6:2 Health Assessment

Front 1

Assessment

2 Types of methods of collecting data

Back 1

is the first step in the nursing process

1. Observation- when you 1st walk in (senses)
2. Examination - actual touching

Front 2

Assessment is a _____________ and _____________ organization, validation, and documentation of data.

Back 2

systematic and continuous

Front 3

All phases of the nursing process depend on the accurate and complete collection of data.

Back 3

True

Front 4

4 Types of Assessment

Back 4

I nspection
P alpation
E mergency
T ime-lapsed

Front 5

Inspection is performed within a specific time after admission to a health care agency

Back 5

True
( comprehensive assessment)

Front 6

Problem Focused Assessment

Back 6

ongoing integrated with nursing care
Example: hourly assessment of clients fluid intake and urine output in an ICU. Assessing clients ability to perform self care

Front 7

Emergency Assessment

Back 7

Identify life threatening problem's
ABC's
airway ( a person's airway)
breathing ( status)
circulation (during cardiac arrest)
-Suicidal tendencies or potential violence

Front 8

Time- Lapsed Reassessment

Back 8

performed several months after initial assessment
- to compare pts current status to baseline data previously recorded
Example: reassessment of a clients functional health patterns in a home care or outpatient setting or in a hospital , at shift change

Front 9

Database

Back 9

all the information about a client ; includes nursing history, physical assessment, physicians history,labs, other health care personnel, ect...

Front 10

Subjective Data

Back 10

Itching, pain, and feelings of worry

(covert data)

Front 11

Objective Data

Back 11

Can be seen, heard, felt or smelled
Labs, x-rays, BP, discoloration of the skin

Front 12

Sources of data

Primary

Back 12

Always pt!

Front 13

Sources of data

Secondary

Back 13

support people, family friends, caregivers, client records, lab tests, other health care professionals, literature, journals texts

Front 14

Data Collection Methods

Back 14

O bservation
I nterview
E xamination

Front 15

Observation Method

Back 15

Vision (size, wt., demeanor)
Smell (body or breath)
Hearing (lung, heart sounds, bowel)
Touch (skim temp, muscle strength -hand grip

Front 16

Examining Method

Back 16

systemic data collection ( sight, hear smell and touch to detect healtyh problem,

Front 17

Techniques of Examination

Back 17

Inspection
Palpation
Auscultation
Percussion

Front 18

Physical examination uses what method?

Back 18

cephalocaudial /head to toe

head, neck, thorax,abdominal, extremities, toes (end)

Front 19

Validating Data

Back 19

Double check, verifying data to confirm that it is accurate and factual

Front 20

Inferences

Back 20

Nurses interpretation

Front 21

Client Physical exam

Back 21

-Perform least invasive to most invasive
-Pt should empty their bladder before visit
-Friends and family should not be present unless asked by pt

Front 22

Physical Examinations Positions

Back 22

Standing
Sitting
Supine
Dorsal Recumbent (back, knees bent)
Sims (side)
Prone
Lithotomy (F legs in stirrups)
Knee to chest (on arms and knees)

Front 23

Primary Techniques used in
Physical Assessment

Back 23

I nspection
P alpation
P ercusion














































A uscultation

Front 24

Inspection

Back 24

mositure, color, size, texture, position, size, color, symmetry

Olfactory - smell
Auditory - hearing

Front 25

Palpation

Back 25

touch, light before deep

light- superficial
Deep- bimanually (2 hands)

Front 26

Palpation

Testing Skin Temperature

Back 26

dorsum/ back of hand
where skin is thinnest

testing for vibrations use the palmar surface of hand

Front 27

Percussion

Back 27

Act of striking the body surface to elicit sounds or that can be heard or vibrations that can be felt
Direct - 2-4 fingertips or pad of middle finger, rapid and movement from wrist
Indirect - striking of an object (finger)

Front 28

Percussion Sounds

Back 28

flatness -muscle, bone, tissue
Dullness -liver, spleen, heart
Resonance- NORMAL hollow sound produced by lungs filled with air
Hyperresonance - ABNORMAL can be heard over emphysemtous lung
Tympany - air filled stomach (gastric air bubbles)

Front 29

Ausultation

Back 29

can be direc 9unaided ear)t or indirect
(stephascope)

Front 30

Stephascope

Flat disc diaphragm

Back 30

high - pitched sounds
bronchial sounds

Front 31

Stephascope

Bell

Back 31

low pitched sounds

heart sounds

Front 32

Auscultation

Back 32

pitch - frequency of vibrations # of vibrations per second
Intensity - amplitude, loudness or softness of a sound
Duration- how long (long or short)
Quality - subjective, whistling, gurgling, or snapping

Front 33

GENERAL SURVEY

Back 33

Health assessment begins with a general survey that involves observation of the pt's general appearance, mental status, and measurement of vital signs, height and weight

Front 34

Breath Odors

Back 34

Diabetes

Front 35

Integumentary System

Back 35

Skin, hair, nails and begins witha generalized inspection

Front 36

hyperhidrosis

Back 36

excessive perspiration

Front 37

bromhidrosis

Back 37

fowul smelling perspiration

Front 38

Pallor

Back 38

skin is result of inadequate circulating blood or hemoglobin and subsequent reduction in oxygenation most readily seen in buccal mucosa
-brown skin pts may appear yellowish brown
-black skinned pts may appear ashen gray

Front 39

Cyanosis

Back 39

a bluish tinge most evident in nail beds, lips, and buccal mucosa

Front 40

Jaundice

Back 40

a yellowish tinge

Front 41

Erythema

Back 41

is a redness

Front 42

Vitiligo

Back 42

is seen as patches of hypopigmented skin and is caused by the destruction of meloncytes in the area

Front 43

Eccymosis

Back 43

is discloration or bruising of the skin

Front 44

Edema

Back 44

presence of excess interstitial fliud. Swelling. May appear shiny and taut ( tight)
1+ barely detectable 2mm
2+ indentation 2-4 mm
3+indentation of 4-7mm
4+ indentation of more than 7 mm

Front 45

Skin lesion

Primary

Back 45

is an alteration in a pts normal skin appearance. Those appear initially in response to some changein the internal or external environment of the skin ( nodule, tumor, pustule, cyst)

Front 46

Skin Lesion

Secondary

Back 46

those that do not appear initially but result from modification such as chronicity, trauma, or infection of the primary lesion

Front 47

( NO ) tented

Back 47

skin goes back to normal

(hooking up skin)

Front 48

Clubbing

Back 48

chronic lack of oxygen
160 degrees- normal
more than 160 early clubbing
more than 180 late clubbing

Front 49

Nails

Excessively thick

Back 49

can appear in the elderly in the presence of poor circulation

Front 50

Nails

Excessively thin

Back 50

or the presence of grooves or furrows can be reflected prolonged iron deficiency.
Horozontal depressions that can result from injury or severe illness

Front 51

Blanch Test

Back 51

can be carried out to test the capillary refill, that is peripheral circulation
(prompt return of color less than 4 sec. or delayed return indicating circulatory impairment)

Front 52

Paronychia

Back 52

ingrown nail

Front 53

Periorbital Edema

Back 53

swelling around the eyes

Front 54

Examination of the eye include:

Back 54

visual acuity ( the degree of detail the eye can discern in an image)

Front 55

Myopia

Back 55

nearsightedness ( ME)

Front 56

Hyperopia

Back 56

farsightedness

Front 57

Presbyopia

Back 57

loss of elasticity of the lens and thus loss of ability to see close objects

Front 58

Astigmatism

Back 58

an uneven curvature of the cornea that prevents horozontal and vertical rays from focusing on the retina (eyes cross)

Front 59

eye alignment

Back 59

xtra occular movement

Front 60

Common inflammatory visual problems

Conjuctivitis

Back 60

inflammation of the bulbar abd palpebral conjunctiva

Front 61

Common inflammatory visual problems

Dacrocystitis

Back 61

inflammation of the lacrimal sac

Front 62

Common inflammatory visual problems

Hordeolum

Back 62

sty is a redness, swelling, and tenderness of the hair follicle of the eyelid

Front 63

Common inflammatory visual problems

Iritis

Back 63

Inflammation of the iris
can be more serious
photophobia ( sensitivity ot light)

Front 64

Cataracts

Back 64

tend to occur on those over 65. This opacity of the lens or its capsule, which blocks light rays is frequently rmoved and replaced by a lens implant
(cloudy pupils)

Front 65

Glaucoma

Back 65

a disturbance in the circulation of aqueous fluid, which causes an increase in occular pressure. Most frequent cause of clindness in people over 40. Danger signs include foggy and blurred vision, loss of perispheral vision, difficulty focusing on close objects,

Front 66

ptosis

Back 66

drooping of eye

Front 67

Ectropion

Back 67

is an outurning of the eyelid

Front 68

Entropion

Back 68

is an inturning of the eyelid

Front 69

Pupils

Back 69

normally black, have round, smooth borders

Front 70

constricted pupils

Back 70

miosis can be result of morphine

Front 71

Enlarged pupils

Back 71

mydriasis may indicate injury or glaucoma, result from drugs such as atropine

Front 72

Unequal pupils

Back 72

may reult from CNS disorder however slight variations are normal

Front 73

Sclera

Back 73

should be white and conjunctiva should be shiny, smooth, and pink or red

Front 74

PERRLA

Back 74

pupils
equally
round
react to
light and
accomodation

Front 75

PERRLA

Back 75

assesses pupil reaction to direct and consensual reaction to light and reaction to accomodation. Assesses peripheral fields. For distance use snellen chart

Front 76

3 parts of Ear

Back 76

external
middle
inner

(use otoscope)

Front 77

lobule
helix
tragus
mastiod

Back 77

earlobe
upper curve
cartililage protrusion at the entrance to the ear canal
bony prominence behind ear

Front 78

Conduction hearing Loss

Back 78

is the result of interupted transmission of sound waves through the outer and middle ear structures

Front 79

Sensorineaural hearing loss

Back 79

is a result of damage to the inner ear, the auditory nerve, or hearing center in the brain

Front 80

HEARING

Back 80

a common hearing deficit with age is loss of ability to hear high frequency sounds. This neurosensory hearing deficit does not respond well to use of hearing aid. The inner ear contains sound transmitting organs and organs which regulate equilibrium

Front 81

Nose and Sinuses

Back 81

Olfactory sense
frontal sinuses above eye, and maxillary sinuses upper cheek

Front 82

Dental caries

Back 82

cavities

Front 83

Glossitis

Back 83

inflammation of tongue

Front 84

Stomatitis

Back 84

inflammation of oral cavity

Front 85

Parotitis

Back 85

inflammation of the paratoid salivary gland

Front 86

Sordes

Back 86

refers to accumulation of fould matter on the teeth and gums

Front 87

Enlarged lymph nodes

Back 87

Lymphadenopathy
may indicate infection, autoimmune disorders, or metastais of cancer

Front 88

Thorax

Back 88

The thoraz comprises the lungs, rib cage, cartilage, and intercostal muscles

vibrations (fremitus) to assess use the ball of your hand to palpate over the thorax and ask pt to repeat "99"

Front 89

Resonance

Back 89

Normal air-filled lung the sound is hollow, loud, low in pitch, and of long duration

Front 90

Bronchial sounds

Back 90

heard over trachea, high pitched, harsh sounds, expiration longer than inspiration

Front 91

Bronchovestibular sounds

Back 91

heard over bronchus moderate blowing sounds inspiration equal to expiration

Front 92

vesicular sounds

Back 92

heard over the base of lungs, soft, low pitched, inspiration longer than expiration
normal at bases

Front 93

Adventitios breath sounds

Back 93

Abnormal breath sounds

Front 94

Adventitios breath sounds

Sterorous

Back 94

breathing is a general

Front 95

Adventitios breath sounds

Stridor

Back 95

is a harsh, high pitched sound heard on inspiration when there is a narrowing of the upper airway, such as lararnx or trachea

Front 96

Adventitios breath sounds

Crackles

Back 96

fine coarse crackling sounds made as air moves through wet secreations most often heard through inspiration

Front 97

Adventitios breath sounds

fine crackles

Back 97

made by air passing through moisture in small air passages and aveoli

Front 98

Adventitios breath sounds

Course crackles

Back 98

made by air passing through moisture in the bronchioles, bronchi, and trachea, can also be documented as rhonchi

Front 99

Adventitios breath sounds

Wheezes

Back 99

continuous sounds that originate in small air passages that are narrowed by secreations, swelling, or tumors

Front 100

Adventitios breath sounds

pleaural friction rub

Back 100

is a grating sound caused by an inflamed pleura rubbing against the chest wall

Front 101

Ausculating Heart Sounds

Back 101

Begin at aorti, pulmonic, Erb's point, tricuspid to mitral area.

Front 102

S1
SYSTOLIC

Back 102

is heard at the "lub" of lub dub
It occurs when the mitral and tricuspid valve close. The sound is low pitched and dull and heard best at the apical area

Front 103

S2

DYASTOLIC

Back 103

is the "dub" in the lub dub. It occurs at the termination of systole and it also represents the closure of the aortic and pulmonic valves. The sound is high pitched and shorter than S1

Front 104

xtra Heart sounds

Back 104

may be S3 and S4 murmurs or bruits

Front 105

PMI
Point of Maximun Impulse

Back 105

over mitral/apical and 4th/5th intercostal space

Front 106

Phlebitis

Back 106

inflammation of vein

Front 107

Palpating Peripheral Pulses

Back 107

Carotid
Brachial
Radial
Femoral
Popiliteal
Dorsal Pedis
Posterior Tibial

Front 108

Peripheral Pulses

Back 108

should be strong abd equal bilaterally. The amplitude may be documented as
0 (absent)
1+ (weak)
2+ (normal)
3+ (increases)
4+ (bounding)

Front 109

absent weak thready pulse indiciates a decreased cardiac output

Back 109

True

Front 110

Forceful bounding pulse (seen in hypertension and circulation overload)

Back 110

True

Front 111

The breast is inspected in 4 quadrants

Back 111

True

Front 112

An increase in nodularity abd tenderness may be associated with the menstrual period or may indicate disease

Back 112

True

Front 113

Palpable nodes are abnormal

Back 113

True

Front 114

SEQUENCE OF PALPATING ABDOMEN

Back 114

inspection
auscultation
percussion
palpation
(use diaphragm on stethascope)

Front 115

Abdomen

Back 115

right upper
right lower
left upper
left lower
percussion and palpation stimulate bowel sounds and thus done after auscultation. Any painful areas should be asessed last

Front 116

Striae

Back 116

fine white lines or silver lines may be present often result of skin stretching

Front 117

Bowel Sounds

Back 117

-use diaphragm on stethascope to auscultate
-They are heard as clicks and gurgles every 5-20 sec.

Front 118

Ascites

Back 118

swelling of the abdomen ( indicating fluid retention called ascites

Front 119

Kyphosis

Back 119

hunched forward

Front 120

Lordosis

Back 120

sideways curvature of spine