CH 16 Health Assessment

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  1. 5 reasons for physical exam?
    • gather basline info of pts health status 
    • supplement, confirm, refute info during H/P
    • ID or confirm nursing Dx
    • make clinical judgements of pts health status 
    • evaluate outcome of care
  2. When meeting a pt for the first time it is important to get a baseline assessment to allow to refer back to what?
    pattern of findings ID when the pt was first assessed
  3. What are the 5 skills of an assessment?
    • Inspection-using eyes to view findings 
    • Palpation-using hands to touch body parts
    • Percussion-tapping body w/ fingertips to produce vibrations
    • Auscultation-sounds produced by body
    • Olfaction -smelling to find abnormalities
  4. For palpation of the abdomen how is it examined?
    Auscultation first then palpation
  5. When are tender areas palpated?
    Last
  6. What is considered light palpation?
    Depressing about 1cm or 1/2 inch
  7. What is bimanual palpation?
    • Using two hands 
    • upper hand applies pressure down and the lower hand feels for findings
  8. What part of the hand should be used to determine internal findings? Why?
    The palm and fingers because they are most sensitive to vibrations
  9. Why should a vital artery never be palpated?
    Because it could cause blood obstruction
  10. What is the purpose of percussion?
    • Sound determines density of underlying tissues 
    • Depends on the location and size of organ 
    • Helps verify abnormalities
  11. What is the bell primarily used for?
    • low pitched sounds
    • vascular or cardiac
  12. What is the diaphragm used for?
    • high pitched sounds
    • lung or bowel sounds
  13. What 4 types of sounds can be heard?
    pitch, intensity, quality, and duration
  14. What is pitch?
    • how freq sounds waves are generated per second 
    • high freq=high pitch
  15. Intensity
    • amplitude of sounds wave 
    • soft or loud (when describing)
  16. Quality when auscultating
    blowing or gurgling
  17. Duration when auscultating
    • short, medium, or long 
    • layers of soft tissue dampen duration of sounds from deep internal organs
  18. Which scale need to be calibrated regularly?
    mechanical scales
  19. What length/weight should an infant be recorded?
    to the nearest 0.5 cm or 1/4 in
  20. In older adults how does pigmentation change?
    increases unevenly
  21. What is disphoresis?
    sedative-hypontic (alcohol)
  22. Spider angiomas
    • alcohol
    • stimulants
  23. What causes increase of vascularity in face?
    alcohol
  24. What drug usage causes red, dry skin
    PCP phencyclidine
  25. How can a stage I ulcer be IDed?
    noting warmth and erythema on skin
  26. What can petechiae indicate
    liver disease, allergic reaction to meds, clotting problems
  27. What is alopecia
    hair loss
  28. How is a normal nail?
    160 degree
  29. What is a clubbing nail? Cause?
    • 180 degree
    • chronic lack of oxygen = heart/lung disease
  30. What are Beau's lines?
    • depressions indicating temp disturbance 
    • severe infection or nail injury
  31. What is Koilonychia (spoon nail)?
    • concave nail 
    • iron deficiency, syphilis, strong soap
  32. What are splinter hemorrhages?
    • red/brown nail streaks 
    • bacterial endocarditis, trichinosis
  33. What are paronychia nails?
    • inflammation of the base of the nail
    • infection, trauma
  34. What does head tilting indicate?
    hearing or vision loss
  35. What is exophthalmos and what does it indicate?
    • bulging eyes 
    • hyperthyroidism
  36. What is strabismus and what does it indicate
    • crossed eyes
    • neuromuscular injury/inherited abnormalities
  37. What is ptosis
    • eyelid drooping over the eye 
    • caused by edema or the III CN
  38. What is an arcus senilis?
    • a thin white ring along the margin of iris 
    • common in aging over 40
  39. What is the normal pupil size range?
    3-7 mm
  40. Continuous pupil dilation indicates what?
    neuro abnormalities, opiate withdraw, glaucoma, trauma, eye meds
  41. Pinpoint pupils indicates what?
    opiate intoxication
  42. What else can alter pupil reaction?
    • intracranial pressure
    • locally applied ophthalmic meds
    • lesions along nerves
  43. What is PERRLA
    pupils equal, round, reactive to light and accommodation
  44. How far should the speculum be inserted into the ear?
    • 1-1.5 cm 
    • 1/2 - 3/4 in
  45. What does a normal ear drum look like?
    shiny, gray, translucent, taught
  46. What are the 3 types of hearing loss
    • conduction-interrupts sound waves form outer to inner
    • sensorineural-inner ear, aud nerve, and hearing center of the brain 
    • mixed-combo of both
  47. What are the adventitious breath sounds
    crackles, rhonchi, wheezing, and pleural friction rub
  48. Where are crackles heard?
    • dependent lobes
    • right and left lung bases
  49. What are the types and characteristics of crackles?
    • fine-high pitched fine,short (end of inspiration)
    • moist-lower,moist (middle of inspiration) 
    • coarse-loud, bubbly (during inspiration)
  50. What are the causes of crackles?
    random/sudden reinflation of alveoli
  51. Where are rhonchi heard?
    over trachea/bronchi
  52. What are characteristics of rhonchi (sonorous wheeze)?
    • loud, low pitched rumbling (during inhal/exhal)
    • cleared by coughing
  53. What are the causes of rhonchi?
    muscular spasms or fluid in larger airways
  54. Where are wheezes heard?
    all over lung fields
  55. What are the characteristics of wheezing?
    • high pitched, continuous, musical
    • during both but louder during exhalation
  56. Where are pleural friction rubs heard?
    over anterior lateral lung fields
  57. What are the causes of pleural friction rubs?
    • inflamed pleura
    • parietal pleura rubbing against visceral pleura
  58. What are the characteristics of pleural friction rubs?
    • dry, grating during inhalation 
    • not cleared with coughing
  59. What is the best position for abdomen assessment?
    dorsal recumbent
Author:
maria_mm_10
ID:
314124
Card Set:
CH 16 Health Assessment
Updated:
2016-01-22 00:21:43
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CH 16 Health Assessment
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