Health & Physical Assessment Flashcards
Review basic assessment techniques and findings for all the systems.
1
Q
Who spends the most time with the client, knows the most about the client, and is able to communicate the client’s needs to the rest of the health care team the most effectively?
A
The nurse
2
Q
What are the 3 areas of assessment the nurse focuses on in order to get a complete picture of the client?
A
- Body: assess the physical systems
- Mind: assess mental health
- Spirit: assess for religious or spiritual beliefs
3
Q
What is the ADPIE nursing process?
A
- Assess: gather data
- Diagnosis: client problems that are based on medical diagnosis
- Plan: goals
- Implement: interventions
- Evaluate: how the client responded to the intervention
The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.
4
Q
What are nursing clinical judgment skills?
A
- interpreting sign and symptom data
- prioritizing what is important
- generating solutions by making a plan
- understanding WHY an intervention is done
- gathering more information if there is not enough to make an informed decision
- evaluating if inteventions or teaching was effective
5
Q
What is a clinical pathway or care plan?
A
A plan that the healthcare team agrees to for guiding client care and is based on evidence based practice (EBP).
6
Q
When does teaching and discharge planning by the nurse begin with a client?
A
During the assessment even while the client is being admitted
During the admission, assessment data is gathered by the nurse such as home environment and available resources so that teaching can begin right away, if there are needs.
7
Q
How should you identify a client before giving meds, doing a procedure, or performing an assessment?
A
By using 2 client indentifiers:
1. name and
2. date of birth, social security number, phone number or address
Name and date of birth is most typically used.
8
Q
What are the two purposes of doing a nursing assessment on a client?
A
- gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.
- notify the health care provider (HCP) of immediate complications or changes in the client’s condition in order to update the care plan.
The HCP can be a doctor, nurse practitioner or physician assistant.
9
Q
What is the typical assessment order for most body systems?
A
- inspect
- palpate
- percuss
- auscultate
10
Q
What is the difference between a focused health assessment and a comprehensive health assessment?
A
- Focused health assessment: Focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.
- Comprehensive health assessment: When the nurse assesses the entire client head to toe.
11
Q
Which main physical systems are assessed in a comprehensive assessment starting from head to toe?
A
- neuro
- respiratory
- cardiac
- gastrointestinal
- kidneys
- musculoskeletal
- skin
12
Q
In addition to the physical assessment of the client, what additional data does the nurse look at to get an overall picture of the client?
A
-
labs
- CBC, BMP or CMP
- labs specific to problem
-
imaging diagnostic tests
- x-rays, CT scan, MRI, etc
- medical and surgical history and physical from HCP
- medication administration record (MAR)
13
Q
How often should a typical nursing physical assessment be done on each of the following units:
- Post-operatively
- ICU
- Progressive or Step-down unit
- Medical-surgical unit
A
- Post-Op: focused assessments every 5- 15 minutes
- ICU: every 1-2 hours
- Progressive or Step-down unit: about every 2-4 hours
- Medical-surgical unit: about every 4-8 hours
14
Q
What is subjective and objective data?
A
Subjective data: what the client tells you
Objective data: what anyone can observe
Subjective data example: the client’s stated pain level
Objective data example: a set of vital signs
15
Q
What conditions cause a higher than normal body temperature?
A
- dehydration
- stress
- ovulation
- strenuous exercise
16
Q
Clients with which conditions should avoid rectal temperature measurements?
A
Those at risk of bleeding or infection should avoid rectal temps.
ex: DIC or leukemia
17
Q
Clients with which conditions should avoid oral temperature measurements?
A
Those that have had oral surgery, because of a risk of trauma to the mouth.
18
Q
What is placed on the finger to obtain a pulse and oxygen reading?
A
pulse oximeter
19
Q
Define:
Posterior and Anterior
A
- Posterior: the back of something
- Anterior: the front of something
20
Q
What is a rapid and basic neuro assessment?
A
Assess the level of consciousness by asking the client 4 questions:
- Person: “What is your name?”
- Place: “Where are you?”
- Time: “What year is it?” or “Who is the president?”
- Situation: “Do you remember why you are here?”
21
Q
Define:
Distal and Proximal
A
- Distal: away from something
- Proximal: closer to something
22
Q
What is PERRLA?
A
PERRLA is using a light to check if Pupils are:
- Equal
- Round
- React to Light
- Accommodate
Remember: pupils constrict as objects get closer.
23
Q
What is the cranial nerves “saying” in order to remember the names of the 12 cranial nerves?
A
Oh, Oh, Oh! To Touch And Feel A Good Velvet, Such Heaven!
- Olfactory
- Optic
- Oculomotor
- Trochlear
- Trigeminal
- Abducens
- Facial
- Acoustic/Vestibulocochlear
- Glossopharyngeal
- Vagus
- Spinal Accessory
- Hypoglossal
24
Q
Draw the cranial nerve face.
A
This will help you to remember the function and location of the nerves.
25
What is the function of **cranial nerve I?**
I. Olfactory: **smell**
26
What is the function of **cranial nerve II?**
II. Optic: **vision**
27
What is the function of **cranial nerve III?**
III. Oculomotor: **movement of pupils and eyelids**
28
What is the function of **cranial nerve IV?**
IV. Trochlear: **downward and inward movement of the eyes**
29
What is the function of **cranial nerve V?**
V. Trigeminal: **chewing**
30
What is the function of **cranial nerve VI?**
VI. Abducens: **eye movement lateral (side to side)**
31
What is the function of **cranial nerve VII?**
VII. Facial: **movement of all the facial muscles and taste**
32
What is the function of **cranial nerve VIII?**
VIII. Acoustic/Vestibulocochlear: **hearing**
33
What is the function of **cranial nerve IX?**
IX. Glossopharyngeal: **swallowing and taste**
34
What is the function of **cranial nerve X?**
X. Vagus: **swallowing and speaking**
35
What is the function of **cranial nerve XI?**
XI. Spinal Accessory: **shoulder movement**
36
What is the function of **cranial nerve XII?**
XII. Hypoglossal: **tongue strength**
37
What is a **Romberg test**?
Used to test a client's **balance**.
## Footnote
Have client stand with feet apart with eyes closed to assess balance.
38
# Define:
Ptosis
When **one eye droops.**
39
What are the **5 areas of the brain?**
1. frontal lobe
2. parietal lobe
3. temporal lobe
4. occipital lobe
5. cerebellum
40
What is the function of the **frontal lobe?**
Controls:
* **thinking**
* **speech**
* **personality changes**
41
What is the function of the **parietal lobe?**
Processes information for:
* **temperature**
* **taste**
* **movement**
42
What is the function of the **temporal lobe?**
Controls:
* **hearing**
* **language comprehension**
* **memories**
43
What is the function of the **occipital lobe**?
Controls vision.
44
What is the function of the **cerebellum**?
## Footnote
Located at the bottom of the brain.
Controls:
* **movement**
* **gait**
* **balance**
45
What are the **4 regions** of the spine?
1. **Cervical:** C1-C8
2. **Thoracic:** T1-T12
3. **Lumbar:** L1-L5
4. **Sacral and Coccyx:** S1-S5
46
What do the **cervical nerves** control?
| (C1-C8)
* breathing
* arm and neck movement
47
What do the **thoracic nerves** control?
| (T1-T12)
The **strength** of the:
* chest
* back
* abdomen
48
What do the **lumbar nerves** control?
| (L1-L5)
The **strength** of the:
* lower abdomen
* buttocks
* legs
49
What do the **sacral and coccyx** nerves control?
| (S1-S5)
The **strength** of the:
* thighs
* lower leg
* genitals
50
What questions are asked during a nursing **lung assessment**?
1. Have you had any **difficulty breathing** at rest or with activity?
2. Have you had a **cough**?
* *If so, is it **dry or a productive** cough with mucus?*
* *If productive with **mucus**, what color is it?*
51
What are the **normal lung sounds**?
* Vesicular
* Bronchial (tracheal)
* Bronchovesicular
52
Where is the **stethoscope** placed when doing a nursing lung assessment?
Place the stethoscope at the top and go **progressively down** the anterior and posterior thorax.
53
# Define:
**Adventitious** lung sounds
**Abnormal** breath sounds
54
What are **diminished** or **absent** breath sounds?
An area of the lungs where the **movement of air cannot be heard**.
55
# Define:
dyspnea, tachypnea, and bradypnea
* **dyspnea:** difficulty breathing
* **tachypnea:** rapid respirations \> 20
* **bradypnea:** slow respirations \< 12
56
What is the difference between **fine, medium,** and **coarse lung crackles**?
**Crackles** are lung sounds caused by **fluid in the lungs**.
* _fine crackles_: **a little bit of fluid in the lungs** that sounds like high-pitched popping sounds; click [HERE](https://www.youtube.com/watch?v=LHqqvrm2j6g) for an audio sample.
* _medium crackles_: **condition is getting worse** and lower-pitched popping sounds.
* _coarse crackles_: **bubbling sounds from fluids** (really bad!); click [HERE](https://www.youtube.com/watch?v=aSor2XBc9K8) for an audio sample.
57
What are **wheezes?**
High squeaky lung sounds.
## Footnote
They are caused by the small airways narrowing, usually in asthma. Click [HERE](https://www.youtube.com/watch?v=T4qNgi4Vrvo) for an audio sample.
58
What are **rhonchi?**
**Low-pitched lungs sounds** that resemble snoring.
## Footnote
It is caused by secretions in the airway. They may clear with cough. Click [HERE](https://www.youtube.com/watch?v=YgDiMpCZo0w) for an audio sample.
59
What is **atelectasis?**
An **incomplete expansion** of the lung that causes diminished breath sounds.
## Footnote
It is most common with pneumonia.
60
What are **Chene-Stoke's** respirations?
**Apnea lasting 10-60 seconds** followed by hyperventilation.
## Footnote
It indicates a dying client but may be normal in babies.
61
What is **stridor**?
A **high-pitched, harsh sound** from an obstructed airway.
62
What is a **pleural friction rub?**
A low-pitched grating sound from **pleurisy** (inflammation in the lungs).
## Footnote
*Click [HERE](https://www.youtube.com/watch?v=QpA5EmmyXx4) for an audio sample.*
63
What is included in a basic nursing **cardiac assessment?**
* asking the client about **chest pain** or chest discomfort
* listening to **heart sounds**
* checking **pulses**
* checking **capillary refill**
* checking **skin temperature** and **color**
* checking for **edema and skin turgor**
* assessing **cardiac rhythm strip**
64
# Define:
Brady and Tachy
* _Brady_ means **slow**
* _Tachy_ means **fast**
## Footnote
**Bradycardia** means a heart rate \< 60
**Tachycardia** means a heart rate \>100
65
Where are the **5 heart sounds located?**
* aortic, pulmonic, Erb's point, tricuspid, mitral
## Footnote
Use the mnemonic: **"APE To Man"** to remember.
66
Explain how the **blood flows** through the heart.
**Blood flow through the heart:**
1. from systemic circulation into the vena cavas
2. right atrium > tricuspid valve > right ventricle
3. pulmonary valve > pulmonary artery > lungs
4. pulmonary veins
5. left atrium > mitral valve > left ventricle
6. aortic valve > aorta
7. systemtic circulation (throughout the body)
8. back to the vena cavas
67
What are the heart sounds **S1 and S2?**
S1 and S2 are the **normal heart sounds**
## Footnote
It is sometimes known as "lub dub".
Click [HERE](https://www.youtube.com/watch?v=FtXNnmifbhE) for an audio sample.
68
What are the heart sounds **S3 and S4**?
* **S3** is usually an abnormal heart sound. Click [HERE](https://www.youtube.com/watch?v=_i2D1KZkN1w) for an audio sample.
* **S4** is almost always associated with cardiac disease. Click [HERE](https://www.youtube.com/watch?v=KcMF8rJDTIk) for an audio sample.
## Footnote
*S3 and S4 are associated with fluid volume overload.*
69
What is a **heart murmur**?
An **abnormal heart sound** other than "lub-dub". It can be a whooshing, swishing or clicking noise.
## Footnote
*Click [HERE](https://www.youtube.com/watch?v=MzORJbyHTT0) for an audio sample.*
70
**Label the pulses on the diagram** from the following choices:
* brachial, carotid, dorsalis pedis, femoral, posterior tibial, radial, ulna, popliteal
71
What are the **4 pulse strengths** and what do they **indicate?**
* **4+**: strong and bounding - indicates fluid volume overload
* **3+**: full pulse - less severe fluid volume overload
* **2+**: normal - easily palpable
* **1+**: weak, barely palpable - indicates fluid volume deficit
72
What is **edema** and **pitting edema** and how is it assessed?
**Edema**: when there's **too much fluid in the body**. It can be localized or throughout the body.
**Pitting edema**: when the **skin remains indented** after pressing with a finger.
**Assessment criteria:**
* **1+, 2mm:** a small pit and rebounds in a few seconds
* **2+, 4mm:** a medium pit and rebounds in a few seconds
* **3+, 6mm:** a deep pit and rebounds in 10-20 seconds
* **4+, 8mm:** very severe edema and rebounds in \>30 seconds
73
What is **anasarca?**
Another word for **generalized edema**.
74
What is **skin turgor** and how is it assessed?
**Assessing the client's fluid status** by pinching a fold of skin.
* If the **skin tents up** = dehydration or fluid volume deficit.
* if the **skin returns to the normal position** = no fluid issue.
75
How is **capillary refill** assessed?
By **pressing down on the nail bed**.
* if the pink color comes back in **< 3 seconds**, that is normal.
* if the pink color comes back in **> 3 seconds**, it is abnormal.
## Footnote
Cap refill assesses the client's blood circulation.
76
# Define:
Syncope
Loss of **consciousness**
77
**Label the gastrointestinal organs** on the diagram from the following choices:
* appendix, esophagus, gallbladder, large intestine, liver, pancreas, rectum, small intestine, stomach
78
What does a basic nursing **gastrointestinal assessment** include?
* listening to **bowel sounds**
* ask when **last bowel movement** was
* ask if **passing gas**
* ask if patient experiences **nausea/vomiting/diarrhea**
* determining **appetite**
79
# Define:
melena
**Blood** in the stool.
## Footnote
Sometimes called "tarry stools".
80
# Define:
hematemesis
**Blood** in the vomit.
81
# Define:
Cachexia
Malnutrition/wasting away.
82
What is the **unique nursing assessment order** for the abdomen/GI?
1. inspect
2. auscultate
3. percuss
4. palpate
## Footnote
It is done from least to most invasive in order to not disturb the abdomen and cause inaccurate findings.
83
What are the **four areas of the abdomen** and **how long** is each quadrant listened to before deciding if there are bowel sounds?
Listen to **each quadrant for 5 minutes** = a total of 20 minutes.
* start at upper left, upper right, lower right, lower left
* go in a counterclockwise direction
84
What are the **different types** of bowel sounds?
1. **absent:** no bowel sounds
2. **hypoactive:** 1 sound every 3-5 minutes
3. **normal:** 5-30 clicks or gurgles per minute
4. **hyperactive:** \> 30 sounds per minute or an increase from the client's baseline
85
How is the **body mass index (BMI)** calculated?
**BMI** = kg ÷ m2
## Footnote
Example: if a client weighs 70 kg and is 1.8 meters tall, the BMI is 70 ÷ 1.82 = **21.6**
* normal weight = 18.5 to \< 25
* overweight = 25 to \< 30
* obese = \> 30
86
# Define:
NPO
Nothing by mouth.
## Footnote
Don't allow the client to eat or drink anything. This is a common order for preventing aspiration during surgeries and procedures or when having an acute GI issue.
87
What are the **2 main functions** of the **pancreas?**
1. **endocrine organ:** to release insulin so the body can regulate glucose/sugar
2. **exocrine organ:** to release enzymes for food digestion
88
What is the **function** of the **gallbladder?**
To **store bile** that's made by the liver for **food digestion**.
89
What are the **4 main functions** of the **liver?**
1. **to make clotting factors** to prevent bleeding
2. **to make proteins** so all the organs and cells can function
3. **to metabolize toxins** and cholesterol
4. **to make bile** for digestion
90
What does a basic **renal/urinary assessment** include?
1. **checking urine:** output and color
1. **monitoring:** intake and output
1. **checking labs:** BUN, creatinine, GFR, electrolytes
1. **urinalysis**
91
What is the **minimum urine output** for an adult and newborn?
* **adult:** at least 30 mL/hour
* **infant** (up to 1 year): at least 2ml/kg/hour
92
What does a basic nursing **musculoskeletal assessment** include?
1. **checking:** muscle strength and range of motion
1. **asking about:** pain, numbness, and tingling
1. **checking:** electrolytes and other labs
1. **imaging tests:** spine and head
93
What are the assigned numbers for **muscle strength?**
* **0** is **no** muscle strength
* **5** is **normal** muscle strength
94
What are the numbers for **deep tendon reflex grading**?
* 0 = no response; always abnormal
* 1+ = a slight but present response; may or may not be normal
* 2+ = a brisk response; normal
* 3+ = a very brisk response; may or may not be normal
* 4+ = a tap elicits a repeating reflex called clonus; always abnormal
## Footnote
Deep tendon reflex grading is using a hammer to tap the knee.
95
**Label the bones** on the diagram from the following:
* cranium, femur, fibula, humerus, patella, pelvis, radius, ribs, scapula, sternum, talus, tibia, ulna, vertebra
96
What is **kyphosis?**
A **curved thoracic spine** (hunchback).
## Footnote
It is common in the elderly with osteoporosis.
97
What is **scoliosis?**
Lateral spine curvature.
## Footnote
It is tested in teenagers.
98
What does a basic nursing **skin assessment** include?
* skin color
* wounds (especially on bony areas)
* rashes
* bruising
* abnormal moles/freckles
* asking about new meds or exposure to infectious diseases (*many cause rashes*)
99
# Define:
**urticaria** and **pruritis**
* urticaria: **hives**
* pruritis: **itching**
100
# Define:
Cyanosis
When the skin has a **blue tint** due to a low oxygen reading.
101
How is **cyanosis** assessed in a **dark-skinned client?**
Look for a bluish color by checking **lips, tongue, nail beds, palm soles, and conjunctiva.**
102
# Define:
erythema
Redness of the skin.
## Footnote
It indicates injury, inflammation or infection.
103
# Define:
pallor
Skin that is **lighter than what the client is normally**.
## Footnote
It can indicate decreased blood flow.
104
# Define:
jaundice
**Yellowing** of the skin, mucous membranes, and whites of the eyes.
## Footnote
It indicates liver failure.
105
# Define:
ecchymosis
Bruising of the skin.
106
What questions are asked for a nursing **pain assessment?**
* **Location:** where is the pain?
* **Severity:** how bad is it? Use appropriate pain scale.
* **Character:** what does it feel like?
* **Onset:** when did it begin?
* **Associated factors:** are there other symptoms that occur with it?
* **Pattern:** what makes it better? what makes it worse?
* What pain meds do you take?
* Do you use alternative therapies to manage pain?
107
What **pain scale** is used for alert and oriented adults?
**0 - 10** pain scale
## Footnote
0 is no pain; 10 is the worst pain.
108
What **two pain scales** can be used for non-verbal adults or young children <10 years old?
FLACC pain scale & Wong-Baker faces pain scale:
* **F**ace
* **L**egs
* **A**ctivity
* **C**ry
* **C**onsolability
109
What are some **signs/symptoms** of pain in an unconscious or non-verbal client?
* ↑ heart rate
* ↑ respirations
* shallow respirations
* facial grimacing
* gasping
* stooped
* moaning
* rubbing a body part
* guarding
* crying
110
# Define:
acute pain
Has a **short duration** and identifiable cause such as a surgery.
## Footnote
Vital signs are typically increased with acute pain.
111
# Define:
chronic pain
Has a **long duration** such as cancer, fibromyalgia, and back pain.
## Footnote
Vital signs are typically normal with chronic pain.
112
What are basic **documentation guidelines** for nursing?
* use black ink
* date/time/name on each entry
* document right after activity
* be factual
* use quotes for subjective data
* document refusals of treatments and calls to HCP
113
How should an **error** be documented in a client's medical chart?
**Draw one line** through the error, initial, and date.
114
What is **u****nacceptable** for nursing documentation?
* do **_NOT_** document for others
* do **_NOT_** leave blank spaces on forms
* do **_NOT_** use unacceptable abbreviations
115
What are **modifiable** risk factors?
Things the client **can change** such as diet or exercise.
116
What are **non-modifiable** risk factors?
Things the client **can't** change, such as family history/genetics, age, and sex.
117
What are the **3 levels** of disease prevention?
1. Primary
2. Secondary
3. Tertiary
118
What are some examples of **primary** disease prevention?
* teaching about a healthy lifestyle (diet and exercise)
* teeth brusing
* car seats and seat belts
* vaccinations
* sunscreen
* not smoking
* preventing falls
* limiting/eliminating alcohol
* wearing masks in public
119
What are some examples of **secondary** disease prevention?
* preventing cancer with mammograms, colonoscopy, pap smear
* stopping smoking
* safer sex practices
120
What are some examples of **tertiary** disease prevention?
* support groups
* cardiac rehab
* skin care for diabetics
121
What are some **neuro changes** in older adults?
* confusion and lethargy with infections
* hard of hearing
* unable to see as well
* decreased sensitivity to pain and temperature
* taking longer to learn and remember
122
What are some **mental health** issues older clients are more at risk for?
* older white men that live alone are higher risk for suicide
* increased risk of being abused
123
What are some **immune** changes that occur with older adults?
* **decreased** healing time
* **decreased** immune system
* **increased** risk of cancer
124
What are some **renal changes** with older adults?
* **decreased** kidney function
* **increased** risk of incontinence
125
What are some **respiratory changes** in older adults?
* decreased lung function
* getting out of breath easier
## Footnote
.
126
What are some **skin changes** in older adults?
* dry skin
* wrinkles
* skin tears
* spider angioma
* varcose veins
* bruising (ecchymosis)
127
What are some **musculoskeletal changes** in older adults?
* osteoporosis
* decreased muscle mass
* increased risk of falls
128
What are some **gastrointestinal changes** in older adults?
* nutritional changes
* loss of teeth
* decreased liver function
129
What is a **pleural friction rub?**
A low-pitched grating sound from **pleurisy** (inflammation in the lungs).
## Footnote
*Click [HERE](https://www.youtube.com/watch?v=QpA5EmmyXx4) for an audio sample.*
