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IM 1 > Health Assessment- Exam 3 > Flashcards

Health Assessment- Exam 3 Flashcards

1
Q

Level of consciousness

A
  • single most important neuro assessment component
  • often first clue of deteriorating condition
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2
Q

Testing level of consciousness (LOC)
ALERT

A

Attentive, follows commands, if asleep - wakes promptly and remains attentive

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3
Q

Testing level of consciousness (LOC)
LETHARGIC

A

drowsy but awakens, slow to respond

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4
Q

Testing level of consciousness (LOC)
OBTUNDED

A

difficult to arouse, needs constant stimulation

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5
Q

Testing level of consciousness (LOC)
STUPOROUS/ SEMI COMATOSE

A

arouses only to vigorous/noxious stimuli, may only withdraw from pain

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6
Q

Testing level of consciousness (LOC)
COMATOSE

A

No response to verbal or noxious stimuli, no movement except deep tendon reflex

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7
Q

Testing level of consciousness (LOC)
What to look for?

ALOSC

A

Alert
Lethargic
obtunded
Stuporous/ semi-comatose
Comatose

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8
Q

Cognitive awareness also known as mentation

A

Is the patient oriented to person, place, and time?
Also know as mentation

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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

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10
Q

Cranial nerves

A
  • 12 pairs
  • sensory, motor, or both
  • not all cranial nerves are always tested
  • listed in order of testing
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11
Q

Olfactory
What number?

A

I

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12
Q

Optic

A

II

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13
Q

Oculomotor

A

III

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14
Q

Trochlear

A

IV

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15
Q

Trigeminal

A

V

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16
Q

Abducens

A

VI

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17
Q

Facial

A

VII

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18
Q

Vestibulocochlear

A

VIII

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19
Q

Glossopharyngeal

A

IX

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20
Q

Vagus

A

X

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21
Q

Accessory

A

XI

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22
Q

Hypoglossal

A

XII

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23
Q

Testing cranial nerves III, IV, and VI
Oculomotor, trochlear, abducens

A

Pupil response and cardinal gaze

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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

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25
Q

PERRLA

A

P Pupils
E equal
R round
R react to
L light and
A accommodations

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26
Q

Cardinal gaze

A

-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

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27
Q

Testing cranial nerve VII
Facial

A

-Ask patient to smile and show teeth
- Ask patient to wrinkle forehead or raise eyebrows

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28
Q

Testing cranial nerve XII
Hypoglossal

A

Ask patient to touch the roof of the mouth with tongue
Protrude tongue out of mouth
Move tongue from side to side

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29
Q

Testing cranial nerve XI
Accessory

A

Place hands lightly on patient shoulders
Ask patient to shrug shoulders

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30
Q

Testing motor function

A

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

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31
Q

Neuro components of assessment

A

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

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32
Q

Auscultation of the lungs - normal sounds

A

Vesicular - periphery of the lungs
Bronchovesticular- closer to the sternum
Bronchial - over trachea

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33
Q

Vestibular lung sounds

A

Periphery of the lungs

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34
Q

Bronchovesticular of the lungs

A

Closer to the sternum

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35
Q

Bronchial of the lungs

A

Over trachea

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36
Q

Abnormal or adventitious sounds

A

Crackles or rales - can be fine or course
rhonchi
Wheezes
Pleural friction rub

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37
Q

Abnormal respiratory patterns

A

Bradypnea
Tachypnea
Apnea
Hyperpnea
Kussmauls
Cheyne-Stokes

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38
Q

Nail shape
What to examine

A

Examine BUE nail shape
Clubbing

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39
Q

Respiratory components of assessment

A

Anterior and posterior lung sounds
Clubbing

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40
Q

LUB - heart sounds

A

Systole or S1 and is the sound associated with the closing of the mitral/ tricuspid valves

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41
Q

DUB - heart sounds

A

Diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves

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42
Q

Aortic location

A

Right base; second intercoastal space to the right of the sternal border

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43
Q

Pulmonic heart sounds

A

Left base; second intercostal space to the left of the sternal border

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44
Q

Tricuspid heart sounds

A

Left lateral sternal border; fifth intercostal space to the left of the sternal border

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45
Q

Mitral heart sound

A

Apex, midclavicular line at the fifth intercostal space

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46
Q

Pulses

A

Carotid
Brachial
Radial
Ulnar
Apical
Femoral
Popliteal
Dorsalis pedis

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47
Q

Assessment of pulses - Carotid

A

One at a time, bilaterally

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48
Q

Assessment of pulses - Radial

A

Bilaterally at the same time

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49
Q

Assessment of pulses - apical

A

With stethoscope for 2 beats

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50
Q

Assessment of pulses - dorsalis Pedis pulses

A

Bilaterally at the same time

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51
Q

Pulse points - 0

A

Absent, non-palpable

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52
Q

Pulse points- 1+

A

Diminished, palpable

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53
Q

Pulse points- 2+

A

Strong, normal

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54
Q

Pulse points - 3+

A

Full, increased

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55
Q

Pulse points- 4+

A

Bounding

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56
Q

Assessment via Doppler

A

Hand held device
Most often used for pedal places

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57
Q

Capillary refill assessment

A

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
Q

Edema Assessment

A

Swelling in the extremities

59
Q

Dependent edema located

A

Most often on feet and ankles, older adults

60
Q

Pitting edema

A

Venous, insufficiency, or heart failure, fluid in tissues

61
Q

Cardiac components of assessment

A

Heart sounds
Carotid pulses
Radial pulses
Pedal pulses
Capillary refill
Assess for edema 

62
Q

Range of motion

A

Neck
Shoulders, upper arms, and elbows
Wrists
Hips
Knees
Ankles 

63
Q

Neck range of motion

A

Move next side to side
Chin to chest
Extension back 

64
Q

Shoulders and upper arms and elbows range of motion

A

Arms out to side
Arm straight up
Touchdown 

65
Q

Wrist range of motion

A

Wrist circles

66
Q

Hips, knees, and ankles range of motion

A

Bilateral hip flexion out
Bend knees
Ankle circles 

67
Q

Strength

A

Hand grip
Total wiggle
Flexion and extension BUE/BLE

68
Q

Musculoskeletal components of assessment

A
  • Neck ROM
  • BUE ROM
  • BLE ROM
  • HGTW
  • flexion/extension BUE and BLE
69
Q

Assessment of skin- inspect head to toe for

A

Hydration
Temperature
Color
Texture
Rashes
Lesions
Cracking 

70
Q

Pallor

A

Pale, or ashen gray

71
Q

Erythema

A

Redness r/t vasodilation 

72
Q

Jaundice

A

Yellow impaired liver

73
Q

Cyanosis

A

Bluish, decree circulation or oxygenation of blood

74
Q

Skin characteristics - temp 

A

Temp should be warm, consistent with room temp

75
Q

Skin characteristics - moisture

A

Moisture from diaphoresis or dry from dehydration

76
Q

Skin characteristics - texture 

A

Texture can be dry in course (elbow/knee) or shiny with no hair (impaired peripheral circulation) 

77
Q

Skin characteristics - Turgor 

A

Turgor test, elasticity of skin related to hydration 

78
Q

Factors affecting the skin

A

Dampness
Dehydration
Nutrition
Circulation
Disease
Jaundice
Lifestyle 

79
Q

Normal skin changes in older adults

A

Epidermidis
Subcutaneous tissue
Collagen and elastin fibers
Hormones
Vascularity
Hair follicles
Melanocytes
Nails
Skin growths

80
Q

Pitting edema is caused by

A

By kidney or heart failure
Leads to excess fluid collection in tissues

81
Q

Assessment of bony prominences 

A

Hips, heels, coccyx, shoulders
Assess for skin integrity
Blanching red spots

82
Q

Assessment of nails

A

Shape
Contour
Cleanliness
Neatly manicured/trimmed 

83
Q

Nails should be..

A

Transparent
Smooth
Rounded
Convex
Hygienic 

84
Q

Assessment of hair - Terminal

A

Scalp, axillae, pubic, and beard 

85
Q

Assessment of hair - Vellus hair 

A

Soft tiny hairs covering body, except on palms and soles 

86
Q

Assessment of hair- what to look for

A

Quantity- alopecia, hirsutism
Distribution
Texture
Color
Parasites 

87
Q

Assessment of ears

A

Symmetry
Drainage
Shape
Hearing defects
Lesions
Redness
Tenderness
Odor 

88
Q

Assessment of nose- what to look for

A

Position
Symmetry
Color
Swelling
Deformities
Discharge
Flaring
Patency
Sinus tenderness 

89
Q

Inspect oral cavity

A

Lips
Oral mucosa
Teeth
Gum/tongue
Breath odor

90
Q

Inspect throat for

A

Lumps
Ulcers
Edema
White spots
Redness
Swallowing 

91
Q

Assessment of neck- inspect neck for

A

Contour and symmetry
Midline trachea
Jugular 

92
Q

Integument components of assessment
What all do we inspect when it comes to the skin?

A

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
Q

Elimination

A

Excretion of waste products from kidneys and intestines

94
Q

Defecation

A

Process of elimination of waste

95
Q

Feces

A

Semi solid mass of fiber, undigested, food, in organic matter 

96
Q

Incontinence

A

Inability to control, urine or feces 

97
Q

Void

A

To urinate

98
Q

Micturate

A

To urinate

99
Q

Dysuria

A

Painful or difficult urination 

100
Q

Hematuria

A

Blood in the urine

101
Q

Nocturia

A

Frequent night urination 

102
Q

Polyuria

A

Large amounts of urine

103
Q

Urinary frequency

A

Voiding at frequent intervals 

104
Q

Proteinuria

A

Presence of large protein in urine 

105
Q

Dribbling

A

Leakage of urine, despite voluntary control of urination

106
Q

Retention

A

Accumulation of urine in bladder, without the ability to completely empty 

107
Q

Residual

A

Urine remaining post void >100ml

108
Q

Structures of the gastrointestinal tract

A

Upper gastrointestinal tract
Small intestine
Large intestine
Rectum and anus

109
Q

Small intestine

A

-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
Q

Large intestine

A
  • colon
  • 2.5” diameter and 5-6’ long
  • 7 segments
    > Cecum
    > ascending colon
    > transverse colon
    > descending colon
    > sigmoid colon
    > rectum
    > anus
111
Q

Kidneys

A

Filter and regulate
Remove waste from blood to form urine

112
Q

Ureters

A

Transport urine from kidneys to bladder

113
Q

Bladder

A

Reservoir for urine until the urge develops

114
Q

Urethra

A

Urine travels from one and exits through urethral meatus 

115
Q

Kidneys pt 2

A

Bilateral
Posterior flanks
Size of fists
Primary regulators of fluid and acid base balance

116
Q

Nephron

A

Functional unit of the kidney

117
Q

What makes up the Kidneys?

A

Nephron
Glomerulus
Bowman’s capsule
Proximal convoluted tubule
Loop of Henle
Distal tubule
Collecting duct

118
Q

Ureters

A

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
Q

Bladder

A

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
Q

Urethra

A

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
Q

Assessment of the abdomen
Examine in this order

A

-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
Q

What do you ask during a assessment of the abdomen?

A

Normal bowel and urine patterns
Appearance
Changes
History of problems

123
Q

Assessment of urethral meatus and perineal area

A

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
Q

GI/GI components of assessment

A

Examination of abdomen- look, listen, feel
Ask questions about habits
Examination of urethral meatus and perineal area

125
Q

Function: Sense of Smell
Ask pt to identify smells
Type: sensory

A

Olfactory I

126
Q

Function: visual acuity
Use snellen chart or ask pr to read printed material while wearing glasses
Type: sensory

127
Q

Function: eye movements, inward, up and inward, up and outward, down and outward
- assess six directions of gaze
Type: motor

A

Oculomotor III

128
Q

Function: downward, inward eye movements
Type: motor
Assess six directions of gaze

A

Trochlear IV

129
Q

Function: facial expression
As patient smiles, frowns, puffs out cheeks

A

Facial VII

130
Q

Function: Hearing
Assess ability to hear spoken word
Type: sensory

A

Auditory
VIII

131
Q

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

A

IX Glossopharyngeal

132
Q

Function: Sensation of pharynx
Movement of vocal cords
- ask patient to say “Ah”
Type: sensory and motor

133
Q

Function: movement of head and shoulders
Ask patient to shrug shoulders and turn head against passive resistance
Type: motor

A

XI spinal accessory
Accessory

134
Q

Function: Position of tongue
Ask patient to stick our tongue to midline and move it from side to side
Type: motor

A

XII Hypoglossal

135
Q

Type: sensory and motor
Sensory nerve to skin of face
Lightly touch cornea with wisp of cotton

A

V Trigeminal

136
Q

Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.

A

Cheyne-Stokes respirations

137
Q

Respirations cease for several seconds

138
Q

Rate of breathing is regular but abnormally slow (les than 12 breaths/min)

139
Q

Rate of breathing is regular but abnormally rapid (greater than 20 B/min)

140
Q

Respirations are abnormally deep, regular, and increased in rate

A

Kussmauls respiration

141
Q

Respirations are labored, increased in depth, and increased in rate (greater than 20 B/min) occurs normally during exercise

IM 1 (34 decks)

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