit
sputum, emesis, stool, blood
160
means of transmission
aerosol, droplet, contact
161
portal of entry
mucous membranes, nonintact skin, GI tract, GU tract, respiratory tract
162
susceptible host
immunosuppressed, elderly, chronically ill, trauma/surgery
163
stages of infections
incubation (pathogen proliferating), prodromal (person is most infectious with vague and nonspecific symptoms), full stage (specific signs and symptoms of disease), convalescent (recovery from infection)
164
gram positive bacteria
1 large cell wall that does stain; easier to kill
165
gram negative bacteria
double phospholipid cell membrane; harder to kill; does not stain
166
broad spectrum vs. narrow spectrum antibiotic
broad kills both whereas narrow kills 1
167
exogenous transmission
entering body from environment
168
endogenous transmission
become infected with own bacteria (micoflora)
169
fungal infections
spread by direct skin contact or indirectly from contaminated floors or soils
