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Health Assessment > Week 1: Assessment Introduction & Foundational Patient Assessments and Techniques > Flashcards

Week 1: Assessment Introduction & Foundational Patient Assessments and Techniques Flashcards

1
Q

3 levels of prevention

A

Primary, secondary, and tertiary

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2
Q

Primary prevention

A

A set of actions that aim to prevent disease or injury from occurring.

Ex. Condoms and pre-exposure vaccinations

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3
Q

Secondary prevention

A

A set of actions that aim to reduce the impact of a disease or injury by detecting and treating it early.

Ex. Screening programs such as mammography to detect breast cancer

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4
Q

Tertiary prevention

A

A set of actions that aim to reduce the impact of an ongoing illness or injury that has lasting effects.

Ex. For people who have had a stroke: Taking aspirin to prevent a second stroke from occurring

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5
Q

5 steps of the nursing process

A

Assessment, diagnosis, planning/outcomes, implementation, and evaluations

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6
Q

4 cognitive skills of the assessment process

A

Clinical thinking, clinical reasoning, clinical judgment, intuitive thinking

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7
Q

Clinical thinking

A

Purposeful and creative thinking aimed at problem-solving

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8
Q

Clinical reasoning

A

Identifies abnormal findings, risk factors, and health promotion and prevention behaviors

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9
Q

Clinical judgment

A

Decisions made based on information available

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10
Q

Intuitive thinking

A

“Gut feeling”

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11
Q

A patient presents at the ambulatory care clinic for complaints of an upper respiratory infection. While assessing this patient, the nurse needs to identify:

A) Physical assessment findings only
B) Normal from abnormal assessment findings
C) Basic anatomy and physiology
D) Diagnostic value

A

B) Health assessment is a skill to identify normal from abnormal findings. Nurses need to identify normal and abnormal variants that may indicate the patient has an upper respiratory infection.

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12
Q

What is the federal initiative that is a science-based framework updated every ten years by the U.S. Department of Health and Human Services, which has goals and objectives for health promotion?

A) World Health Organization
B) Healthy People 2030
C) U.S. Preventative Services Task Force
D) Robert Wood Johnson Foundation Initiative

A

B) Healthy People 2030 identifies health and risk factors for disease and has goals and objectives for health promotion and disease prevention

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13
Q

A 34-year-old patient is about to deliver her first baby. Her husband appears to be supportive but appears worried and nervous. The patient has come to the hospital since her contractions are 8 minutes apart. She has been in labor for 8 hours and has a past medical history of high blood pressure. She states, “I never took prenatal classes and don’t know what to do.” What cognitive skill should you begin to implement?

A) Nursing Process
B) Nursing Assessment
C) Critical Thinking
D) Intuitive Thinking

A

C) Critical thinking is a problem-solving, reflective process that uses a process of purposeful and creative thinking about resolving problems.

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14
Q

A patient was recently diagnosed with type 1 diabetes and needs teaching about the importance of skin and foot care. This is an example of what level of health prevention?

A) Primary
B) Secondary
C) Tertiary
D) None of the above

A

C) Tertiary prevention encompasses the restoration of health after illness or disease has occurred. Skin care and foot care help prevent complications of diabetes.

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15
Q

4 objective assessment techniques

A

Inspection, auscultation, percussion, and palpation

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16
Q

Assessment order

A

Inspection -> palpation -> percussion -> auscultation

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17
Q

Inspection

A

To look and assess the physical aspects of the body, posture, appearance, and behavior

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18
Q

Inspection: 5 requirements

A

Comfortable room temperature, good natural lighting, PPE if necessary, draping to maintain modesty, and compare symmetry of body parts from left to right

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19
Q

Inspection: 7 characteristics assessed

A

Location, size, color, pattern, shape, odors, and symmetry

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20
Q

Palpation

A

Using the fingers and hands to assess

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21
Q

Palpation: Hand parts and purposes

A

Finger pads: Fine assessment, skin texture, shape, pulse, crepitus.
Dorsal (back) hand: Assess temperature.
Ulnar surface (ball) of the hand: Assess vibration, fremitus, thrills

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22
Q

Palpation: Equipment

A

Gloves, additional PPE (if needed)

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23
Q

Light palpation: Purpose

A

Feel for surface characteristics

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24
Q

Deep palpation: Purpose

A

Feel for deeper characteristics such as organs

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25
Q

Percussion

A

Tapping body parts

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26
Q

Percussion: Equipment

A

Gloves, additional PPE (if needed)

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27
Q

Percussion: 3 types

A

Direct, indirect, and indirect fist (blunt)

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28
Q

Direct percussion: Purposes (2)

A

Assess size, consistency, and boarders of body organs and presence/absence of fluid

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29
Q

Direct percussion: Technique

A

Lightly tap with 1-2 fingertips on the area to be percussed

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30
Q

Direct percussion: Sound characteristics (4)

A

Frequency (pitch): high, low, dull. Intensity: soft (solid tissue), moderate (fluid-filled), loud (air-filled). Duration: length of time sound is heard. Quality: what does it sound like

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31
Q

Indirect percussion: Technique

A

Lay the middle finger of the nondominant hand on the area to be assessed. Short and sharp taps with the middle finger of the dominant hand on the non-dominant hand

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32
Q

As the density of the underlying structure increases, the percussion sounds become (softer/louder)

A

Softer

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33
Q

5 specific percussion sounds

A

Tymphany, dull/thud-like, resonance, hyper resonance, and flatness

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34
Q

Percussion sounds: Tympany (Intensity, pitch, quality, structures)

A

Intensity: Loud.
Pitch: High.
Quality: Drumlike.
Structures: Air-filled structures, typically abdominal areas

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35
Q

Percussion sounds: Dull/thud-like (Intensity, pitch, quality, structures)

A

Intensity: Soft to moderate.
Pitch: Medium.
Quality: Thud-like.
Structures: Solid organs, fluid collection, or areas of consolidation such as a tumor or mass

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36
Q

Percussion sounds: Resonance (Intensity, pitch, quality, structures)

A

Intensity: Moderate to loud.
Pitch: Low.
Quality: Hollow.
Structures: Normal lungs

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37
Q

Percussion sounds: Hyperresonance (Intensity, pitch, quality, structures)

A

Intensity: Very loud.
Pitch: Low.
Quality: Booming.
Structures: Over air-filled spaces such as hyperinflated lungs

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38
Q

Percussion sounds: Flatness (Intensity, pitch, quality, structures)

A

Intensity: Soft.
Pitch: High.
Quality: Dull.
Structures: Areas of increased density such as muscle, bone, joints, and solid masses

39
Q

Indirect fist percussion: Purpose

A

To assess organ tenderness

40
Q

Indirect fist percussion: Technique

A

Gently lay your nondominant hand over the area to be assessed. Using the ulnar surface of your closed dominant hand, firmly thump the dorsum of the nondominant hand

41
Q

4 body systems assessed using auscultation

A

Cardiovascular, respiratory, gastrointestinal, and peripheral vascular

42
Q

Auscultation: 4 characteristics of sound

A

Duration, intensity, pitch, and quality

43
Q

Direct auscultation: Purpose

A

To listen to and assess sounds produced by the body without a stethoscope (not common)

44
Q

Indirect auscultation: Purpose

A

To listen to sounds produced by the body with an amplification device

45
Q

Indirect auscultation: Equipment

A

Stethoscope, Doppler, PPE (if needed)

46
Q

A patient is reporting abdominal discomfort and constipation. The first step just prior to performing an assessment on this patient is to:

A) Put on a disposable gown
B) Wash your hands
C) Stand on the left side
D) Put on gloves

A

B) Always wash your hands before and after an assessment preferably in front of the patient. Health assessment requires direct contact with the patient.

47
Q

Inspection requires the use of the three senses except the sense of:

A) Hearing
B) Seeing
C) Smelling
D) Feeling

A

D) You do not feel the patient when you are looking at and inspecting the patient.

48
Q

The patient states that he has a lump under his upper right arm. What part of the hand is best to use to assess the lump?

A) Dorsal surface
B) Finger pads
C) Ulnar surface
D) Anterior surface

A

B) Finger pads assess fine discrimination and sensations on the surface areas such as texture, shape, consistency, pulses, and crepitus (popping sounds under the skin).

49
Q

What percussion sound will be heard over increased tissue density such as bones?
A) Tympany
B) Dullness
C) Resonance
D) Flatness

A

D) Flatness is heard over increased tissue density such as bones

50
Q

A patient comes to the urgent care clinic stating that his left eye feels “gritty.” The nurses puts on gloves and gently pulls down the lower lid to assess the eye. What technique is the nurse using?

A) Palpation
B) Indirect Inspection
C) Direct Inspection
D) Percussion

A

B) Direct inspection is carefully visualizing and inspecting a specific area. Indirect inspection is using specific equipment to improve visualization of an area such as an ophthalmoscope to look at the internal structure of the eye.

51
Q

5 vital signs

A

Temperature, pulse rate, respiratory rate, blood pressure, and pain

52
Q

Sequence of vital sign assessment

A

Temperature -> pulse -> respiratory rate -> blood pressure

53
Q

Temperature: Locations (4)

A

Oral, tympanic (ear), temporal, and rectal

54
Q

Oral temperature: Normal values

A

97.5F to 99.5F (36C to 37.5C)

55
Q

Oral temperature: Hypothermia

A

<95F

56
Q

Oral temperature: Hyperthermia

A

> 100F

57
Q

Pulse: Locations (2)

A

Radial and apical

58
Q

Radial pulse: Normal values

A

60-100 bpm

59
Q

Radial pulse: Bradycardia

A

<60 bpm

60
Q

Radial pulse: Tachycardia

A

> 100 bpm

61
Q

Radial pulse: Quality and scale

A

0 = Absent: Pulse cannot be felt.
1 = Weak/thready: Pulse is barely felt and can be easily obliterated by pressing with the fingers.
2 = Normal quality: Pulse is easily palpated, not weak or bounding.
3 = Bounding or full: Pulse is easily felt with little pressure; not easily obliterated

62
Q

Respiration rate: Normal values

A

12-20 breaths per minute

63
Q

Respiration rate: Characteristics

A

Depth, rhythm, and effort

64
Q

Blood pressure: Normal values

A

<120 mmHg / <80 mmHg

65
Q

Blood pressure: Locations

A

Upper arm, forearm, and thigh

66
Q

Acute pain: Physical changes (8)

A

Inc. BP, inc. RR, dilated pupils, diaphoretic (sweaty), inc. restlessness, inc. verbal responses (crying, moaning), nausea, and tissue damage/injury

67
Q

Chronic pain: Physical changes (7)

A

Normal vital signs, normal pupils, no restlessness, no verbal response, no nausea, dec. functional capacity

68
Q

Sources of pain: Cutaneous pain

A

Superficial, sharp pain from skin and SQ tissue

69
Q

Sources of pain: Colicky pain

A

Fluctuating, wave-like pain. Usually GI

70
Q

Sources of pain: Nociceptive pain

A

Damage or inflammation to the sensory nerves in soft tissue

71
Q

Sources of pain: Nociceptive, somatic pain

A

Diffuse, sharp, and well-localized in superficial structures; dull, achy, and diffuse in deep somatic structures

72
Q

Sources of pain: Nociceptive, visceral pain

A

Achy, dull, deep, crampy pain typically in the abdominal region

73
Q

Sources of pain: Neuropathic pain

A

Damage to PNS or CNS with numbness and tingling

74
Q

Phantom limb pain

A

Pain in the perceived missing limb

75
Q

Psychogenic pain

A

Pain with no organic or structural cause, mental.

76
Q

Transmitting pain

A

When pain travels through nerve transmission to other parts of the body

77
Q

Transmitting pain: Radiating pain

A

Starts in one area and spreads out to another part of the body (e.g., toothache that radiates to the ear or head).

78
Q

Transmitting pain: Referred pain

A

Felt in an area away from the actual source of the pain (e.g., gallbladder pain may be felt in the shoulder or upper thoracic region of the back)

79
Q

2 mnemonics to assess pain

A

OLDCARTS and OPQRST

80
Q

OLDCARTS attributes

A

O = Onset.
L = Location.
D = Duration.
C = Character.
A = Aggravating or Alleviating factors.
R = Related symptoms.
T = Treatment.
S = Severity

81
Q

OPQRST attributes

A

O = Onset.
P = Provocation and palliates.
Q = Quality.
R = Radiation and region.
S = Severity.
T = Timing or temporal

82
Q

5 pain scales

A

Numeric Rating Scale (NRS), Wrong-Baker Faces Pain Rating Scale, Verbal Rating Scale (VRS), CRIES scale, and Iowa Pain Thermometer (IPT)

83
Q

CRIES scale: Attributes

A

C = Crying.
R = Requires O2 for SaO2 <95%.
I = Increased vital signs (BP and HR).
E = Expression.
S = Sleepless

84
Q

CRIES scale: Clinical use

A

Infants <34 weeks

85
Q

CRIES scale: Scoring

A

A score of >4 is notable

86
Q

3 pain assessment tools

A

McGill Pain Questionnaire (MPQ), Pain Assessment Tool, and Pain-QuILT

87
Q

2 pain assessment tools for communicatively impaired patients

A

Critical Care Pain Observation Tool (CPOT) and Pain Assessment in Advances Dementia (PAINAD) Scale

88
Q

4 types of pain duration

A

Acute (short term), chronic (long term), intractable (constant), or intermittent (comes and goes)

89
Q

Normal values: Oral temperature

A

97.5F to 99.5F
36C to 37.5C

90
Q

Tympanic, temporal, and rectal temperature values will always be _____ than oral temperature values

A

Higher

91
Q

Normal values: Radial pulse

A

60-100 bpm
40-60 bpm for athlete
Regular rhythm

92
Q

Normal values: Respiratory rate

A

12-20 breaths/min
Even pattern, regular rhythm

93
Q

Normal values: Blood pressure

A

<120/<80

Health Assessment (13 decks)

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