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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