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CSM Nursing > Health Assessment (Head to Toe) > Flashcards

Health Assessment (Head to Toe) Flashcards

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1
Q

what is inspection?

A

use sight to assess size, shape, color, and symmetry

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2
Q

what is palpation?

A

use touch to assess temperature, vibration, texture, tenderness, and size

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3
Q

things to note about palpation:

A
  • use dorsal surface of hand to assess temperature
  • use palmar surface of hand to assess vibration
  • assess most tender areas last
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4
Q

what is percussion?

A

tap body parts to assess location, size, shape, and tissue density

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5
Q

in what order do most assessments occur and what is the exception?

A
  1. inspect
  2. palpate
  3. percuss
  4. auscultate
    with the exception of the abdomen
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5
Q

what is auscultation?

A

listen for sounds and asses volume, intensity, duration, frequency, and quality

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6
Q

in what order do you assess the abdomen and why?

A
  1. inspect
  2. auscultate
  3. percuss
  4. palpate
    this is because palpation and percussion of the abdomen can alter bowel sounds during auscultation
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7
Q

describe the levels of orientation:

A

gives insight into a patient’s cognitive functioning

  • person: “tell me your name”
  • place: “where are we right now?”
  • time: the patient can correctly identify the day of the week, the month, or the year
  • event/situation: “who is the president?” or “what brought you to the hospital?”
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8
Q

describe the levels of consciousness:

A
  • Alert: awake, opens their eyes spontaneously
  • Lethargic: extremely drowsy. can be awakened by speaking to them, but they fall back to sleep when not stimulated
  • Obtunded: difficult to arouse. requires vigorous shaking or shouting and constant stimulation for cooperation
  • Stuporous: responds only to vigorous shaking or painful stimuli
  • Comatose: completely unconscious and unresponsive to pain. abnormal posture may be present
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9
Q

What are the abnormal postures sometimes present in comatose patients?

A
  • Decorticate: arms flexed and rotated inward, legs extended and rotated inward
  • Decerebrate: head arched back, arms and legs extended
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10
Q

what are expected temperature ranges for adults, children, and infants?

A

Adults: 96.8-100.4F
Children: 97.4-99.6F
Infants: 97.4-99.6F

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11
Q

describe what food/fluid intake can do to oral temperature

A

food or fluid intake can alter temperature. wait at least 15 minutes after patient has consumed anything before taking temperature orally

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12
Q

what is the most accurate method of taking temperature?

A

taking temperature rectally

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13
Q

describe the various methods of taking a patients temperature:

A
  • Oral: place probe beneath the patient’s tongue in the posterior sublingual pocket. ask the patient to close lips around the probe.
  • Temporal: slide probe from the center of the forehead to the hairline behind the ear.
  • Tympanic: for adults, pull the pinna up and back, children younger than 3 years old, pull the pinna down and back. angle thermometer toward patients jaw line.
  • Axillary: place probe in the center of the axilla. have patient bring down arm close to the body.
  • Rectal: place patient in modified left lateral recumbent (Sims) position. Use lubrication and insert about 1” angled toward the umbilicus.
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14
Q

describe the pulse assessment:

A

assess pulse rate, regularity, strength, and equality

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15
Q

pulse assessment methods:

A
  • Radial: feel the wrist proximal to the thumb, using the pads of your first three fingers
  • Apical: listen with stethoscope at the fifth intercostal space at the left midclavicular line.
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16
Q

describe the scale components of the Glasgow Coma Scale?

A
  • Eye Opening: (4) spontaneously, (3) in response to voice, (2) in response to pain, (1) no eye opening
  • Verbal Response: (5) coherent/oriented, (4) incoherent/disoriented, (3) inappropriate words, (2) sounds but no words, (1) no vocalization
  • Motor Response: (6) follows commands, (5) local reaction to pain, (4) general withdrawal to pain, (3) decorticate posture, (2) decerebrate posture, (1) no motor response
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17
Q

describe Glasgow Coma Scale scoring

A

Maximum score: 15 Minimum score: 3
* Mild head injury: 13-15
* moderate head injury: 9-12
* severe head injury: < 8

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18
Q

what is the Glassgow Coma Scale?

A

Scale used to assess extent of consciousness based on three subcategories. often used for patients who have sustained head trauma

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19
Q

What are you checking when you check pulse?

A
  • Rate
  • Regularity: pulse should be regular (equal length pauses between beats)
  • Strength: how forceful the pulse feels against examiners fingers 2+ = normal
  • Equality: pulse should feel equal in strength and frequency bilaterally.
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20
Q

what are the expected pulse rate ranges?

A
  • Adults: 60-100 bpm
  • Children: 70-120 bpm
  • Infants: 100-160 bpm
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21
Q

what are some exceptions to unexpected pulse findings?

A
  • Athletes may have a below average heart rate
  • Sinus arrhythmia is a common and harmless irregularity in children and young adults
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22
Q

what is a sinus arrhythmia?

A

increased HR with inspiration and decreased HR with expiration

23
Q

what are some unexpected pulse findings?

A
  • Bradycardia (<60BPM)
  • Tachycardia (>100BPM)
  • Irregular pulse (irregular lengths between pauses)
  • Pulse alternans (alternating strong and weak beats)
  • Pulse deficit (difference between apical pulse and peripheral pulse)
24
Q

what are the pulse strengths?

A

0: absent
1+: diminished
2+: strong
3+: bounding

25
Q

what are the assessment components of respiration?

A
  • Rate
  • Depth
  • Rhythm
  • Effort
26
Q

describe the respiratory assessment technique:

A
  • While your fingers are still in place after checking the patients pulse, observe the rise and fall of the patients chest without mentioning that you are counting respirations
  • for a regular pattern, count for 30 seconds and multiply by 2
  • for an irregular pattern, ** count for a full minute **
27
Q

describe expected findings for a respiratory assessment (rate, depth, rhythm, effort):

A

Expected rate ranges:
Adult: 12-20 breaths/minute
Children: 20-30 breaths/minute
Infants: 30-60 breaths/minute
** Depth **: consistent breaths that are neither deep nor shallow
** Rhythm **: breaths should occur at regular intervals
** effort **: work of breathing is easy and unlabored

28
Q

what are unexpected findings associated with respiratory assessments?

A

Tachypnea: RR > 20 breaths/min
Bradypnea: RR<12 breaths/min
Hyperventilation: deep, rapid respirations
Hypoventilation: shallow, slow respirations
Irregular respirations: e.g. Cheyne-Stokes, Biot’s respirations
Apnea: absence of respirations for longer than 15 seconds
Dyspnea: difficulty breathing including the use of accessory muscles, nasal flaring, or retractions

29
Q

what is SpO2?

A

a measurement of oxygen saturation of arterial blood using pulse oximetry

30
Q

what are expected SpO2 ranges for healthy patients?
what is expected from a patient with COPD?

A

Healthy patient: 95-100%
Patient with COPD: low 90s

31
Q

where is the probe placed while measuring SpO2?

A

finger, earlobe, or toe

32
Q

what can affect the accuracy of an SpO2 measurement?

A
  • nail polish
  • hypotension
  • peripheral vascular disease
  • edema
  • skin pigmentation
  • skin temperature
33
Q

how can hypoxemia be diagnosed with a patient that has low SpO2 readings?

A

hypoxemia can only be diagnosed with an ABG (arterial blood gas) test

34
Q

what is the assessment technique for checking BP manually?

A
  1. choose appropriate arm
  2. position patients arm relaxed and supported at heart level, with legs uncrossed
  3. choose appropriate cuff size and apply snuggly 1 inch above the brachial artery
  4. palpate the radial pulse while inflating the cuff until pulse disappears
  5. continue inflating the cuff an additional 30 mmHg
  6. place stethoscope over the brachial artery while slowly and steadily releasing air from the cuff
  7. note the measurement at first sound (systolic BP) and when the sound disappears (diastolic BP)
35
Q

when checking blood pressure manually, you should avoid using an arm with…

A

a running IV infusion, PICC line, AV fistula, or on the the same side as a mastectomy

36
Q

what size BP cuff and bladder should be used to check BP?

A

the cuff width should be 40% of arm circumference and the bladder should surround 80% of arm circumference

37
Q

what happens if a BP cuff is too large or too small?

A

Too large: you will get a low reading
Too small: you will get a high reading

38
Q

what are expected BP ranges?

A

Adults: SBP < 120 mmHg and DBP < 80 mmHg
Children: SBP 90 - 110 mmHg **and DBP = 55 - 75 mmHg
Infants: SBP = 65-90 mmHg and DBP = 45 - 65 mmHg

39
Q

what are the ranges for levels of hypertension in adults?

A

Elevated: SBP 120-129 and DBP < 80 mmHg
Stage 1 Hypertension: SBP 130-139 or DBP 80 - 89 mmHg
Stage 2 Hypertension: SBP 140 or higher and/orDBP 90 mmHg or higher
Hypertensive Crisis: SBP > 180 mmHg and/or DBP > 120 mmHg

40
Q

what does patient positioning do to blood pressures?

A

increased BP when patient is lying flat
decreased BP when patient is sitting or standing

41
Q

what is orthostatic vitals?

A

when you check blood pressure and pulse while patient is lying down, sitting up, and standing.

42
Q

when do you assess orthostatic vitals?

A
  • when ordered by the provider
  • when a patient report includes fainting/syncope
    hypovolemia, and certain medications.
43
Q

what is the orthostatic vitals assessment technique?

A
  1. have patient lie supine for at least 5 minutes and check BP and pulse
  2. sit patient upright, wait 2-3 minutes, then take their BP and pulse
  3. stand patient up, wait 2 minutes, then check BP and pulse
    monitor patient for dizziness or weakness during assessment
44
Q

what is the Orthostatic Hypotension criteria?

A

a drop in SBP of 20 mmHg or more when changing positions and/or a drop in DBP of 10 mmHg or more when changing positions

45
Q

what should you teach a patient with orthostatic hypotension?

A
  • change positions slowly
  • sit on side of bed and dangle legs for a few minutes before standing up
  • increase fluid intake
  • call for help prior to ambulation
46
Q

what are the components of pain assessment? (OLD CARTS)

A
  1. Onset: when did the pain start?)
  2. Location: where does it hurt?
  3. Duration: is it consistent, or does it come and go?
  4. Characteristics: what does the pain feel like?
  5. Aggravating/Relieving factors: does anything make it feel worse? does anything make it feel better?
  6. Radiation: does the pain move anywhere else?
  7. Treatment: have you tried anything to treat the pain? (e.g. ice or medication)
  8. Severity: rate the pain using an appropriate pain scale
47
Q

what is nociceptive pain?

A

pain described as aching or throbbing

48
Q

what is neuropathic pain?

A

pain described as shooting or burning

49
Q

PAIN SCALES
age range and components of CRIES

A

Age range: 6 months of younger
Components:
Crying
Requires O2
Increased vital signs
Expression
Sleeplessness

50
Q

PAIN SCALES
age range and components of FLACC

A

Age range: 2 months - 7 years
Components:
Face
Legs
Activity
Cry
Consolability

51
Q

PAIN SCALES
age range and components of FACES (Wong-Baker)

A

Age range: 3 years and older
Components: uses diagram of six faces to rate pain on a scale of 0-10

52
Q

PAIN SCALES
age range and components of Oucher

A

Age range: 3-13 years
Components: uses six photographs to rate pain on a scale of 0-10

53
Q

PAIN SCALES
age range and components of Numeric

A

Age range: 8 years and older
Components: rate pain on a scale of 0-10

54
Q
A

CSM Nursing (9 decks)

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