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Nursing 100 > Quiz 3: Health Assessment > Flashcards

Quiz 3: Health Assessment Flashcards

1
Q

General Health History Collection

A
  • Childhood Illnesses?
  • Chronic Illness?
  • Surgeries?
  • Vaccinations?
  • Allergies?
  • Medications?
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2
Q

What is the acronym for Key Elements of Health Interviews

A

P- past medical history (illnesses and current health)
L- Last oral intakes
E- Events leading to illness/injury
A- Allergies and reactions
S- Symptoms
E- Each Prescribed med and supplements

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3
Q

Subjective Data

A

What the patient says; cannot be directly measured
- Pain is a 4/10
- Heart is beating out of my chest
- “I feel..”

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4
Q

Objective Data

A

What the data says; can be directly measured
- Heart rate is
- Blood Pressure is
- Respiratory rate is
- Imaging results
- Observed behaviors

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5
Q

What are the essential interventions when obtaining health history and physical assessments

A
  • Comfy room temp for patient
  • Hands and Stethoscope is warm
  • Close doors and curtains for privacy
  • Don’t expose more of the body then whats needed
  • explain what you’re doing before you start
  • Obtain verbal consent
  • Perform hand hygiene and collect supplies
  • Introduce myself and answer pt questions
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6
Q

What are expected and unexpected findings of the Head and Neck

A

Expected:
- Symmetry, no depressions, no masses, no tenderness, head is normocephalic size

Unexpected:
- Mass, limited ROM of neck, enlarged lymph nodes

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7
Q

What are the techniques for the head and neck

A

Inspection, Palpation, Auscultation

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8
Q

What are some questions to ask about the head and neck

A
  • Do you get headaches? If yes how often? Location of them?What do you do for pain relief?
  • Any past head injuries?
  • Neck pain?
  • Can you move your head and shoulders with ease?
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9
Q

What are expected and unexpected findings of the Eyes

A

Expected:
- 20/20 vision
- Pt can read 35.6cm print
- No distortion, blurry, blueness
- uncovered eye doesnt move when covered eye does
- No redness
Unexpected:
- loss of visual fields, asymmetrical light reflexes, periobital edema, conjunctivitis,

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10
Q

What are the techniques for the Eyes

A

inspection with limited palpation

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11
Q

What are some questions to ask about the eyes

A

How is your vision?
Noticed any changes?
Any blurry or double vision?
Pain or light sensitivity?
Glasses or contacts?
Last eye exam?
Diabetes?

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12
Q

What are some expected vs. unexpected findings of the Ears, nose, mouth and throat

A

Expected:
- equal size and similar shape
- smooth skin, pink color
- warm, no tenderness
- ID 3/6 whispered words
Unexpected: otitis externa, osteoma, polyp, retracted drum, decreased hearing activty

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13
Q

What are the techniques for the ear, nose, mouth and throat

A

Inspection and palpation

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14
Q

What are some questions to ask about the ear, nose, mouth and throat region

A

How well can you hear?
Hearing aids?
ringing or buzzing?
history of ear infections?
Pain or stiffness?
Any draining from nose?

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15
Q

what are some health history componets?

A

name, address, contact information
date of birth, age
gender
race, ethnicity
relationship status
occupation, employment status
insurance
emergency contact information
family, others living at home
advance directives

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16
Q

What does a general survey consist of

A
  • how does their skin color look?
  • Do they look clean or unkempt?
  • Facial expressions?
  • Do they look to be in distress?
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17
Q

How is the Abdomen assessed?

A
  • Inspection, auscultation, percussion and palpation
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18
Q

Why is the abdomen assessed in a different order

A

Bc pressing and touching can irritate the area and be uncomfy for the patient, also could alter bowel sounds so we want to listen and look first.
- Also if there is a blockage we don’t want to cause trauma

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19
Q

What is the normal order for assessments

A

Inspection, Palpation, Percussion, Auscultation

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20
Q

What are the assessment techniques used across the lifetime

A
  • Talk slower
  • Give more response time
  • Sitting comfy
  • Warmer room/ good temp for them
  • Typical abnormal findings are not abnormal as they age
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21
Q

Techniques for assessing the breasts

A

Inspection and palpation

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22
Q

Questions to ask about the breasts

A
  • Do you perform self-exams? How often?
  • Have you noticed any tenderness or lumps?
  • Do you have any thickening, tenderness or pain?
  • History of breast cancer?
  • Taking any meds that would effect your breast tissue?
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23
Q

Do both male and females get breast exams?

A

yes

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24
Q

Best time to perform a breast self exam?

A

4-7 days after menses begin or right after menstruation ends

25
Assessing the Thorax and Lungs
- Anterior and posterior thorax and lungs - Posterior with pt standing or sitting - Anterior with pt sitting, lying or standing - Looking to see if they have chest discomfort? (Chest or heart) - SOB? - Cough? - Does chest look equal? rising and falling? - How is the pt presenting? Grimacing - Also assess the spine, ribcage, trachea (deviations can be related to thyroid diseases),
26
What are the techniques for assessing the thorax and lungs
- inspection, palpation, percussion and auscultation
27
Questions to ask about the lungs/thorax region
- Do you have any chronic conditions? - Take any meds for the respiratory system? - Have you ever has pneumonia, if so when? - Do you get colds and coughs frequently? where: Upper/lower resp tract? - Smoke/vape? - History of asthma, lung disease? - Allergies? Seasonal? - Do you have sputum, what does it look like? Smell?
28
What supplies do you need to assess the heart?
- Stethoscope, blood pressure cuff, watch (seconds)
29
Questions to ask about the heart
- Any cardiac problems? - Hypertension? Anyone in the family? - Take any meds for your heart? - History of heart trouble? Preexisitng diabeties, lung diseases? - Do you have high BP or high cholesterol? - Chest pain? - Feet or ankle swelling?
30
Assessing the Abdomen
- Observing shape of abd, palpating for masses, auscultating for vascular sounds - Have pt pee before exam - Divide abd into 4 quadrants
31
Questions to ask about the abdomen
- Ever have NV, cramping? - Any appetite changes? - Weight changes recently? - Vomiting blood? - Any black or tarry stools? - often uses laxatives or enemas? - What does their stools look like?
32
Questions to ask about Musculoskeletal system?
- Any pain in your joints? - Weakness or twitching? - Recent falls? - Exercise or play sports?
33
Questions to ask about the neurologic system
- Noticed any change in your vision, speech, ability to think or loss of memory? - Dizzy or headaches? - Seizures? Triggers? - Ever have weakness or tremors?
34
What tools do you need for inspection?
Pen light, otoscope, opthalmoscope
35
How do you palpate?
- Looking for areas of crepitus (Bubbly or crunchy) due to emphysema - Assess expansion and have them take deep breathes with your hands on the back bottom back (W hands) (10th rib) - Tender areas last - Be light (1cm) and deeper (4cm) to eval abd organs or masses - Be systemic about it and stay calm
36
What tools are needed for physical assessments?
- Gown - Drapes - Scale - Thermometer - Stethoscope - BP cuff - Eye chart and eye exam tools - Gloves - Pulse ox - Clock
37
What is a normal respiration rate
- 12-20 breaths/min - Checking rhythms too - Asking if they get SOB
38
What is tachypena
RR over 20 breaths/min - Can be due to anxiety, pain, infection
39
What is bradypena?
RR of less then 12 breaths/min - Can be electrolyte imbalance, or opioid medications
40
what is barrel chest and what does it indicate?
- area will stick out more, means pt could have a respiratory disease like cystic fibrosis or COPD - Lungs are holding lots so they rib cage is
41
Expected vs. Unexpected findings in the Thorax and lungs
Expected: - Anterior-posterior diameter of the chest is less then the lateral diameter Unexpected: - Barrel Chest - Funnel Chest - Scolosis or kyphosis - trachea (deviations can be related to thyroid diseases), sternum for structure abnormalities - Depressions or elevations
42
How to assess cyanosis and what foes it mean?
Cyanosis: assess fingers, mouth and toes Normal Pulse OX Symmatry- 95-100% You know that POXS is less then
43
How to percuss?
- Percuss every 4-5 cm over intercostal spaces - Looking to see if there is any resonance - Expect to hear dullness over bones or diaphragm
44
How to auscultate?
- Use the diaphragm of stethoscope - Have pt if able sit upright and take several deep breaths, with slight holding - Start at bases of lung and listen over intercostal space - The do posterior side - Listening for vesicular (low pitch), bronchovesicular (med pitch) and bronchial (high pitch)
45
Abnormal Breath sounds?
- Crackles (pulmonary edema, pneumonia), start at base and move up, cant have water at top if not on bottom - Rhonci-low pitched, rumbling sounds caused by air moving - Wheezing: high pitched sounds, seen with bronchiospasm, means airway is being narrowed - friction rub: low pitched sounds - diminished breath sounds and absent breathsounds
46
Inspection in Abdomen
- Is it concave, flat? - Any leasions? - Stretchmarks, abrasions? - Can you see pulse of the abd aorta? - Is it symmetrical?
47
Auscultation in the Abdomen
- Normal to hear bowel sounds in all 4 quadrants - Listen for a full 5 mins per quadrant (unless you hear it rightaway)
48
What are Borborygmi
gurgling sounds from the digestive process
49
Five places to auscultate with the bell
Abdominal aorta bilateral renal arteries bilateral iliac arteries.
50
Percussion
looking to percuss on areas to allow a gentle compression or movement or a tapping
51
Murphy's Sign
- Exam Technique - To determine if pt has any gallbladder disease - Identify pts symptoms that align with galbladder - Positive finding: unable to inhale/sudden halt inspiratory
52
Blumberg sign
- Have pt lie supine, - Tells us if it is their appendix - Positive finding: more pain with release then compression
53
Why we use the compare method
- Abnormal finding could be present in one side and not the other - Good to assess both and then compare
54
Differences between venous and arterial ulcers
Venous: - Present on medial malleous Arterial: - Found on toes
55
1+ edema
- 2mm deep and rebounds immediately
56
2+ edema
- 3-4mm deep and rebounds in 15 secs or less
57
3+ edema
5-6mm that rebounds in 60 secs
58
4+ edema
8mm or more rebounds in 2-3 mins
59
What is my responsibility as a nurse
Assess, interpret, report, and document your assessment findings - If anything's abnormal I must report and then follow up

Nursing 100 (17 decks)

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