Health Assessment Exam 1

Front 1

ADOPIE

Back 1

Assessment

Disgnosis

Outcome

Planning

Implementation

Evaluation, then reassess

Front 2

Order of assessment

Back 2

Inspection

Palpation

Percussion

Auscultation

Front 3

10 pieces of the general survey

Back 3

Age

Gender

Facial expression/affect

Speech

Position

Body posture

Dress

Hygiene

Symmetry

Physical deformities

Front 4

Temperature averages

Back 4

Normal oral 98.6°F, 37.2 C (96.4 to 99.1)

Elderly 97.5° F or 36.2 C

Front 5

Convert F to C & back

Back 5

C=5/9(F-32)

F=(9/5)C +32

Front 6

Pulse is what

Back 6

Flow felt as a result of pressure wave generation from stroke volume

Front 7

Normal HR

Back 7

60-100

Front 8

What is stoke volume

Back 8

Amount of blood pumped out with each heart beat. Typically 70

Front 9

What happens at systolic and diastolic pressure readings

Back 9

Systolic pressure is the max p felt during ventricular contraction or systolic

Diastolic pressure is the elastic recoil, or the pressure that blood exerts constantly between contractions

Front 10

CO =?

Back 10

Cardiac output

CO=SVxHR

Front 11

Aging persons vital changes

Back 11

Rarely present with fever

Greater risk for hypothermia

Pulse may become more irregular with stiffening arteries

Shallower respirations with lower vital capacity

Often a wider pulse pressure or overall increased BPs

Front 12

Pain

Back 12

Subjective data, felt due to nociceptors that detect pain

Front 13

4 phases of nociception

Back 13

Transduction - ap generation

Transmission - ap moves along the nerve fibers from site to the spinal cord

Perception - ap reaches brain

Modulation - dialing in the pain based on context

Front 14

Neuropathic pain

Back 14

Abnormal processing, difficult to assess and treat due to a nerve injury

Common in shingles and uncontrolled diabetes

Front 15

OLDCARTS initial pain assessment

Back 15

Onset

Location

Duration

Characteristics of the pain

Associated symptoms

Relieving factors

Timing

Severity

Front 16

Structures in epidermis

Back 16

Hair and follicles

Sebaceous glands

Sweat glands

Accrine produce saline sweat

Apocrine produce perspiration

Front 17

Skin changes in pregnancy

Back 17

Linea Negra (pigmentetion on midline of abdomen)

Chloasma - face discoloration

Stretch marks

Front 18

Dark skin conditions

Back 18

Keloid scars - raised

Vitiligo- hypopigmentation

Front 19

Skin changes with aging

Back 19

Loss of elasticity

Flat "age" spots show in sunny spots

Easy bruising

Skin breakdown more common

Decrease in melanocyte fx --> gray

Front 20

Zosteriform

Back 20

Red, raised clustered vesicular lesions in a linear formation that do not cross the midline.

Front 21

Vesicle

Back 21

Fluid filled lesion up to 1cm

Ex chickenpox, small blister

Front 22

ABCDE of skin

Back 22

Asymmetry

Border

Color

Diameter

Elevation and enlargement

Front 23

Schamroths window

Back 23

Shows the profile of the nail and can show clubbing

Nail profile should be <180°

Front 24

Macule

Back 24

Flat colored, less 1cm

Ex freckle, nevi

Front 25

Papule

Back 25

Elevated, less than 1 cm

Ex wart, elevated mole

Front 26

Plaque

Back 26

Papule larger than 1cm

Ex psoriasis

Front 27

Patch

Back 27

Macule larger than 1cm

Ex, vitiligo, chloasma

Front 28

Nodule

Back 28

Solid, elevated larger than 1cm than extends deeper than a plaque or papule

Ex fibroma, intradermal nevi

Front 29

Wheal

Back 29

Superficial raised and reddish, edemous

Ex Mosquito bite, allergic rxn

Front 30

Tumor

Back 30

Larger than a few cm, hard or soft and deeper in dermis

Ex lipoma

Front 31

Urticaria

Back 31

Hives, wheals coalesce to form extensive reaction and often pruritic

Front 32

Cyst

Back 32

encapsulated fluid-filled cavity in dermis or subcutaneous

Front 33

Pustule

Back 33

Pus filled cavity

Ex acne

Front 34

Bulla

Back 34

Larger vesicle than 1 cm, superficial in epidermis

Ex blister

Front 35

thyroid disorder symptoms

Back 35

overactive (rare) - tachy, diaphoresis, weight loss, GOITER, nervousness, heat intolerance

underactive - fatigue, weight gain, low HR, edema in face, coarse hair, cool dry skin, cold intolerance

normally swells in pregnancy

Front 36

parotid gland location, what causes enlargement?

Back 36

2 salivary glands located anterior to earlobe

occurs with mumps, rapid & painfully

can occur due to blockage of duct due to abscess or tumor

Front 37

aging adult face & neck

Back 37

facial bones more apparent

skin sags

lower face shrinks with tooth loss

senile tremors

kyphosis (rounding of neck)

be sure to assess ROM slowly

Front 38

protective components of the eye

conjunctiva

cornea

sclera

Back 38

conj - transparent covering of eyelid

cornea - transparent covering over iris and pupil

sclera - white fibrous layer covering eye

Front 39

function of the iris

Back 39

iris controls the light admitted into the retina, works to contract & dilate the pupil

pupil change in size based on light and distance (accomodation)

Front 40

aging adult eyes

Back 40

pupils decrease in size and near vision worsens

lens fibers thicken & yellow

Front 41

testing eye function

Back 41

accomodation to test pupils

corneal light reflex tests that dilation is equal and parallel

cover test can detect deviated alignment

Front 42

PERRLA

Back 42

pupils are equal, round and react to light and accommodation

Front 43

conductive hearing loss

Back 43

partial loss due to mechanical dysfuncion of middle or outer

caused by blockage, foreign bodies, or otosclerosis (decrease in ossicle mobility) often due to ototoxic drugs - most common mode of hearing loss in aging

Front 44

perceptive hearing loss

Back 44

inner ear pathology, increase in amplitude of sound doesn't usually help

Front 45

labrynthitis

Back 45

can cause vertigo

Front 46

aging adult ears

Back 46

sagging lobes,

high-tone frequency loss

not normal but common: otosclerosis

Front 47

leukoplakia

Back 47

chronic irritation of buccal mucosa, white patches that do not go away with scrubbing

can be precancerous

Front 48

what are the palpable sinuses

Back 48

frontal (medial to orbits and above)

maxillary (medial to cheekbones)

Front 49

what is the most common site of a nosebleed?

Back 49

Kiesselbach's plexus, because several arteries meet there

Front 50

pregnant women and their noses and mouths

Back 50

stuffiness

epistaxis

bleeding gums or swollen gums

Front 51

aging adult nose & mouth

Back 51

nose more prominent with age

decreased senses of smell and taste

natural loss of teeth and yellowing

lips fold in

Front 52

tonsil grading

Back 52

1+ visible

2+ halfway to uvula

3+ touch uvula

4+ touch one another

Front 53

stages of pressure ulcers

Back 53

stage 1 - Localized redness will not blanch

stage 2 - Partial-thickness dermis erosion presents as a shallow open ulcer with a red, pink wound bed with no slough

stage 3 - The area has a crater-like appearance.Full thickness tissue loss. Subcutaneousfat may be visible but bone, tendon ormuscle are not exposed. slough may be present.

stage 4 - Full thickness tissue loss with exposedbone, tendon or muscle. Slough oreschar may be present on some parts ofthe wound bed. Often includeundermining and tunneling.

unstageable - Full thickness tissue loss in which thebase of the ulcer is covered by slough or eschar in the wound bed.

Front 54

cerumen purpose

Back 54

protect and lubricate the ear

Front 55

pain in an older adult indicates...

Back 55

a pathological condition or an injury and is not a normal process of aging

Front 56

best practice for hand washing during a physical examination

Back 56

Wash hands before and after every physical examination

Front 57

what is a DTI?

Back 57

Purple or maroon localized area of discoloredintact skin or blood-filled blister due todamage of underlying soft tissue frompressure and/or shear. The area may bepreceded by tissue that is painful, firm,mushy, boggy, warmer or cooler as comparedto adjacent tissue

Front 58

what is a major finding we look for in assessment of the tongue?

Back 58

ulcerations on the side of the tongue with rolled edges

Front 59

A patient in pain requires a physical assessment. What is the best way to organize and start the assessment?

Back 59

Organize the assessment to minimize patient position changes and discomfort, starting with nontender areas

Front 60

an irregular pulse must be counted for _____ to be accurate.

Back 60

a full 60 sec.

Front 61

The holistic model of health as used in nursing includes what 3 items:

Back 61

Mind, body, and spirit are interdependent.

Disease is multifaceted.

Assessment is expanded to include patient values, lifestyle, culture and stressors

Front 62

what is the most reliable indicator or pain?

Back 62

subjective report by the patient

Front 63

A 36-year-old woman who has recently given birth complains of purple squiggly lines over her abdomen since pregnancy. The nurse recognizes that she is describing:

Back 63

striae gravidarum, aka stretch marks

Front 64

When the nurse palpates an enlarged lymph node, he/she should also check:

Back 64

The area they drain for the source of the problem.

Front 65

when auscultating a pt's BP, the nurse should check what 3 things

Back 65

the arm is bare, the cuff is the correct size for the arm, and the patient is not crossing their feet

Front 66

what assessment findings indicate poorly controlled acute pain?

Back 66

increased BP, tachycardia, hypoventilation.

Front 67

what assessment findings indicate poorly controlled chronic pain?

Back 67

depression, confusion

Front 68

what type of pain is due to an abnormal processing of the pain impulse through the PNS or CNS?

Back 68

neuropathic pain. an abnormal processing of the pain message.

Front 69

where does visceral pain originate?

Back 69

larger interior organs: gallbladder, liver, kidneys, pancreas

Front 70

how would we identify deep somatic pain?

Back 70

sources such as the blood vessels, joints, tendons, muscles and bone

Front 71

cutaneous pain is derived from...

Back 71

skin and subcutaneous tissues

Front 72

what nonverbal behaviors are associated with chronic pain?

Back 72

sleeping a lot, bracing, and rubbing painful spots

Front 73

nonverbal behaviors associated with acute pain

Back 73

moaning, diaphoresis, restlessness

Front 74

in a patient with dementia who cannot verbally communicate, how should a nurse assess for pain after a fall?

Back 74

assess breathing, body language including bracing and agitation, and note any groaning, crying or yelling

Front 75

parameters for prehypertension

Back 75

systolic 120-139, diastolic 50-89

Front 76

kyphosis and flexion in the knees and hip found on assessment of an 80 y/o indicate

Back 76

normal physiological changes of aging

Front 77

prominent bonylandmarks, decreased body weight , a decrease insubcutaneous fat from the face and periphery, and additional fat deposited onthe abdomen and hips on assessment of an 80 y/o indicate

Back 77

normal physiological changes of aging

Front 78

what vital sign changes occur with aging?

Back 78

-systolic BP increases, causing widened pulse pressure

-both systolic and diastolic BP incease

-pulse should stay the same

-temp usually lowers

Front 79

body temperature can be influenced by...

Back 79

diurnal cycle, exercise, and age

Front 80

method for a rectal temp in a comatose adult

Back 80

A lubricated rectal thermometer (with a short, blunt tip) is inserted only 2 to 3cm (1 inch) into the adult rectum and left in place for 2 minutes.

Front 81

proper time to measure radial pulse

Back 81

Recent research suggests that the 30-second interval multiplied by 2 is the mostaccurate and efficient technique when heart rates are normal or rapid and whenrhythms are regular. If the rhythm is irregular, then the pulse is counted for 1full minute.

Front 82

3 aspects of pulse to assess

Back 82

rate rhythm and force

Front 83

5 factors affecting BP

Back 83

CO

PV resistance

blood volume

blood viscosity

elasticity of vessel walls

Front 84

using a BP cuff that is too narrow yields...

Back 84

a falsely high BP because it takes extra pressure to compress the artery

Front 85

how to check for an ausculatory gap

Back 85

cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpatedpulse disappears

Front 86

how to calculate pulse pressure

Back 86

-the difference between systolic and diastolic blood pressure(170 – 100 = 70)

-it reflects the stroke volume

Front 87

general description of epidermis

Back 87

outermost skin that is thin and tough, replaced every 4 weeks and stratified into several zones.

Front 88

general description of the dermis

Back 88

is elastic, contains nerves and sensory receptors, vasculature and lymph vessels

Front 89

Accrine glands

Back 89

produce saline sweat, no odor. on skin surface.

Front 90

aging skin normally wrinkles and thins due to

Back 90

An increased loss of elastin and a decrease in subcutaneous fat

Front 91

xerosis

Back 91

excessive dryness in the skin

Front 92

erythema

Back 92

intense redness of the skin caused by excess blood (hyperemia)in the dilated superficial capillaries

Front 93

what are liver spots

Back 93

clusters of melanocytes that appear on theforearms and dorsa of the hands after extensive sun exposure

Front 94

signs of nail clubbing

Back 94

nail base has an angle of 180 or greater, and feel spongy

Front 95

within the eye, sympathetic stimulation causes

Back 95

pupil dilation and elevates the eyelid

Front 96

presbyopia def and cause

Back 96

farsightedness, due to loss of lens elasticity with age

Front 97

ptosis

Back 97

drooping of the upper eyelid

Front 98

normal eye changes in relation to aging

Back 98

decrease in tear production, loss of eyebrow hair, slower pupillary light reflex, smaller pupil size

Front 99

anisocoria

Back 99

pupils of unequal size, abnormal finding in most people

Front 100

macular degeneration

Back 100

most common cause of blindness. loss of central vision, with periphery intact.

Front 101

A patient is unable to differentiate between sharp and dull stimulation to bothsides of her face. this indaicates possible danage to which CN?

Back 101

cranial nerve 5, trigeminal nerve

Front 102

5 areas in the body where lymph nodes are accessible for palpation

Back 102

head

neck

arms

inguinal area

axilla

Front 103

a few reasons facial bones are more prominent in face with aging

Back 103

decreased skin elasticity

decreased subcutaneous fat

decreased moisture in the skin

Front 104

cluster headaches are felt where

Back 104

around the eye, temple, forehead and cheek. usually unilateral.

Front 105

two main assessment findings with hyperthyroidism

Back 105

goiter

tachycardia

Front 106

a bruit

Back 106

audible whooshing sound from turbulent blood flow through a narrowed area on an artery. on palpation it is a thrill.

Front 107

thyroid enlargement during pregnancy indicates

Back 107

a normal process due to hyperplasia