Health Assessment - Chapter 25

Front 1

Adventitious Breath Sounds

Back 1

Abnormal breath sound heard over the lungs.

Front 2

Auscultation

Back 2

Listening for sounds within the body.

Front 3

Bronchial Sounds

Back 3

those heard over the trachea; high in pitch and intensity, with expiration being longer than inspiration.

Front 4

Bronchovesicular Sounds

Back 4

normal breath sounds heard over the upper anterior chest and intercostal area.

Front 5

Bruits

Back 5

unusual sounds, usually abnormal, heard in auscultation.

Front 6

Comprehensive Assessment

Back 6

health history and complete physical examination, ussually conducted when a patient first enters a healthcare setting, provides a baseline for comparing later assessment.

Front 7

Cyanosis

Back 7

bluish coloring of the skin and mucous membranes

Front 8

Ecchymosis

Back 8

collection of blood in subcutaneous tissues that causes a purplish discoloration

Front 9

Edema

Back 9

accumulation of fluid in extracellular spaces

Front 10

Emergency Assessment

Back 10

rapid focused assessment conducted to determine potentially fatal situations.

Front 11

Erythema

Back 11

redness of the skin

Front 12

focused assessment

Back 12

assessment conducted to assess a specific problem; focuses on pertinent history and body regions.

Front 13

inspection

Back 13

purposeful and systematic observation

Front 14

jaundice

Back 14

yellow appearance of the skin

Front 15

ongoing partial assessment

Back 15

assessment that is conducted at regular intervals during care of the patient; concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions

Front 16

pallor

Back 16

paleness of the skin

Front 17

palpation

Back 17

method of examining by feeling a part with the fingers or hand

Front 18

percussion

Back 18

act of striking one object against another for the purpose of producing a sound; used to assess the location, shape, size, and density of body tissues

Front 19

petechiae

Back 19

small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure

Front 20

precordium

Back 20

anterior surface of the chest wall overlying the heart and its related structures

Front 21

turgor

Back 21

Tension of the skin determined by its hydration

Front 22

vesicular breath sounds

Back 22

normal sounds of espirations heard on auscultation over peripheral lung areas.

Front 23

Four types of Assessments

Back 23

Comprehensive, ongoing partial, focused and emergency.

Front 24

Six components of a Health History

Back 24

Biographical Data, Reason for Seeking Health Care, History of Present Health Concern, Medical History, Family History and Lifestyle

Front 25

Four Primary Assessment Techniques

Back 25

Inspection, Palpation, Percussion and Auscultation.

Front 26

What is the sequence of techniques for abdomen assessment?

Back 26

Inspection, Auscultation, Percussion and then Palpation.

Front 27

Four characteristics of sound are assessed by ausculation. They are

Back 27

Pitch, Loudness, Quality and Duration.

Front 28

The General Survey Consists of:

Back 28

Appearance and Behavior, Vital Signs, and Height and Weight.

Front 29

What are the Characteristics of Masses Determined by Palpation?

Back 29

Shape, Size, Consistency, Surface, Mobility, Tenderness and Pulsatile.

Front 30

What are the Tones of Percussion?

Back 30

Flat-Soft, Dull-Medium, Resonance-Loud, Hyperresonance-Very Loud, Tympany-Loud

Front 31

What are the possible changes in skin color?

Back 31

Erythemia, Cyanosis, Jaundice, and Pallor

Front 32

Where is Turgor usually assessed?

Back 32

On the sternum or under the clavicle.

Front 33

What is the pitting Edema scale?

Back 33

0-none, +1-trace, 2mm, +2-moderate, 4mm, +3-deep, 6mm, +4-very deep, 8mm,

Front 34

What is the normal angle between the nail and its base in the finger?

Back 34

160 degrees

Front 35

PERRLA

Back 35

Pupils, Equal, Round, Reactive, Light, and Accomodation

Front 36

Direct Auscultation

Back 36

unaided ear, such as respiratory wheezes or the creaking joint

Front 37

Indirect Auscultation

Back 37

aided, stethoscope which amplifies sounds inside the body, ie, bowel, heart and lung sounds.

Front 38

Barrel Chest

Back 38

An increased anteroposterior diameter as in COPD and emphysema.

Front 39

Crepitation

Back 39

Crackling, the quality of a fine bubbling sound, Bubble Wrap

Front 40

What are the four quadrants of the abdomen?

Back 40

right upper, right lower, left upper and left lower.

Front 41

Why is percussion and palpation done after auscultation of the abdomen?

Back 41

percussion and palpation stimulate bowel sounds.

Front 42

peristalsis

Back 42

The movement of the intestine. Waves of contraction and relaxation of the intestine by which the contents are propelled onward.

Front 43

What is the frequency of normal bowel sounds?

Back 43

These clicks and gurgles usually occur every 5 to 20 seconds.

Front 44

What part of the stethoscope is used to auscultate bowell sounds?

Back 44

Diaphragm

Front 45

What part of the stethoscope is used to auscultate the aorta, renal arteries, and iliac arteries for bruits?

Back 45

Bell

Front 46

What is the Glasgow Coma Scale?

Back 46

A standardized assessment tool that assesses the level of consciousness.

Front 47

What three levels of awareness are important to evaluate orientation?

Back 47

Time, Place, Person

Front 48

Expressive Aphasia

Back 48

The individual understands written and spoken words but cannot write or speak to communicate effectively.

Front 49

Receptive Aphasia

Back 49

The individual cannot understand written or spoken words.

Front 50

What are 4 purposes of documention?

Back 50

Identify actual and potential health problems, make nursing diagnoses, plan appropriate care, and evaluate the patient's responses to treatment.