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Health Assessment > Unit 2: Approach to clinical setting > Flashcards

Unit 2: Approach to clinical setting Flashcards

1
Q

Proper Hand Washing Technique

A
  • 15-20 seconds “happy birthday” twice

- luke warm water and antibacterial soap

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2
Q

c-diff

A

smelly, painful, explosive diarrhea every 15 minutes

- can last 6-8 weeks in a health person

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3
Q

Tools of physical assessment

A

insepction, palpation, percussion, auscultation

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4
Q

Inspection

A
  • visual exam of body including movement and posture. smell also
    use of equipment may help:
  • penlight -eyes, dilation
  • otoscope - ears, tempanic membrane
  • ophthalmoscope - eyes, distribution of blood vessels, retina
  • nasal speculum - open up nose and look
  • vaginal speculum
  • woods lamp (black light) for fungal infections or corneal abrasion)
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5
Q

palpation

A
  • use of hands to feel texture, size, shape, consistency, location of certain parts, and identify painful or tender areas
  • requires nurse to move into personal space
  • gentle touch, warm hands, short nails
  • Light and Deep (requires training, can rupture spleen or gallbladder)
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6
Q

parts of hands for palpation

A
  • fingertips: skin texture, swelling (edema), pulsations, lumps
  • fingers and thumb (grasping): shape, consistency of an organ or mass
  • dorsal of hands and fingers: temperature
  • base of fingers/ulnar surface of the hand: vibrations
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7
Q

Percussion

A
  • yields characteristic vibration sounds
  • determines density, location and size of underlying organs or to elicit DTRs
    LUNGS = resonance = air
    ABDOMEN = fluid/air = tympany
    ORGAN/MASS = solid = dullness
    BONE = dense = flat
  • hyperresonance = too much air (COPD)
    Use percussion in two areas:
    1: costal vertebral angle - back where ribs end - kidney stones, kidney infection
    2: Sinuses: sinus infection
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8
Q

indirect percussion

A
  • use middle finger only
  • tap twice and lift up
  • you can use this to estimate the size of organs
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9
Q

Auscultation

A

listen to sounds within the body with a stethoscope

  • listen for sound characteristics: intensity, pitch, duration and quality
  • DIAPHRAGM: high pitch noises (respirations, abdomen)
  • Bell: Low pitch (heart,
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10
Q

patient positioning

A
  • move no more than 4 times throughout exam. laying, sitting, standing, sitting
  • lithotomy position - vaginal exam in stirrups
  • trandelenburg - feet up higher than head (central line placement)
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11
Q

thermometers

A

electronic:
tympanic: ear - varied accuracy
temporal: uses in fared, highly accurate

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12
Q

stethoscope

A

diaphragm: high pitched sounds, respiratory, bowel sounds, normal heart sounds
Bell: soft/low-pitched sounds - extra heart sounds, vascular sounds,

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13
Q

sphygmomanometer

A

measures arterial blood pressure

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14
Q

pulse ox

A

measures arterial oxygen saturation in blood

- % of hemoglobin that is binded to an oxygen molecule

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15
Q

weight

A

daily weight certain patients:

  • CHF patients (edema)
  • gastric bypas (weight loss surgery)
  • dialysis patients (urinary issues)
  • infants with failure to thrive
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16
Q

visual acuity and screening

A

snellen chart is a wall chart placed 20 ft from patient

- E chart is used for young children and on-english speaking patients

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17
Q

otoscope

A

used to look at tyrannic membrane. sends small puffs of air to evaluate fluctuation of tympanic membrane in children

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18
Q

penlight

A
  • illuminate mouth or nose
  • highlight a lesion
  • evaluate pupillary constriction
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19
Q

nasal speculum

A

used to inspect lower and middle turbinates of the nose.

20
Q

tuning fork

A

auditory screening and and vibratory sensation

21
Q

reflex hammer

A

used to test deep tendon reflexes “percussion hammer”

22
Q

doppler

A

usees ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart sounds and peripheral pulses

23
Q

goniometer

A

degree of flexion and extension of joint

24
Q

monofilament

A

used to test lower extremity sensation

- small, flexible wirelike deice attached to handle NEURO

25
Q

transilluminator

A

used to differentiate characteristics of tissue, fluid, air in specific body cavity

26
Q

woods lamp

A

detects fungal infection of skin, detects corneal abrasions (with use of florescent dye)

27
Q

general inspection

A

begins the moment the nurse meets the patient

  • physical appearance, hygiene, body structure and movement, emotional and mental status, behavior
  • use this to guide your health assessment
  • note: assistive divice for walking, happy/depressed, dressed appropriate for weather, wounds, hygiene
28
Q

chachexia

A

very very thin and malnourished

29
Q

VITAL signs

A 
weight  
Height 
temperature 
pulse 
respiratory rate 
Blood Pressure 
02 saturation
30
Q

Weight

A

BMI: overweight = 25-30
obese = 30 - 34
morbidly obese = 35+

weight to hip ratio is important
android obesity = around the middle
synoid obesity = butt

31
Q

Temperature

A

body temp is regulated by the hypothalamus

  • heat gained through process of metabolism and exercise
  • heat lost through satiation, convection, conduction, and evaporation
  • temps = 96.4 - 99.1 (normal)
  • avg. 98.6 = stable core temperature at which cellular metabolism is most efficient

ORAL: safe and relatively accurate. delay 10 minutes if patent ingested hot or cold liquids or smoked. under tongue to get the carotid artery temp
TYMPANIC & AUXILLARY & RECTAL

32
Q

heart rate

A 
grade/strength of pulse
0 - none
1 - weak/thready
2 - normal
3 - full & strong

most common pulse location is radial pulse

33
Q

pulse

A

apical pulse = use stethoscope over heart and count sounds for 1 minute

  • 5th intercostal space at the mid-clavicular line
  • use stethoscope
  • PMI = point of maximal impulse

carotid artery - one finger, one side at time. can cut off blood flow to brain. lowe 3rd of neck

34
Q

resp rate

A

make sure patient is unaware

  • check depth: deep, normal or shallow
  • normal breathing = even, quiet, and effortless when patient is sitting or laying down
35
Q

blood pressure

A

force of blood against arterial walls

  • reflects relationship between cardiac output and peripheral resistance
  • Cardiac output = volume of blood ejected from heart each minute
  • peripheral vascular resistance = force that opposes flow of blood through vessels; narrow arteries = high resistance and high BP
  • blood pressure is dependent on cardiac output, PVR, viscosity of blood, intravascular blood volume, and elasticity of vessel walls
36
Q

Systolic BP

A

max pressure exerted on arteries when ventricles eject blood from heart contract

37
Q

diastolic BP

A

min amount of pressure exerted on vessels when ventricles relax

38
Q

BP measurements

A
  • systolic/diastolic 120/80
  • pulse pressure = diff between systolic and diastolic and normally ranges between 30 mmhg and 40mmhg
  • orthostatic BP = series obtained when the patient is lying, sitting, and then standing
  • Korotkoff sounds are blood flow sounds that healthcare providers observe while taking blood pressure with a sphygmomanometer over the brachial artery in the antecubital fossa. These sounds appear and disappear as the blood pressure cuff is inflated and deflated.
39
Q

thigh BP

A

take when arm pressure is contraindicated or abrnoamlly high (adolescents and young adults)

40
Q

physiologic factors that affect BP

A
  • age: gradual rise through childhood and into adulthood
  • gender: after puberty, females show a lower BP than makes. after menopause females have higher BP
  • race: AA have higher BP than white.
  • diurnal variations: daily cycle of peak and trough occurs. BP climbs high in late PM and declings early morning
  • emotions: rises with fear, anger, and pain
  • pain: rises with pain/stress
  • personal habits: exercise, sedentary, nutrition, etc.
41
Q

commons erros in BP Measurements

A

improper arm position: above heart = low, below heart = high

improper cuff size: too narrow = high, too loose = high

deflating cuff: too fast = ow cyst and high dis, too slow = high dis

42
Q

pain = 5th vital sign

A

wing-baker Faces pain field = kids

43
Q

Abnormal Body/Height Proportions

A
  • hypopituitary dworfism: deficiency in growth hormone in childhood results in retardation of growth below 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency
  • gigantism: excessive secretion of growth hormone by anterior pituitary resulting in overgrowth of entire body. increased height, weight and delayed sexual development
  • achondroplastic dwarfism: genetic disorder in converting cartilate to bone results in normal trunk size, short arms and legs, short stature. large head with frontal bossing and misplace hypoplasia.
  • anorexia nerovosa: psych disorder sever life-threatening weight loss
  • acromegaly: excessive secretion of growth hormone in adulthood, after normal completion of body growth. causes overgrowth of bone in face, head, hands, and feet but no change in height.
  • Marfan’s syndrome: connective tissue disorder. tall, thin stature, hyperflexible joints
  • endogenous obesity/Cushing’s syndrome: ACTH excess by pituitary will stimulate adrenal cortex to secrete excess cortisol. weight gain and edema with central trunk and cervical obesity, round face, accompanied by muscle wasting, weakness, thin arms and legs
44
Q

nociceptive pain

A
  • arises from somatic structures like bone, joint or muscle. results from activation of normal neural systems
45
Q

neuropathic pain

A

occurs because of abnormal processing of sensory input

Health Assessment (8 decks)

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