Health Assessment- Exam 3 Flashcards
1
Q
Level of consciousness
A
- single most important neuro assessment component
- often first clue of deteriorating condition
2
Q
Testing level of consciousness (LOC)
ALERT
A
Attentive, follows commands, if asleep - wakes promptly and remains attentive
3
Q
Testing level of consciousness (LOC)
LETHARGIC
A
drowsy but awakens, slow to respond
4
Q
Testing level of consciousness (LOC)
OBTUNDED
A
difficult to arouse, needs constant stimulation
5
Q
Testing level of consciousness (LOC)
STUPOROUS/ SEMI COMATOSE
A
arouses only to vigorous/noxious stimuli, may only withdraw from pain
6
Q
Testing level of consciousness (LOC)
COMATOSE
A
No response to verbal or noxious stimuli, no movement except deep tendon reflex
7
Q
Testing level of consciousness (LOC)
What to look for?
ALOSC
A
Alert
Lethargic
obtunded
Stuporous/ semi-comatose
Comatose
8
Q
Cognitive awareness also known as mentation
A
Is the patient oriented to person, place, and time?
Also know as mentation
9
Q
Testing cognitive awareness
A
What is your name and date of birth?
> oriented to person
Where are you right now?
> orientated to place
What year/day is it?
> oriented to time
10
Q
Cranial nerves
A
- 12 pairs
- sensory, motor, or both
- not all cranial nerves are always tested
- listed in order of testing
11
Q
Olfactory
What number?
A
I
12
Q
Optic
A
II
13
Q
Oculomotor
A
III
14
Q
Trochlear
A
IV
15
Q
Trigeminal
A
V
16
Q
Abducens
A
VI
17
Q
Facial
A
VII
18
Q
Vestibulocochlear
A
VIII
19
Q
Glossopharyngeal
A
IX
20
Q
Vagus
A
X
21
Q
Accessory
A
XI
22
Q
Hypoglossal
A
XII
23
Q
Testing cranial nerves III, IV, and VI
Oculomotor, trochlear, abducens
A
Pupil response and cardinal gaze
24
Q
Pupil response
A
-Examine size and shape of pupils and compare to scale
- start at ear with penlight and move in toward nose
- note change in size and speed of reaction
- with penlight, move penlight close to and away from pupils
25
PERRLA
P Pupils
E equal
R round
R react to
L light and
A accommodations
26
Cardinal gaze
-Use top of unlit penlight
- have pt follow with eyes only
- about 9-12” from face move the end of penlight in an “H” motion
27
Testing cranial nerve VII
Facial
-Ask patient to smile and show teeth
- Ask patient to wrinkle forehead or raise eyebrows
28
Testing cranial nerve XII
Hypoglossal
Ask patient to touch the roof of the mouth with tongue
Protrude tongue out of mouth
Move tongue from side to side
29
Testing cranial nerve XI
Accessory
Place hands lightly on patient shoulders
Ask patient to shrug shoulders
30
Testing motor function
Will complete as part of neuro and musculoskeletal assessments
- hand grasp and toe wiggle ( HGTW)
- flexion and extension with resistance
- all done bilaterally on BUE and BLE
31
Neuro components of assessment
LOC and orientation
Pupil response and cardinal gaze
Smile and show teeth, raise eyebrows
Tongue to roof of mouth, out, side to side
Shoulder strength with resistance
HGTW
Flexion/ extension BUE and BLE
32
Auscultation of the lungs - normal sounds
Vesicular - periphery of the lungs
Bronchovesticular- closer to the sternum
Bronchial - over trachea
33
Vestibular lung sounds
Periphery of the lungs
34
Bronchovesticular of the lungs
Closer to the sternum
35
Bronchial of the lungs
Over trachea
36
Abnormal or adventitious sounds
Crackles or rales - can be fine or course
rhonchi
Wheezes
Pleural friction rub
37
Abnormal respiratory patterns
Bradypnea
Tachypnea
Apnea
Hyperpnea
Kussmauls
Cheyne-Stokes
38
Nail shape
What to examine
Examine BUE nail shape
Clubbing
39
Respiratory components of assessment
Anterior and posterior lung sounds
Clubbing
40
LUB - heart sounds
Systole or S1 and is the sound associated with the closing of the mitral/ tricuspid valves
41
DUB - heart sounds
Diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves
42
Aortic location
Right base; second intercoastal space to the right of the sternal border
43
Pulmonic heart sounds
Left base; second intercostal space to the left of the sternal border
44
Tricuspid heart sounds
Left lateral sternal border; fifth intercostal space to the left of the sternal border
45
Mitral heart sound
Apex, midclavicular line at the fifth intercostal space
46
Pulses
Carotid
Brachial
Radial
Ulnar
Apical
Femoral
Popliteal
Dorsalis pedis
47
Assessment of pulses - Carotid
One at a time, bilaterally
48
Assessment of pulses - Radial
Bilaterally at the same time
49
Assessment of pulses - apical
With stethoscope for 2 beats
50
Assessment of pulses - dorsalis Pedis pulses
Bilaterally at the same time
51
Pulse points - 0
Absent, non-palpable
52
Pulse points- 1+
Diminished, palpable
53
Pulse points- 2+
Strong, normal
54
Pulse points - 3+
Full, increased
55
Pulse points- 4+
Bounding
56
Assessment via Doppler
Hand held device
Most often used for pedal places
57
Capillary refill assessment
Pressed skin of nail bed to produce blanching, release pressure and observe time taken for color Return, should be less than 2 to 3 seconds, BUE and BLE
58
Edema Assessment
Swelling in the extremities
59
Dependent edema located
Most often on feet and ankles, older adults
60
Pitting edema
Venous, insufficiency, or heart failure, fluid in tissues
61
Cardiac components of assessment
Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for edema 
62
Range of motion
Neck
Shoulders, upper arms, and elbows
Wrists
Hips
Knees
Ankles 
63
Neck range of motion
Move next side to side
Chin to chest
Extension back 
64
Shoulders and upper arms and elbows range of motion
Arms out to side
Arm straight up
Touchdown 
65
Wrist range of motion
Wrist circles
66
Hips, knees, and ankles range of motion
Bilateral hip flexion out
Bend knees
Ankle circles 
67
Strength
Hand grip
Total wiggle
Flexion and extension BUE/BLE
68
Musculoskeletal components of assessment
- Neck ROM
- BUE ROM
- BLE ROM
- HGTW
- flexion/extension BUE and BLE
69
Assessment of skin- inspect head to toe for
Hydration
Temperature
Color
Texture
Rashes
Lesions
Cracking 
70
Pallor
Pale, or ashen gray
71
Erythema
Redness r/t vasodilation 
72
Jaundice
Yellow impaired liver
73
Cyanosis
Bluish, decree circulation or oxygenation of blood
74
Skin characteristics - temp 
Temp should be warm, consistent with room temp
75
Skin characteristics - moisture
Moisture from diaphoresis or dry from dehydration
76
Skin characteristics - texture 
Texture can be dry in course (elbow/knee) or shiny with no hair (impaired peripheral circulation) 
77
Skin characteristics - Turgor 
Turgor test, elasticity of skin related to hydration 
78
Factors affecting the skin
Dampness
Dehydration
Nutrition
Circulation
Disease
Jaundice
Lifestyle 
79
Normal skin changes in older adults
Epidermidis
Subcutaneous tissue
Collagen and elastin fibers
Hormones
Vascularity
Hair follicles
Melanocytes
Nails
Skin growths
80
Pitting edema is caused by
By kidney or heart failure
Leads to excess fluid collection in tissues
81
Assessment of bony prominences 
Hips, heels, coccyx, shoulders
Assess for skin integrity
Blanching red spots
82
Assessment of nails
Shape
Contour
Cleanliness
Neatly manicured/trimmed 
83
Nails should be..
Transparent
Smooth
Rounded
Convex
Hygienic 
84
Assessment of hair - Terminal
Scalp, axillae, pubic, and beard 
85
Assessment of hair - Vellus hair 
Soft tiny hairs covering body, except on palms and soles 
86
Assessment of hair- what to look for
Quantity- alopecia, hirsutism
Distribution
Texture
Color
Parasites 
87
Assessment of ears
Symmetry
Drainage
Shape
Hearing defects
Lesions
Redness
Tenderness
Odor 
88
Assessment of nose- what to look for
Position
Symmetry
Color
Swelling
Deformities
Discharge
Flaring
Patency
Sinus tenderness 
89
Inspect oral cavity
Lips
Oral mucosa
Teeth
Gum/tongue
Breath odor
90
Inspect throat for
Lumps
Ulcers
Edema
White spots
Redness
Swallowing 
91
Assessment of neck- inspect neck for
Contour and symmetry
Midline trachea
Jugular 
92
Integument components of assessment
What all do we inspect when it comes to the skin?
Inspect hair and scalp
Inspect ears
Inspect nose
Inspect mouth and throat
Inspect and palpate neck
Excess skin Turgor
Inspect skin on back and bony prominences
Inspect skin of BUE and BLE
Inspect nails 
93
Elimination
Excretion of waste products from kidneys and intestines
94
Defecation
Process of elimination of waste
95
Feces
Semi solid mass of fiber, undigested, food, in organic matter 
96
Incontinence
Inability to control, urine or feces 
97
Void
To urinate
98
Micturate
To urinate
99
Dysuria
Painful or difficult urination 
100
Hematuria
Blood in the urine
101
Nocturia
Frequent night urination 
102
Polyuria
Large amounts of urine
103
Urinary frequency
Voiding at frequent intervals 
104
Proteinuria
Presence of large protein in urine 
105
Dribbling
Leakage of urine, despite voluntary control of urination
106
Retention
Accumulation of urine in bladder, without the ability to completely empty 
107
Residual
Urine remaining post void >100ml
108
Structures of the gastrointestinal tract
Upper gastrointestinal tract
Small intestine
Large intestine
Rectum and anus
109
Small intestine
-Folded, twisted, and coiled tube from stomach to large intestine
- 1” diameter and 20 feet long
- most digestion and absorption happens here
- chyme travels via peristalsis
- 3 segments
> duodenum
> jejunum
> ileum
110
Large intestine
- colon
- 2.5” diameter and 5-6’ long
- 7 segments
> Cecum
> ascending colon
> transverse colon
> descending colon
> sigmoid colon
> rectum
> anus
111
Kidneys
Filter and regulate
Remove waste from blood to form urine
112
Ureters
Transport urine from kidneys to bladder
113
Bladder
Reservoir for urine until the urge develops
114
Urethra
Urine travels from one and exits through urethral meatus 
115
Kidneys pt 2
Bilateral
Posterior flanks
Size of fists
Primary regulators of fluid and acid base balance
116
Nephron
Functional unit of the kidney
117
What makes up the Kidneys?
Nephron
Glomerulus
Bowman’s capsule
Proximal convoluted tubule
Loop of Henle
Distal tubule
Collecting duct
118
Ureters
Tubule structures
Urine traveling through ureters is typically sterile
Ureters, enter bladder, obliquely, and posterior lead to prevent reflux
Obstructions cause peristaltic waves, severe pain often referred to as renal colic 
119
Bladder
Hollow, distensible, muscular organ
In men- bladder lies against interior wall of rectum
In women - bladder rest against interior walls of uterus and vagina
When bladder is full, it extends above symphysis pubis
Normal bladder - 500ml
Can exceed to 1000 mL 
120
Urethra
Turbulent flow washes urethra free of bacteria
Dissents through pelvic floor muscles
Contraction of pelvic floor, muscles can’t prevent flow of urine
In women urethra is short 1 1/2 -2 1/2 in leads to prevalence of infection
In men, urethra is long 8 inches serves in both GU and reproductive system. Three sections 1) prostatic 2) membranous 3) penile 
121
Assessment of the abdomen
Examine in this order
-Inspection (look) - observe size, shape, contour, skin integrity
-auscultation (listen) - bowel sounds, four quadrants > normal hypoactive, hyperactive
- palpation (feel) palpate for tenderness, pain, masses 
122
What do you ask during a assessment of the abdomen?
Normal bowel and urine patterns
Appearance
Changes
History of problems
123
Assessment of urethral meatus and perineal area
Inspect urethral orifice for erythema, discharge, swelling, or odor
Signs of infection, inflammation, or trauma
Perineal area : color, condition, presence of urine or stool 
124
GI/GI components of assessment
Examination of abdomen- look, listen, feel
Ask questions about habits
Examination of urethral meatus and perineal area
125
Function: Sense of Smell
Ask pt to identify smells
Type: sensory
Olfactory I
126
Function: visual acuity
Use snellen chart or ask pr to read printed material while wearing glasses
Type: sensory
Optic II
127
Function: eye movements, inward, up and inward, up and outward, down and outward
- assess six directions of gaze
Type: motor
Oculomotor III
128
Function: downward, inward eye movements
Type: motor
Assess six directions of gaze
Trochlear IV
129
Function: facial expression
As patient smiles, frowns, puffs out cheeks
Facial VII
130
Function: Hearing
Assess ability to hear spoken word
Type: sensory
Auditory
VIII
131
Function: taste and ability to swallow
Ask patient to identify sour or sweet taste on back of tongue
Use tongue blade to elicit gag reflux
Type: sensory and motor
IX Glossopharyngeal
132
Function: Sensation of pharynx
Movement of vocal cords
- ask patient to say “Ah”
Type: sensory and motor
X Vagus
133
Function: movement of head and shoulders
Ask patient to shrug shoulders and turn head against passive resistance
Type: motor
XI spinal accessory
Accessory
134
Function: Position of tongue
Ask patient to stick our tongue to midline and move it from side to side
Type: motor
XII Hypoglossal
135
Type: sensory and motor
Sensory nerve to skin of face
Lightly touch cornea with wisp of cotton
V Trigeminal
136
Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.
Cheyne-Stokes respirations
137
Respirations cease for several seconds
Apnea
138
Rate of breathing is regular but abnormally slow (les than 12 breaths/min)
Bradypnea
139
Rate of breathing is regular but abnormally rapid (greater than 20 B/min)
Tachypnea
140
Respirations are abnormally deep, regular, and increased in rate
Kussmauls respiration
141
Respirations are labored, increased in depth, and increased in rate (greater than 20 B/min) occurs normally during exercise
Hyperpnea
