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health assessment > Lab Final > Flashcards

Lab Final Flashcards

1
Q

Heath history

A

Neuro
HEENT
Respiratory
Cardiac
Peripheral
Abdominal
Musculoskeletal
Integument

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2
Q

General survey

A

Appearance-Alert, appears their age, even skin color, in tact
Body structure
Mobility behavior-no crutches or wheelchair

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3
Q

Obtain vitals

A

Electronic monitor- temp, radial pulse, respirate rate, oxygen, blood pressure

Any pain???

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4
Q

Mental status
Neuro 1

A

Patient is alert..
Name?
Where are you?
Why are you here?
Year?

Rate-4

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5
Q

Perrla
Neuro 2

A

Assess pupils response bilateral
Pupil
Equal
Round
React to light
L
Accommodation

Assess for light reaction (hand between eyes)
Accommodation: (bring pen to and from face) eyes should follow

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6
Q

Sensation
Neuro 3

A

Cotton ball on face, upper extremities and lower extremities

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7
Q

Hearing
Neuro 4

A

Whisper behind them with one ear covered..(3 words)

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8
Q

DTRS
Neuro 5

A

Test knee reflex- rate 1 or 2
Babinski- outline J on foot
(Positive Babinski seen on babies is when toes fan instead of curl)

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9
Q

HEENT 1
Palpate head

A

No bumps, no tenderness, even hair distribution

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10
Q

Face
HEENT 2

A

Face is symmetrical, nose midline, structures are aligned

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11
Q

Oral
HEENT 3

A

Using light to assess mucous membrane
Uvula-midline
Soft palate- rises

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12
Q

Enlarged lymph nodes
HEENT 5

A

Palpate 2 lymph sites

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13
Q

Assess for symmetry
Respiratory 1

A

Describe AP to transverse chest configuration 1:2
Chest expansion: feel for C7..down to C10..hold hands flat and have them breathe

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14
Q

Capillary refill
Respiratory 2

A

Capillary refill: less than 2 seconds
Check for clubbing: 160 or less
Cyanosis: blue coloring in nails, lips, fingers

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15
Q

Breath sound
Respiratory 3

A

Bronchial-high pitched
Bronchovesicular- moderate pitch
Vesicular-low pitch

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16
Q

Auscultate
Respiratory 4

A

Anterior-6
Lateral-right lobe, 5th rib
Posterior-10

Ladder pattern
Describe lung sounds

17
Q

Assess chest
Cardiac 1

A

Explain precordium for lifts/heaves/pulsations

18
Q

Assess for JVD
Cardiac 2

A

Lay flat, no pillow, have client face the left..raise bed

30-45 degrees

19
Q

Assess carotid
Cardiac 3

A

Palpate bilateral
Auscultate with bell

20
Q

Auscultate apical pulse
Cardiac 4

A

5 to 6th intercoastal, mid-clavicle
Listen for 60 seconds
Regular rate
Normal rhythm

21
Q

Identify and Auscultate heart sounds
Cardiac 5

A

Z pattern…
Aortic:
Pulmonic:
Erbs:
Tricuspid:
Mitral:
Bell for murmurs

22
Q

Identify 2 peripheral pulse sites
Peripheral cardio 1

A

Radial and brachial

23
Q

Identify 4 lower peripheral pulses
Peripheral cardiac 2

A

Femoral, popliteal, posterior tibia, dorsalis pedis

24
Q

Assess radial pulse
Peripheral cardiac 3

A

Assess radial- bilateral
Grade radial pulse-2 normal rhythm

25
Q

Assess dorsal is pedis
Peripheral cardiac 4

A

Assess dorsal is pulse: bilateral
grade: 1 or 2 normal rhythm.

26
Q

Edema
Peripheral 5

A

No edema

27
Q

Abdomen 1

A

Inspect- convex, distended umbilicus, midline
Auscultate-RLQ, RUQ, LUQ, LLQ
Percussion
Palpate

28
Q

Abdominal 2

A

Aortic, iliac, femoral arteries-no bruits (brewes) using the Bell.

29
Q

Assess gait
Musculoskeletal 1

A

Get up and go test
Romberg test-balance…stay with client for safety

30
Q

Upper extremities strength
Muscular 2

A

Assess and and grade upper extremities bilateral
Grade:

31
Q

Lower extremities strength
Muscle 3

A

Assess and grade lower extremities bilateral
Grade:

32
Q

Assess ROM upper
Muscles 4

A

Flexion, extension, abduction, adduction, external rotation, internal rotation, circumduction
Elbow: flexion, extension, supination, pronation
Wrist: flexion, extension, inversion, eversion

33
Q

Assess ROM lower
Muscles 5

A

Flexion, extension, abduction, adduction, external rotation, interval rotation

Knee: flexion, extension , shallow knee bend, step walking
Ankle: dorsiflexion, plantar flexion, inversion, eversion

34
Q

Assess skin color
Integumentary 1

A

Skin color; even skin tone
No bumps, lesions, even hair distribution

35
Q

Palpate skin upper and lower
Integumentary 2

A

Warm temperature
Moist skin
Turgors

health assessment (9 decks)

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