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Health Assessment 1080L > test 1 > Flashcards

test 1 Flashcards

1
Q

what is subjective data?

A

What the person says about themselves

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2
Q

what is objective data

A

What you observe by inspection, percussion, palpation, and auscultation during physical examinations

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3
Q

what is clinical reasoning methods?

A
  • diagnostic reasoning
    -Nursing process
    -Critical thinking
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4
Q

what is diagnostic reasoning?

A

1) attending to available cues
2) formulating a diagnostic hypothesis
3) gathering data relative to tentative hypothesis
4) evaluating each hypothesis with new data to arrive at the final diagnosis

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5
Q

what is the nursing model consists of?

A
  • assessment –>diagnostic reasoning–> planning–> implementation–> evaluation
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6
Q

Critical Thinking and Priorities?

A

First-level priority problems: These are immediate and life-threatening issues, such as those affecting a patient’s airway, breathing, or circulation (ABC Vital Signs).

Second-level priority problems: These are urgent but not immediately life-threatening, including concerns like acute pain.

Third-level priority problems: These are important but less urgent issues, often related to education, knowledge, or resource allocation for long-term care.

Collaborative problems: These require the involvement of multiple healthcare professions, often for managing complex or chronic conditions.

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7
Q

the concepts of health

A

Biomedical model
–-> Health = absence of disease
Behavioural model
–->Treatment of disease + prevention
Socioenvironmental model
–-> Sociological and environmental aspects

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8
Q

what is the purpose of interview?

A
  • gather data
  • establish rapport
  • teaching(health promotion)
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9
Q

implied contract

A

time and place
intro and explanation
purpose of the interview
length of interview
what will occur
others present
confidentiality

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10
Q

what can assist in the conversation with pt?

A
  • facilitation
  • silence
  • reflection
  • empathy
  • clarification
    -interpretation
    -explanation
    -summary
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11
Q

Ten Traps of Interviewing

A

providing false reassurance
giving unwanted advice
using authority
using avoidance language
engaging in distancing
professional jargon
using leading or biased questions
talking to much
interrupting
using “why” questions

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12
Q

Non Verbal Cues

A

physical appearance
posture
gestures
facial expressions
eye contact
voice
silence
bodily exposure and touch

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13
Q

to complete health history

A
  • Biographical data
  • Source of history
  • Reason for seeking care
    – Record as quote
  • Current health or history of current illness
    – OPQRSTUAAA
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14
Q

inspection

A

concentrated watching
general survey
compare sides (symmetry)

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15
Q

palpation

A

involves using touch to examine the body’s structures, identify tenderness, masses, temperature variations, and pulses

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16
Q

what do we use finger tips for during palpation?

A

skin texture, presence
of lumps

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17
Q

how about dorsum (back of hand palpation)

A

used for temp

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18
Q

Base of Fingers or Ulnar Surface

A

Vibration

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19
Q

Percussion

A
  • involves tapping or striking the body to assess internal structures and identify abnormalities.
  • it help’s evaluate the density, size, and location of organs and tissues within the body, particularly in the chest and abdomen.
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20
Q

what are the types of Percussion?

A

Direct percussion
– Striking hand contacts body directly
Indirect percussion
– Stationary hand
– Striking hand

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21
Q

Characteristics of percussion?

A

– Resonant: lungs
– Hyper-resonant: hyperinflated lungs
– Tympany: stomach
– Dull : solid organs, bones
– Flat: bones

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22
Q

Auscultation

A

involving the use of a stethoscope to listen to sounds
– Diaphragm: High pitched
– Bell: Low pitched

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23
Q

Vital Signs - Normal Ranges (TPRBPSP02)

A

Temperature
-oral: 35.8-37.3
-tympanic: 36.5-37.5
Pulse: 60-100 bpm
Respiratory rate: 12-20 respirations per minute
-blood pressure: 120/80
- oxygen saturation: >95% on room air
pain assessment

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24
Q

Korotkoff’s sounds

A

Stage 1 is where sound starts = systolic blood pressure
Stage 5 is where sound ceases = diastolic blood pressure

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25
Q

respiration less than 10 called

A

Bradypnea

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26
Q

respiration more than 10 called

A

Tachypnea

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27
Q

pulse less than 60

A

Bradycardia

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28
Q

pulse more than 100

A

Tachycardia

29
Q

the force of the pulse

A

0=absent
1=weak
2=normal
3=bounding
Apical Pulse - 5th intercostal space at midclavicular line

pulse deficit - mismatch between apical pulse and peripheral pulse

30
Q

stages of measuring blood pressure

A

Stages
fully compressed = silence(120+)
partially compressed =korotkoffs sounds (80-120)

free flowing = silence (0-80)

stage 1 is where sound starts
stage 5 is where sound ceases

Auscultatory Gap - silence in the middle of korotkoffs sounds, not normal

31
Q

Inspection of Musculoskeletal

A

size and contour of each joint
skin and tissue of each joint
note swelling and discolouration
visual differences between muscle symmetrically

32
Q

Palpation of Musculoskeletal

A

skin temperature
muscles
bony articulations
joint capsule

33
Q

Temporomandibular joint

A

Inspection
Palpation
- Open and close mouth
Range of motion
- Open mouth maximally, test muscle strength
- Protrude and retract lower jaw
- Side to side/laterally
Palpate muscles of mastication

34
Q

Cervical Spine

A

Inspection
- Alignment of head and neck
Palpate
- Spinous processes and muscles
Motion and expected range
- Touch chin to chest
- Lift chin
- Move each ear to shoulder
- Turn chin to each shoulder
(REPEAT WITH OPPOSING FORCE)

35
Q

shoulders

A

Inspection
- Compare shoulders posteriorly and anteriorly
- Pain
Palpate
- Shoulders and axillae
- Palpate bilaterally, comparing side to side
- Start at clavicle and work out to shoulder
Motion and expected range
- Flexion and hyperextension
- Abduction and adduction
- Internal rotation
- External rotation
(REPEAT WITH OPPOSING FORCE)

36
Q

elbow

A

Inspect while flexed and extended
Palpate - flex arm 70 degrees and support arm
Motion and expected range
- flexion and extension
- Pronation and supination
(REPEAT WITH OPPOSING FORCE - support the joint with one hand and provide opposing force with the other)

37
Q

wrist & hand

A

Inspect
- Joints and dorsal and palmar sides
- Positioning of wrist and fingers, abnormalities, skin, muscles
Palpate
- Over each joint in the hand
- Support hand
- Start at wrist and move toward distal fingers
Muscle testing
- Flex against resistance: Arm supine on table
- Grip strength
Special Considerations
- Phalen test: Hold hands back to back for 60 seconds. Expected - no symptoms
- Tinel’s Sign: Direct percussion at median nerve Expected - no symptoms

38
Q

hip

A

Raise leg
* Bend knee to chest
* Flex knee and hip and swing foot out
and in
* Swing leg laterally & medially
* Adduction and abduction
* Stand and swing leg back

39
Q

knee

A
  • Inspect
  • Joint and muscle
  • Palpate
  • Supine position and relaxed quadriceps muscle
  • Start proximal (above patella) and move distal
  • Motion and expected range
  • Bend knee
  • Extend knee
  • Watch knee during gait
  • Muscle strength
  • Flex knee against resistance
40
Q

ankle and foot

A

Inspect - sitting, standing, and walking
Palpate joints
- Start proximal and move distal
- Support the ankle while palpating
Motion and expected range
- Point toes down
- Turn soles out
- Flex and straighten toes
Muscle strength - flex and extension against resistance

41
Q

spine

A
  • Inspect
  • Standing – posture
  • Palpate spinous processes
  • Motion and expected range
  • Stabilize pelvis
  • Bend sideways, forwards, backwards
  • Twist shoulders to each side
42
Q

Techniques of Communication

A
  • Introducing the Interview
  • The Working Phase
  • Open and Closed Questions
  • How your responses can impact the interview
  • Ten Traps of Interviewing!
  • Non-verbal Skills
  • Closing the Interview
43
Q

when inspecting the skin

A

we look for changes in color, lesions, texture, moisture levels, temperature, turgor, and signs of edema or swelling
- also assess wounds, scars, skin integrity, hygiene, and inquire about allergies and skin conditions.

44
Q

subjective data for Neurological System assessment

A
  • Headache
  • Head Injury
  • Dizziness or Vertigo
  • Seizures
  • Tremors
  • Weakness
  • Incoordination
  • Numbness/Tingling
  • Difficulty Swallowing
  • Difficulty Speaking
  • Significant Past History
  • Environment or Occupational
    hazards
  • Older Adult
  • Falls, Cognitive Function, Tremor,
    Vision Changes
45
Q

what is introducing phase

A

is the initial stage of a conversation or interaction where participants greet each other, introduce themselves, state the purpose or context, build rapport, and set expectations.

46
Q

what is Working Phase

A

– Open ended questions first
* Listen FOR concerns
* Listen TO descriptions
* Listen for what is missing
– Closed ended questions
* Specific information
* Elicits facts
* Limits rapport

47
Q

Examples of how do you close an interview with pt?

A

Is there anything else you would like to mention?
Are there any questions you would like to ask?
Are there any other areas I should have asked
about?
Did we accomplish what you had hoped?

48
Q

what does oxygen Saturations measure?

A

Measures percentage of oxygen bound to the hemoglobin

49
Q

Stage 1 Pressure Ulcer

A

epidermis only
-Intact skin with non-blanchable redness in a localized area.
- Typically found over bony prominences.
- May exhibit changes in firmness, softness, or temperature compared to adjacent skin.

50
Q

Stage 2 Pressure Ulcer:

A
  • Partial thickness skin loss involving the epidermis and dermis.
  • Presents as a shallow open ulcer with a red-pink wound bed.
  • May appear as a clear fluid-filled blister.
  • No slough present.
51
Q

Stage 3 Pressure Ulcer

A

-Full thickness tissue loss, with subcutaneous fat visible.
- No exposure of bone, tendon, or muscle.
- May include undermining and tunnelling.

52
Q

Stage 4 Pressure Ulcer

A

-Full thickness tissue loss with exposed bone, tendon, or muscle.
-Often includes undermining and tunnelling.

53
Q

Deep Tissue Pressure Injury

A
  • Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration.
  • May involve epidermal separation revealing a dark wound bed or blood-filled blister.
54
Q

Unstageable Pressure Ulcer

A

Full thickness loss where the base of the ulcer is covered by slough and/or eschar in the wound bed.

55
Q

Mucosal Membrane Pressure Ulcer

A

Ulcers found on mucosal membranes.
-Typically caused by devices at the location of the injury.
-These ulcers cannot be staged due to mucosal anatomy.

56
Q

Incontinence/Moisture Lesion

A

-Caused by incontinence or moisture, not pressure and shear.
-Skin remains damp, and the damage may occur in various skin areas, not limited to bony prominences.

57
Q

how do we assess mental status?

A

Level of Consciousness
* Arousal
*Gross response to stimuli
* Glasgow Coma Scale
* Awareness
* Aware of orientation
* Name, location, time
* A & O x 3

58
Q

Cranial Nerve I

A

Olfactory
Function: Responsible for the sense of smell. (coffee test smell)

59
Q

Cranial Nerve II

A

optic
Function: Responsible for vision.
Mnemonic: “Optic for eyesight; think of binoculars.”

60
Q

Cranial Nerve III, IV and VI (3,4,6)

A
  • Oculomotor (CN III) controls most eye muscles for eye movement and pupil constriction.
  • Trochlear (CN IV) controls the superior oblique muscle for downward and lateral eye movement.
  • Abducens (CN VI) controls the lateral rectus muscle for moving the eye outward.
    Mnemonics:
    “Oculomotor moves your eyes and makes your pupils constrict.”
    “Trochlear, the ‘down and out’ nerve, helps you look down and out.”
    “Abducens abducts your eye, making it look outward.”
61
Q

Cranial Nerve V (5)

A

trigeminal nerve
Function: Sensation in the face, as well as chewing muscles.
Mnemonic: “Trigeminal touches your face and lets you chew gum in three branches.”

62
Q

Cranial Nerve VII

A

facial
Function: Controls facial expressions, taste, and salivation.
Mnemonic: “Facial gives your face expression and taste.”

63
Q

Cranial Nerve VIII

A

Vestibulocochlear
Function: Responsible for hearing and balance.
Mnemonic: “Vestibulocochlear helps you hear the sounds of your crazy vestibule party.”

64
Q

Cranial Nerve IX (9)

A

Glossopharyngeal
Function: Involved in swallowing, taste, and sensation in the back of the throat.
Mnemonic: “Glossopharyngeal glosses over the back of your throat.”

65
Q

Cranial Nerve X

A

Vagus
Function: Controls many visceral functions, including heart rate, digestion, and speech.
Mnemonic: “Vagus wanders through your body, affecting heart, gut, and larynx.”

66
Q

Cranial Nerve XI

A

Spinal Accessory nerve
Assessing size, strength, ROM and resistance of the
Sternocleidomastoid and Trapezius
( Controls neck and shoulder muscles.)

67
Q

Cranial Nerve XII

A

Hypoglossal
Function: Controls the tongue muscles for speech and swallow

68
Q

OPQRSTUV??

A

Onset: when did this begin and how
Provocative: what makes the pain start
Quantity / Quality: what does it feel like and is it constant
Radiation / Region: where does it actually hurt and does it spread to other parts of the body
Severity: on a scale of 1-10, 10 being the worst pain in your life
Timley: when did it occur and how often does it happen
Understanding: what is the patients perception of the pain
Value: what does the patient expect their pain level to be

Health Assessment 1080L (2 decks)

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