Health Assessment And Physical Examination Flashcards
two types of data
subjective and objective
what the patient tells us about their world is what type of data
subjective
where nurse has results and data/vital signs is what type of data ____
objective
what are the methods of data collection?
interview, nursing health history, physical examination, and diagnostics/lab results
interview has 3 phases
orientation phase, working phase, and termination phase
types of physical assessment are ___
comprehensive, focused, system specific, and ongoing
head to toe, normal assessment is ___
comprehensive
if you have already done comprehensive, and going back to check on one area
focused
system specific
similar to focused
patient comes in often, do head to toe but assess the ongoing issues
ongoing
what’s been going on is the ____
baseline history
vital signs, inspection (looking), ausculation (listening), and palpation (feel) is what part of the assessment
examination
how do you assess a patient?
look, listen, feel
nursing process and physical assessment is done in what order?
assessment, outcome identification, planning, implementation, and evaluation
good lighting, expose all of part to be examined, use penlight for ears, eyes, and mouth. observe for color, shape/symmetry, position and movement is what technique of the assessment?
inspection
touch is what technique of assessment?
palpation
light palpation is how many cm or inch in depth?
1 cm or 0.5 inch
deep palpation is how many cm or inch in depth?
4 cm or 2 inch
listen, frequency (# of oscillations/sound waves) per second generated by vibrating object, loudness (amplitude of a sound wave), quality (descriptive), duration (length of time that sounds last- short, medium, long)
auscultation
smell, abnormal or normal
olfaction
_____ typically taken prior to exam and begin with general survey
health history
_____ is the single most important assessment component and often first clue of deteriorating conditon
level of conciousness
how do you test level of consciousness?
alert, lethargic, obtunded, stuporous/semi-comatose, and comatose
attentive, follows commands, if asleep-wakes up promptly and remains attentive
alert (LOC)
drowsy but awakens, slow to respond
lethargic
difficult to arouse, needs constant stimulation
obtunded
arouses only to vigorous/noxious stimuli, may only withdraw from pain
stuporous/semi-comatose
no response to verbal or noxious stimuli, no movement
comatose
pt oriented to person, place, and town, also known as mentation
cognitive awareness
how do you test cognitive awareness?
name, DOB, where are they right now, what year/day it is, and what brought you in
PERLA is testing on what cranial nerves?
cranial nerves III, IV, and VI
examine size and shape of pupils and compare to scale
pupil response
PERLA stands for _____
pupils, equal, react to, light, and accommodation
using the tip of unlit penlight and have pt follow with eyes only and about 9-12 inches from face in “H” motion is called ____
cardinal gaze
ask patient to smile and show teeth, wrinkle forehead or raise eyebrows, looking for symmetry is testing what cranial nerves
cranial nerve VII
ask patient to touch roof of mouth with tongue, protrude tongue out of mouth and side to side is testing what cranial nerve?
cranial nerve XII
place hands on patient shoulders lightly and ask pt to shrug shoulders is testing what cranial nerve?
cranial nerve XI
BUE means
bilateral upper extremities
BLE means
bilateral lower extremities
crackles or rales, rhonchi, wheezes, and pleural friction rub are what?
abnormal or adventitious sounds of lungs
can be fine or course at the base of the lungs-high pitching popping sounds
crackles or rales
can be cleared with coughing typically, over the trachea and bronchial area (wet sounds ,roaring)
rhonchi
airways get restricted/narrowed, air passing through the tube fast
wheezes
lining around lungs and has fluid here, if lining gets dry, it is rubbing tissue on tissue
pleural friction rub
abnormally slow, under 12 RR
bradypnea
greater than 20
tachypnea
absence of respirations, no respirations or period of apnea
apnea
high respirations
hyperpnea
rapid, deep breathing at a constant rate
kussmaul’s
depth and rate are irregular with periods of apnea
cheyne-stokes
anterior and posterior lung sounds and clubbing of fingers
respiratory components of assessment
systole or S1 and is the sound associated with the closing of the mitral/tricuspid valves
“LUB” sound
diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves
“DUB” sound
when is there a longer pause between what heart sounds?
S2 and S1
location of the heart sounds
aortic, pulmonic, tricuspid, and mitral
aortic location
right base, second intercostal space to the right of the sternal border
pulmonic location
left base, second intercostal space to the left of the sternal border
tricuspid location
left lateral sternal border, 5th intercostal space to the left of the sternal border
mitral location
midclavicular line at the 5th intercostal space
swelling in the extremities is ____
edema
most often on feet and ankles, older adults and standing
dependent edema
venous insufficiency or heart failure; fluid in tissues
pitting edema
heart sounds, cartoid pulses, radial pulses, pedal pulse, capillary refill, assess for edema
cardiac components of assessment
neck ROM, BUE ROM, BLE ROM, HGTW, flexion/extension BUE/BLE are ____
musculoskeletal components of assessment
hydration, temperature, color, texture, rashes, lesions and cracking are assessment of ___
skin
pale or ashen gray
pallor
redness r/t vasodilation (a lot of blood flow to area)
erythemea
yellow, impaired liver (can see in sclera of eye)
juandice
bluish, decreased circulation or oxygenation of blood
cyanosis
____ test is elasticity of skin related to hydration
turgor
caused by kidney or heart failure and leads to excess fluid collection in skin tissue
pitting edema
nails should be ____
transparent, smooth, rounded, convex, and hygienic
patent nares means:
the nostrils are open
excretion of waste products from kidneys and intestines
elimination
process of elimination waste
defecation
semisolid mass of fiber, undigested food, inorganic matter
feces
observe size, shape, contour, skin integrity of abdomen
inspection
bowel size, four quadrants, normal hypoactive, hyperactive- start in RLQ, RUQ, LUQ, LLQ
auscultation
palpate for tenderness, pain, and masses of the abdomen
palpation
inability to control urine or feces
incontinence
to urinate
void
to urinate
micturate
painful or difficult urinating
dysuria
blood in the urine
hematuria
frequent night urination
nocturia
large amounts of urine
polyuria
voiding at intervals
urine frequency
the need to void all at once
urinary urgency
presence of large protein in urine
proteinuria
leakage of urine despite voluntary control of urination
dribbling
accumulation of urine in bladder without the ability to completely empty
retention
urine remaining post void >100 mL
residual
primary regulators of fluid and acid-base balance
kidneys
tubule structures that enter into the bladder
ureters
urine traveling through ureters is typically _____
sterile
ureters enter bladder ____ & ______ to prevent reflux
obliquely and posteriorly
in women the uretha is short, ___ to ____ inches
1.5 inches to 2.5 inches
in men, the uretha is ___ inches, serves in both the GI and reproductive systems
8 inches
in men, the ____ lies against the anterior wall of rectum
bladder
in women, the ___ rest against anterior walls of uterus and vagina
bladder
normal bladder is ____ mL
500
bladder can extend to ____ mL
1000
What are normal sounds of the lungs?
Vesicular, bronchovesicular, and bronchial
Filter and regulate, remove waste from blood to form urine
Kidneys
Transport urine from kidneys to bladder
Ureters
Reservoir for urine until the urge develops
Bladder
Urine travels from bladder and exits through urethral meats
Urethra
