WK 1 Health Assessment Flashcards
Cheif Complaint, Review of systems, Past Medical History, Past Surgical History, Social History, Functional ability are all what?
Health History
In a Health Assessment, health history what is the Keyword of discussion. Is the health history Subjective or Objective
Symptoms (what the paitent feels / communicates)
Subjective
components of a Health Assessment
Health History, Physical Examination, Documentation of Data
The ____ is usally a chronological description of the progress of the paitents present illness from the first sign and symptom to the present
HPI. History of Present Illness
Key Points: Systematic method, Data collected focuses on clients health compared with norms
HPI History of Present Illness
A digital version of a chart with patient information stored in a computer
EMR electronic medical record
4 techniques for physical examination
Inspection, Palpatation, Percussion, Ausculation
______ targets both the clinical and outcome stages of a disease. It is implemented in symptomatic patients and aims to reduce the severity of the disease as well as any associated sequelae
Tertiary prevention
condition which is the consequence of a previous disease or injury
Sequelae
This type of Technique for a Physical Assessment includes posture and smells
Inspection
Previous history, Onset, Location, Duration, Character, Alieviating / Aggravating Factors, Radation, Timing, Severity / Self - Treatment are all factors to what?
Parts of the History of Present Illness
Which is part of the (Health History)
In the 2nd part of the Health Assessment, Physical Examination what is the Keyword to this process? Is the process Subjective or Objective
Signs (Clinical Findings)
Objective
The bimanual technique for Palpatation places hands on which sides of an organ ir mass
Anterior and posterior
A digital record of health information
EHR Electronic Health Record
screening to identify diseases in the earliest. stages, before the onset of signs and symptoms, through measures such. as mammography and regular blood pressure testing.
Secondary Prevention
POLDCARTS
(Health History) Previous History of Illness
Onset
Location
Duration
Character
Alleviating/ Aggravating symptoms
Related symptoms
Timing
Severity
Intervening before health effects occur, through. measures such as vaccinations, altering risky behaviors (poor eating. habits, tobacco use), and banning substances known to be associated. with a disease or health condition.8,9
Primary Prevention
This technique uses hands to feel for texture, size, shape, consistency, location and Id painful areas
Palpation
Palpation: palmar surface of fingers and finger pads are more sensitive than finger tips True or False
True
Which side of the hand is better for assessing temperature
Dorsal
This technique is used to evaluate size, boarders, and consistency of internal organs, Determine Tenderness, Determine Extent of fluid in the body
Percussion
Which part of th3 hand is mos4 sensitive to vibration?
Ulnar surface of hand to 5th finger
The act of listening to the sounds of the body is called
Auscultation
Percussion Tones
Loud, high pitched sound heard over the abdomen
Tympanny
Percussion sound: is heard over the liver
Dullness
Depth of light and deep palpation
1cm and 4cm
4 sound characteristics of Auscultation
Intensidad, Pitch, Duration, Quality
Percussion sound: Heard over normal lung tissue
Resonance
This Chart for Farsightedness is placed 20ft away. Provides an Acuity Number
Snellen Chart
In-Direct Percussion the tip of the middle finger _____ the nurse strikes the interphalangeal joint , or just distal to joint that lies against clients skin
The plexor
What do the 2 numbers at the top of a Snellen Chart Represent?
Top: Distance from chart
Bottom: Distance normal person should be able to see
Percussion sound: is heard in over inflated lungs, as in emphysema
HyperResonance
Percussion sound: is heard over bones and muscles
Flatness
This instrument to inspect the internal structures of the eye consists of a series of lenses, mirrors, and light aperture
Ophthalmoscope
Earpeices, Binauruals, Tubing, and Head consisting of a Diaphragm and Bell make up this instrument used for Auscultation
Stethoscope
____ uses ultrasonic waves to detect and amplify hard to hear vascular sounds like Fetal Heart Tones and Peripheral Pulses
Doppler
The Green then Red Lines on the Snellen Chart serve what purpose?
Color and field perception
This instrument used to inspect the external auditory canal and tympanic membrane consist of: Magnifying Lens, Light Source, Speculum instered into the Auditroy Canal
Otoscope
The Nasal Speculum comes in 2 Varities:
1. Simple Nasal Speculum which with a pen light inspects the lowe4 and middle turbinates of the nose.
- Broad-tipped, cone-shaped device that is placed on th3 end of a _____
Otoscope
This instrument has 2 purposes: Auditory Screening and Assessment of Vibrations
Tuning Fork
When using a Doppler to hear Vascular sounds, Coupling Gel is applied to skin and then _____ is slid over the skin until blood flow is heard in ear peices
Transducer
Inability to feel the monofilament on the feet suggest this problem
Reduced peripheral sensation
This chart held 14 inches away is used to measure near sightedness
Jaeger and Rosenbaum
Produces a bright light that is used to differentiate between Tissue, Fluid, and Air in a body cavity
Transiluminator
_____ Determines the degree of Flexion or extension of a joint
Goniometer
Percussion or Reflex hammer is used to test….
Deep tendon reflexes
small, flexible wire-like device attached to a handle that bends at 10g pressure that is used to test sensación on the feet is called this
Monofilament
This device is used to inspect the lower and middle Tubinates of the nose.
Nasal Speculum
Comprehensive data pertaining to the patients health and / or suitation.
Part of the nursing process
Assessment
___ refers to the systematic method of collecting and analyzing data for the purposes of planning paitent-cented care CORRECT
Heath Assessment
Behavior motivated by desire to increase well-being and actualiza of human potential
Health Promotion
Provide patient-centered care, work in interdisciplinary teams, evidence based practice, apply quality improvements, use informatics. Are considered what?
The 5 core competicies
Nursing Process: Nurse analysis of the assessment data to determine issues
Diagnosis
Consist of screening efforts to promote early detection of disease
Health Promotion:
Secondary Prevention
Prioritize Hypothesis is which part of the nursing process
Outcomes / Planning
Comprehensive, Problem-Based / Focused, Episodic / follow-up, Shift , Screening are all types of what?
Assessments
Clinical Judgement has 4 parts Naptime Interrupted, Raccoons Raided Rations!
Noticing, interpreting, responding, reflecting
Nursing Process: The RN IDs expected results for a plan individualized to the health care consumer or suitation
Outcome ID
Behavior motivated by desire to actively avoid illness, detect it early, live comfortably with it
Health Protection
Nursing Process: Coordination of Care, Health Teaching, Consultation (APRN) & Prescriptive Authority(APRN) are this part
Implementation
Health Promotion: Primary Prevention
Prevent disease through promtion of healthy lifestyle
Organization of data from the health Assessment my be done in 2 mannerz
1.Body system format (cardiovascular, musculoskeletal, visual)
- Coonceptual Format: Oxygenation, perfusion, mobility)
Recognize Cues is which part of the nursing process
Assessment
Assessment, Diagnosis, Outcomes/ Planning, Implantation, Evaluation are known as
Nursing process
Taking Action is which part of the nursing process
Implementation/ Interventions
Directed towards minimize the disability from acute/chronic disease or injury and helping paitents maximize health
Tertiary Prevention
Comprehensive data pertinent to the paitents health or situation
Assessment
6 Types of Assessments: CPF-ESS Assessments:
Comprehensive, Problem-Based, Focused Assessments, Episodic/ follow-up, Shift, Screening
nurse adds which information in the paitents health history
- Paitent keeps scratching left arm
- Paitents skin is warm to touch
- Paitent reports itching of her eyes
- Paitents temp is 100 F °
- Because its health history and this is a Subjective finding that is appropriate
Hand hygine, PPE, Managing Contaminated Equipment, Environmental Controls, Respitory hygine/Cough Etiquette, and _______.
Primary elements of Standard Precautions
Patient Placement
The Transmission Based Precautions are guidelines for control of infections among paitents with known or suspected infections. Name the 3 guidelines in the book
Contact, Airborne, Droplets
In which part of the Nursing Process is concerned about:The Paitient Response to what is happening. Exp. Paitent with asthma is restless and anxious. The Response restless/ anxious are the key factors
Diagnosis
Patient had a stroke and has impaired swallowing and impaired mobility is which part of the nursing process
Diagnosis
This part of the Nursing Process is concerned with Establish the Goal.
What it will look like when the paitent meets their goal
Outcome Identification
black-light used to detect fungal infection
Woods lamp
Part of the nursing process. What interventions you will do to help your paitent meet their goals
Planning
Type of data in which what you can see or validate
Objective
The Nursing Diagnosis is the patients ______ to what is happening
Response
The Diaphragm on the stethoscope is uswd to hear these types of sounds.
The bell on the stethoscope is used to hear these types of sounds
Diaphragm = high pitched, breath, bowel, norm heart beats
Bell = soft low pitched sounds like “extra heart beat and vascular sounds”
This technique invloves using the plexor to evaluate adult sinus
Percussion
What is the difference between the Outcome and Planning in the nursing ?
Outcome: Goals. What the Paitent will look like to be better.
Paitent will ambulate by himself in 1 month
Planning: “Interventions” what the Nurse will do to help paitent meet their goals.
The process of Nurse related actions to achieve the goals set in the Outcome
Paitent interview for a Focused assessment should start with what?
History of Present Illness
Poldcarts
What sounds does the doppler detect
Fetal heart sounds and peripheral pulses
Type of data in which what you are told
Subjective
This technique of the physical assessment is used to determine extent of fluid in a body cavity
Percussion
Chickenpox (Varicella) , Measles (Rubeola) Flu all have this type of Precautions
Airborne
COMPONENTS OF HEALTH ASSESSMENT
1) HEALTH HISTORY (Subjective) They tell you what is wrong
2) PHYSICAL EXAMINATION (Objective) you examine them
3) DOCUMENTATION OF DATA
The bell of a stethoscope is used for…
The diaphragm is used for…
Bell = Low sounds
Diaphragm = High sounds
Health History includes
Biographical Information:
Chief Complaint (CC):
Present Illness (PI):
History of Present Illness: POLD CARTS
Past Medical History
Medications and Allergies:
Family History (FH):
Social History (SH):
Review of Systems (ROS): Conduct a systematic review of all body areas
Psychosocial History:
Developmental History (for Pediatric Patients)
Nutritional History:
Cultural and Spiritual Beliefs:
Environmental Exposures
Nursing Process
Acronym
ADO PIE
History of Present Illness
Acronym
POLD CARTS
It involves a proactive approach to healthcare that goes beyond the treatment of illness and focuses on preventing health problems, promoting healthy behaviors, and enhancing quality of life.
Health Promotion
Comprehensive data pertaining to the paitents health or situation
Assessment
Getting a prescription for Concerta and then having to come back in 2 weeks to talking about it is which type of assignment?
Episodic / Follow-up
In this type of assessment we cover all the body systems in 4 minutes.
Shift assessment
Clinical Manifestaciones (2)
Signs & Symptoms
Crepitus, Palpation
Describe feeling
Crackling or grating sound caused by bones rubbing against each other, also called creaky joints.
Bubble wrap
Atelectasis = More or Less fremitus
Correct answer
Less
During 2 handed Percussion
the finger that taps is called:
The finger that is being tapped and pressed against the skin is called:
Pleximeter
Plexor
How much does 1 liter weight in metric
1 Kg
Disease someone may not feel a tuning fork on the lower extremities
Diabetes
Health Assessment contains 3 parts
Collection of Objective Date
Collection of Subjective Data
Documenting Findings
Primary, Secondary, Tertiary Prevention
Condoms, Pre-exposure Vaccines, Male Circumcision
Postexposure vaccines, Regular BP checks, mammogram, Pap smear, colonoscopy
Screening of patients with diabetes for diabetic retinopathy to prevent blindness, prevention of opportunistic infections in HIV patients, oxygen therapy to COPD patients
Primary
Implemented before disease starts
Condoms, Pre-exposure Vaccines, Male Circumcision
Secondary
Early detection & intervention
Postexposure vaccines, Regular BP checks, mammogram, Pap smear, colonoscopy
Tertiary
Addresses existing conditions
Screening of patients with diabetes for diabetic retinopathy to prevent blindness, prevention of opportunistic infections in HIV patients, oxygen therapy to COPD patients
