Physical Health Assessment/HEENT chap 30 (575-618) Flashcards
Typically, a complete heath assessment begins with what type of framework?
A health assessment usually begins with a head-to-toe framework
According to cancer screening guidelines, at what age can men get screened for colorectal cancer?
At age 50: fecal bld test beginning at age 50, sigmoidoscopy or BE every 5 yrs, colonoscopy every 10 yrs
According to cancer screening guidelines, at what age can women get screened for breast cancer?
Clinical breast examination every 3 years from 20 to 40 and then annually beginning at age 40/mammogram annually after 40
According to cancer screening guidelines, at what age can you get examined for cancers of the thyroid, testicles, ovaries, lymph nodes, oral region, and of the skin?
Men and women over age 20 should be examined every 3 years and annually over age 40
Scenario of assessment: Pt c/o of abd pain. How are you suppose to assess?
Inspect, auscultate, palpate the abd; assess V/S
Pt is admitted w/head injury. What do you assess?
Assess LOC using Glasgow Coma Scale, assess PERRLA, assess VS
The nsg prepares to administer a cardiotonic drug to a pt. After doing your 3 checks, 5 rights, what else are you suppose to assess?
Assess apical pulse, know parameters, compare w/baseline data
The pt has just had a cast applied to LE. What are you to assess?
Assess for peripheral perfusion of toes, capillary test, pedal pulse if able, and VS
The pt’s fluid intake is minimal. What are you to assess?
Assess pt’s tissue turgor, I&Os, and VS
Why is it important to have the pt empty their bladders prior to a health examination?
Pts will feel more relaxed and facilitates palpations of the abd and pubic area
What’s the sequence of assessment for examining children?
With children, I’m to proceed from least invasive/uncomfortable to the more invasive (head, neck, heart, lungs, ROM before ears, mouth, abd, and genitals)
What are the four primary methods used in an examination?
Inspection, palpation, percussion, and auscultation
In order to assess the female genitals, rectum, and reproductive tract, what position should the pt be in?
Dorsal recumbent (Back-lying position w/knees flexed and soles of feet on the surface) or Lithotomy (back-lying position w/feet in stirrups and hips in line w/edge of table)
In order to assess the head, neck, ax, anterior thorax, lungs, breasts, heart, VS, abd, extremities, peripheral pulses, in what position should the pt be in?
Supine (back-lying position w/legs extended)
In order to assess the head, neck, posterior/anterior thorax, lungs, breasts, ax, heart, VS, U/LE, and reflexes, what position should the pt be in?
sitting
How do you perform a light palpation?
Use dominate hand’s fingers parallel to the skin surface and press gently while moving the hand in a circle. If determining a mass, never hold pressure, palpate the area several times instead.
Characteristics of masses should be documented as: location, size, shape, consistency, surface, mobility, pulsatility, tenderness
Location (site on the body, dorsal/ventral surface), size (length/width in cm), Shape (oval, round, elongated, irregular), Consistency (soft, firm, hard), Mobility (fixed, mobile), Pulsatility (present or absent), Tenderness (degree of tenderness to palpation)
How do you use palpation to test for skin temp?
Use the back of hand as the skin is thinnest
When are areas of tenderness palpated?
Areas of tenderness are palpated last
The act of striking the body to elicit sounds that can be heard or vibrations that can be felt is called
percussion
Striking the area to be percussed w/the pads of two, three, or four fingers or w/the pad of the middle finger in rapid strikes is using which type of percussion
direct percussion (commonly used on the sinuses)
To strike an area to be percussed using an object held against the body such as a pleximeter (middle finger of nondominate hand) while using the tip of the plexor (middle finger of dominate hand) to strike is what type of percussion
indirect percussion (commonly used on the thorax)
A flatness sound (extremely dull quality) elicit by percussion may be located from:
muscle or bone
A dullness sound (thud-like quality) elicit by percussion may be located:
liver, heart
A resonance sound (hollow quality) elicit by percussion may be located:
normal lung
A hyperresonance sound (booming quality) elicit form percussion may be located:
emphysematous lung
A tympany sound (musical quality) elicit from percussion may be located:
stomach filled w/gas (air)
The process of listening to the sounds produced within the body is called:
auscultation
What is the difference between direct and indirect auscultation?
direct auscultation is the use of the unaided ear (listening to a respiratory wheeze or grating movement of a joint) whereas indirect auscultation is the use of a stethoscope (BS, valve sounds of the heart, BP)
What sounds can be best transmitted by both the diaphragm and bell of a stethoscope?
the diaphragm best transmits high-pitched sounds (bronchial sounds) whereas the bell best transmits low-pitched sounds (some heart sounds)
Auscultated sounds are documented according to pitch, intensity, duration, and quality.
Pitch (number of vibrations per second), Intensity (amplitude: loudness or softness of sound), Duration (length: long or short), Quality (subjective description of sound: whistling, gurgling, snapping)
A normal head size is referred to as:
normocephalic
You’re assessing the head and you find edema of the eyelids. This finding is:
abnormal and may indicate kidney or cardiac disease
You’re assessing the head and you notice a protrusion of the eyeballs (exophthalmos) w/elevation of the upper eyelids resulting in a staring or startled expression: This finding is:
abnormal and may be caused by hyperthyroidism
You’re assessing the head and you noticed that the face is dry and puffy w/thinning hair of the scalp and eyebrows. This finding is:
abnormal and may be caused by hypothyroidism or myxedema
Protrusion of the eyeballs w/elevation of the eyelids is called and indicates what?
exophthalmos that may be caused by hyperthyroidism
You’re assessing the head and you noticed that the pt’s face is round with reddened cheeks. You also notice excessive hair growth on upper lips and chin. This finding is:
abnormal and called moon face that may be caused by increased adrenal hormone production or administration of steroids
You’re doing a head assessment and you notice that the eyes, cheeks, and temples seem sunken in. This finding is:
abnormal and may be cause by prolong illness, starvation, or dehydration.
The degree of detail the eye can discern in an image is called?
visual acuity
The area an individual can see when looking straight ahead is called?
visual field (2nd optic nerve)
You are assessing the pt’s eyes and the pt says that he cannot see very clearly from afar without the aid of glasses. The pt has?
myopia (nearsightedness)
You’re pt is over 45 years of age and complains that he cannot close objects due to the loss of elasticity of his lens. Your pt has?
presbyopia and usually begins at age 45+