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41 Cards in this Set

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Health Assessment
a systematic method of collecting date about a patient for the purpose of determining the patient health status
Health History
Subjective data about the client condition given by the client.
Physical Exam
objective data
Three types of physical exam
Health Screen
Focused
Comprehensive
Steps to Assessment
Health History, physical exam, data validation, data clustering/organizing, data prioritizaion, documentation, formulate nursing care plan
OLDCARTS
Onset, Location, Duration, Characteristics or quality, associated factors (after meals, when walking etc), releiving factors, timing/frequency, severity/setting.
Components of a Physical Exam
Biographical Data, Current Health (chief complaint, oldcarts), past health hx (hospitalizations, surgeries, medications, allergies (meds, other, food), immunizations, childhood illnesses, recent travel, military service.. Family history, review of systems(head to toe approach), psychosocial history.
UTI signs in the elderly
frequency, urgency, nocturia, confusion (number 1 sign), may be no dysuria
MI signs in the elderly
may have no chest pain or atypical pain (jaw), tachycardia, hypoxemia, syncope, dysrhytmia
Pneumonia signs in the elderly
non productive cough, no high WBC, tacypnea, Nausea, vomiting, confusion
Hyperthyroid symptoms in the elderly
lethargy, weakness, afib, Congestive heart failure.
Depression symptoms in the elderly
memory problems, confusion, withdrawl.
Percussion Sounds
Resonance (lung tissue), hyper resonance, dullness, flat, tympany (abdominal tissue)
Auscultation sites
heart, lung, bowel, vascular
Auscultation observations
rate, loudness, speed, regularity, patterns, bilateral, hypoactive bowel, hyperactive bowel, bruit, quality, duration, frequency.
Decerebrate (response to painful stimuli)
outward rotation and extension of arms, brain damage
Purposeful (response to painful stimuli)
attempts to remove applied stimulus
Non-purposeful (response to painful stimuli)
movement to painful stimuli but no relation to the pain
Decorticate (response to painful stimuli)
flesion or arms to chest, cortex damage
Levels of Arousal and Awareness
Alert, lethargic,obtunded, stuperous, semi-comatose, comatose
Alert
responds well and appropriately
Lethargic
sleepy but can respond
obtunded
open eyes to loud noise but ususally only for the duration of the stimulus. Seems confused and disoriented
Stuperous
opens eyes only on vigorous stimulation don't respond
Semi-Comatose
awakens only to painful stimuli but very briefly, reflexes present
Comatose
no reflexes, no response
Orientation
Time, place, person
Testing for memory
Long term, short term
Long term memory test
what year were you born, what town were you born in.
Short term memory
what did you have for breakfast
Aphasia
difficulty speaking
sensory or receptive language problems
pt doesn't understand input
motor or expressive language problems
pt cant get the words they need out.
Reflexes
deep tendon, cutaneous, dermatomes.
Respirations- assessment
rate, quality, type
Respirations by type
dyspnea-shortness of breath, tachypnea-rapid breathing, labored, orthopnea- easier breaths if sitting up, paroxysmalnoctornal dyspnea-sudden attack of respiratory distress
breath sounds
vesicular, bronchovesicular, tracheal
Vesicular breath sounds
soft, heard over most of the lung fields, inspiration is longer than expiration 5-2 ratio
Bronchovesicular breath sounds
mid lung, inspiration equals expiration in time
Tracheal breath sounds
central , loud sounds, 2:5 ratio inspiration to expiration
Abnormal breath sounds
crackles (rales) found in CHF, ronchi (pneumonia), wheezes (asthma), friction (pleural rub), stridor