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;
36 Cards in this Set
- Front
- Back
H&P (History and ____)
Date Demographic data Source of referral Chief complaint(s) History of present illness Past history |
physical
|
|
H&P
Current health status Family history of illness Psychosocial history Review of all systems ++++++called baseline Review of all systems includes ht, wt, vital signs and head to toe exam include, head, neck, upper extremities, chest (respiratory and cardiac) Digestive, reproductive, and urinary in abdomen, lower extremities. Musculoskeletal, interaumentary, nervous, endocrine, vascular, and lymphatic assessed as one moves along body. Review H and P. |
Information
|
|
Variances from Normal
Discriminate normal from abnormal Use observation skills Ask questions Note changes in condition Employ strong assessment skills _____variances to supervisor Critical funct be able to discriminate betwn normal and ++++ conditions. |
Report
abnormal |
|
General Survey: posture, distress, body proportion and size, color, odors, character of speech, vital signs, ht and wt, open eye, best motor response
Look at patient as ----, before dividing assessment into systems. overall impression valuable because it gives clues as to what to focus on. Determines where to focus if time limited Strong assessment _____ needed What to look for in general survey |
whole
skills |
|
Psychosocial Assessment
Part of general survey -------- status. Is affect congruent with content Mental status- Behav approp, attention span, recall info, incorporate new info, Appearance- Appropriate dress, grooming, good hygiene, |
emotional
|
|
Critical function of health care worker:
Discriminate between ___ and abnormal conditions and situations |
normal
|
|
Physical Assessment Skills
Inspection Auscultation Palpation _______ |
Percussion
|
|
Assess Systems
Musculoskeletal- discomfort with movement, assess strength, gait, inspect joints, range of motion Integumentary- color and temp of skin, New cuts, scrapes, bruises Circulatory- vital signs, wt, pain or swell in extremities, pulse points, assess capillary refill. Longer to return to pink. Inspect neck for distention of jugular veins. Assess for activity intolerance. Respiratory- rate and rhythm. Colors of skin and mucous membranes. Diff with breathing, Cough. Is there dyspnea or difficulty breathing? Barrel chest -chronic respiratory cond. Cyanosis skin of white is pink. Inspect Black. Does the pt breath easier in sitting or standing position- ORTHOPNEA Digestive- size and contour of abdomen. Changes in bowl pattern. When was last bowel movement? Any abdominal discomfort? Sudden changes in wt and appetite. ________ Appearance of the urine. Burning? Frequency? Hesitancy? Nocturia? Incontinent? Palpation and percussion of the bladder. |
urinary
|
|
Assess Systems
Eyes- Pain, foreign body sensation, itching, irritation, fatigue Ears- drainage, hearing aid, cochlear implant, diff hearing in one ear or both, Nervous- Numbness or tingling. Changes in skin temp, color, change in mobility and prob with emot or mental status. Endocrine= diabetes or thyroid are usually id in other systems. Female reproductive- Menstruate? Any pain, discharge, itching, or discomfort, Any lumps in breast or discharge from nipples. Male ________- any discharge from or sores noted |
reproductive
|
|
Inspection
Using senses of vision, hearing, and smell for observation of patient condition Auscultation Listening to sounds inside body with aid of _______ |
stethescope
|
|
Palpation
Using hands and fingers on exterior of body to detect evidence of abnormalities in various ____body organs |
internal
|
|
Pain Assessment
_____ information Use pain assessment scale 0 to 10 If pt cognitively unable to rate pain, Wong-Baker Pain Rating Scale used or for 3 or younger. 0 = no pain 10 = worst pain imaginable Wong-Baker FACES Pain Rating Scale |
Subjective
|
|
Pain Assessment
Compare levels before and after pain medications Note ______ cues |
nonverbal
|
|
Activities of Daily Living (ADL) Assessment
Actions done on regular basis to meet _____ needs Inability to perform ADLs. ADLs include: bathing, eating, toilet, shopping, laundry, cleaning, pay bill, and dressing. Assistance needed as long as unable to do so Many diseases and cond diminish Soc workers, case managers, and discharge planners |
physical
|
|
Vital Signs (VS)
Temperature ________ Pulse Blood pressure Temp measures heat in the body and indicates presence of infection or disease. The pulse measures how fast the heart is beating. The respiratory rate indicates how fast breathing. The BP how hard the heart is working to distribute blood thru body. |
Respiration
|
|
Temperature
Normal range essential to homeostasis Afebrile and febrile ---------- fever Continuous fever Night sweats |
Intermittent
|
|
Doing laundry is ADL
Action done on ______ basis to meet physical needs Gardening and playing piano not actions required to meet physical needs |
regular
|
|
Pulse- when heart contracts and forces blood out of heart into arteries
Pulse points- TEMPORAL (either side of forehead), CAROTID(on front side of neck on either side of trachea) BRACHEAL(located on the inner side of antecubital space crease in elbow). RADIAL (located in the wrist, thumb side) FEMORAL- Located in the crease where the upper thigh joins the body.______- Located behind the knee. DORSALIS PEDIS- Located on top of the foot arch. WHEN TAKING A PULSE THE FOLLOWING OBSERV MADE: Rate- The number of beats that occurs in one minute. Rhythm-When the beat occurs at regular intervals, it is called a REGULAR RHYTHM. IRREGULAR RHYTHM Beats do not occur at regular intervals REGULAR IRREGULAR RHYTHM- - Recurring or consistent pattern of irregular rhythm. |
Rhythm-
POPLITEAL |
|
Pulse Volume refers to the strength of the beat.
Thready Pulse- very fine and barely perceptible. Taking an apical pulse requires a ++++++. An apical pulse is taken when irregular rate, on cardiac pts. and when radial pulse An apical radial pulse deficit found in many cardiac pts. difficult to palpate. Over the heart. An abnormally low pulse is _____ and an abnormally high pulse is tachycardia. Pulse Deficit difference between 2 pulse readings. _____ volume Radial pulse Stethoscope Apical pulse Bradycardia |
Stethescope
Pulse Bradycardia |
|
Pulse
Tachycardia Pulse rates vary with ____ Apical-radial pulse deficit- found in many cardiac pts |
age
|
|
Respiration
Process of ______ air through lungs Inhalation (inspiration) Exhalation (expiration) Eupnea- Normal breathing Tachypnea- ___ the normal rate breathing Bradypnea- below the normal rate breathing |
moving
above |
|
Respiration- moving air into and out of the lungs
Ensure patient unaware of respirations being counted Rate- the number of respiratory cycles that occur in one minute. Rhythm____- temporary absence of respirations Cheyne-Stokes= breathing pattern iwth a period of apnea of 10-60 sec. which then followed by a gradually inc depth and freq of respirations. |
Apnea
|
|
Respiration
Respiratory effort Respiratory rates ----- with age |
vary
|
|
A. Abnormally high heart rate
Tachycardia Abnormally high respiratory rate Tachypnea Abnormally+++++ respiratory rate- Bradepnea Bradycardia Abnormally low heart rate |
low
|
|
Blood Pressure (BP)
______ is the highest pressure in the Cardiovascular system Diastolic is the lowest pressure in the Cardiovascular system Hypotension- lower than normal BP Hypertension higher than normal BP Sphygmomanometer and stethescope needed to take manual BP Sphygmomanometer Rightly tighty lefty losey Pts with very large or small arms may need bigger cuffs No further than 1 to 11/2 inch antecubital space |
Systolic
|
|
Temp
Oral and aural route temp are the ____, but temporal artery and rectal run a degree ____. Axillary under arm runs a degree lower. |
same
higher |
|
Other factors that affect temp: age of pt( ____ in child than adult), time of dy (morning is lower), and pregnancy higher.
|
higher
|
|
Types of thermomemters: electronic, tympanic (aura), chemical dot, and ______
|
temporal
|
|
Electronic better than glass ______
|
mecury
|
|
Temp within normal range ____, and elevated febrile.
|
afebrile
|
|
BP is affected by age, certain medications and disease conditions, _____ activity, posture of the pt, and emotions. White coat syndrome High BP in doctors office but not +++++
|
physical
home |
|
Orthostatic Postural Hypotension- blood ____ in lower extremities and BP drops quickly. Recent surgery, bedrest. Low BP and low pulse also prone to this problem Dizziness.
|
pools
|
|
If neither arm available, ____ artery.
|
popliteal
|
|
Don't take arm reading after _____, masectomy, hemodyalsis shunt, IV fusion, shunt for dialysis,
|
surgery
|
|
Height and Weight
Height usually stable after adulthood Except with ______ Many factors affect weight |
osteoporosis
|
|
Height and Weight
Types of scales: Standing balance- balanced prior to use, and pt must be able to stand up _____ Chair and wheelchair- allows pt to sit while weighed. Mechanical lift- sling positioned under pt and lifted to be weighed. Bed Scales pt does not have to be moved. Digital BMI- body mass index |
steady
|