Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
41 Cards in this Set
- Front
- Back
|
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
|
