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T2-Health Assess
HA Worksheet - FI
| Question | Answer |
|---|---|
| List 4 skills of assessment in order | Inspection, Palpation, Percussion, Auscultation |
| Give a reason to use Inspection skill of assessment. | Visual, hearing, smell to determine normal/abnormal |
| Give a reason to use Palpation skill of assessment. | To examine all accessible parts of skin, kidneys, etc. |
| Give a reason to use Percussion skill of assessment. | To observe abnormalities with vibrating sound |
| Give a reason to use Auscultation skill of assessment. | To listen to sounds made by body |
| What sounds are the bell of the stethoscope used to hear? | Low pitch sounds by low velocity movement of blood |
| What sounds are the Diaphragm of the stethoscope used to hear? | high pitched sound by high velocity movement of air, blood |
| In what situations can the vital signs not be delegated to an assistant? | Unstable pts, post-op pts |
| What are the normal VS ranges for avg adults? | BP 120/80, RR 60-80, HR 60-80 |
| What are the normal VS ranges for older adults? | Higher BP systolic due to descresed elasticity, |
| Name at least 2 factors that can affect the HR | exercise, temp, emotion, drugs, hemmorage |
| When is an apical pulse absolutely necessary? | When you have a auscultory gap in BP, need to take apical pulse for 1 full min |
| Discuss the ways nicotine and caffeine can affect the BP | Narrows the blood vessels, more pressure on walls = increased BP |
| What defines hypertension? | Systolic BP 140 mmHg or greater and Distolic BP of 90 mmHg or greater or taking antihypertensive med |
| What is orthostatic hypotension? | When pt with a normal BP develops light-headedness or dizziness when standing and BP drops |
| What interventions should you use to maintain your pts safety during orthostatinc hypotension? | Take BP supine, sitting, and standing and ask Pt if they feel dizzy or light-headed. |
| Name 4 of the common mistakes made in taking a BP | Ill-fitting cuff (bladder), arm above/below heart level, stethoscope ill-fitting (hearing deficiency or pressed too hard), inflation/deflation notes too high/low |
| Out of the common mistakes made in taking a BP, what mistakse can cause a false high or low reading? | Cuff too big or too small, Cuff wrapped too loosely or unevenly, Arm above/below HR level |
| Name at least 2 factors that can affect the RR | Exercise, Acute Pn, Anxiety, Smotking, Meds, Body position, Neurological injury, Hemoglobin Function |
| Name 2 diagnoses that may alter pulse oximeter reading accuracy | PVD, Hypothermia |
| List the possible cause and best place to assess for Pallor skin color. | Anemia - Look for pallor in the face, mouth, conjuctiva, nail beds |
| List the possible cause and best place to assess for Jaundice skin color. | Liver Disease - Look for Jaundice in the sclera, mucous membranes, skin |
| List the possible cause and best place to assess for Cyanosis skin color. | Lung Disease, cold T - Look for cyanosis in the lips, nail beds, conjunctiva and palsm |
| When can a TB (PPD) skin test be read? | Between 48-72 hrs after test has been performed |
| What happens if you have a positive TB skin test? | Chest X-Ray |
| Which client may not have a reliable TB skin test? | Someone that's immunocompromised |
| List the expected type of rash or lesions seen with chicken pox (varicella). | Generalized pruritic maculopapular rash with vesicles in various stages |
| List the expected type of rash or lesions seen with Meninococcal Meningitis. | Purpura |
| List the expected type of rash or lesions seen with Thrombocytopenia. | Petchiae |
| Capillary refill < 3 sec indicates adequate ___ blood flow. | Arterial |
| Define Orthopnea related to the Respiratory Assessment. | Difficulty breathing |
| Define Dyspnea related to the Respiratory Assessment. | SOB |
| Define Tachypnea related to the Respiratory Assessment. | Fast breathing rate |
| Define Eupnea related to the Respiratory Assessment. | Normal breathing |
| Where should you listed to the lungs to ensure auscultation of all lobes? | Posterior chest, lateral cheast, anterior chest |
| Discuss the qualities of Rhonchi breath sounds | Sonorous wheezing |
| Where would you hear Rhonchi the most? | Heard over trach and bronchi. May be cleared with coughing |
| Discuss the qualities of Crackles/Rales breath sounds | Fine crackles are high pitched fine, short. Moist crackles are lower, more moist sounds. |
| Where would you hear Crackles/Rales the most? | Fine crackles heard during end of inspiration. Moist crackles heard during middle of inspiration. |
| Discuss the qualities of Wheezing breath sounds | High pitched continuous musical sounds like squeaking. |
| Where would you hear Wheezing the most? | Heard continuously during inspiration, heard over all lung fields |
| Discuss the qualities of Stridor breath sounds | High pitched whistling sound heard on inspiration |
| Where would you hear Stridor the most? | In the upper respiratory tract |
| Discuss the qualities of Pleural Friction Rub breath sounds | Dry, grating quality |
| Where would you hear Pleural Friction Rub the most? | Heard best during inspiration, loudest over lower lateral anterious surface |
| Define Kyphosis related to a thoracic assessment. | Hunchback - exaggeration of posterior curvature |
| Define Lordosis related to a thoracic assessment. | Swayback - increased lumbar curvature |
| Define Scoliosis related to a thoracic assessment. | Lateral curvature of spine |
| Define Barrel Chest related to a thoracic assessment. | Characterizes aging and chronic lung disease |
| Are Kyphosis, Lordosis, Scholiosis, or Barrel Chest normal? | Kyphosis and Barrel chest is normal in aging adults |
| What is a pulse deficit? | Inefficient contraction of heart fails to transmit pulse wave to peripheral pulse site |
| What causes a pulse deficit? | Dysrhythmias |
| What do the S1 and S2 sounds represent? | S1 - lub, low pitched and dull. S2 - dub, higher pitched and shorter sound |
| What is JVD? | Jugular Vein Distention - visible bulging of the jugular vein |
| How is JVD determined? | When sitting, JV distended in pts with right-sided heart failure |
| What is a bruit? | Blowing sound in the carotid artery |
| What part of the stephoscope is used to listen for a bruit? | Bell |
| Where might you hear a bruit? | In the carotid artery |
| Describe arterial insufficiency | Less blood flow to body |
| Describe venous insufficienty | Causes tissue changes, indicating inadequate circulatory flow back |
| List 4 risk factors for breast cancer | Family Hx, Women over 40, Early onset of menarche (before 13), Late age response (after 50) |
| At what age and how often should a women see a healthcare provider for a breast exam? | Age 20-40, every 3 yrs |
| At what age and how often should a women see a healthcare provider for a mammogram? | Over 40, every year |
| What time of the month should a pre-menopausal female complete a self breast exam (SBE)? | Last day of menstrual cycle |
| What time of the month should a post-menopausal female complete a self breast exam? | first day on month |
| What time of the month should a pregnant female complete a self breast exam? | Every month at same time |
| How does the order of a GI assessment differ from other systems and why? | IAPP because you don't want to palpate before listening |
| How do you determine the diff in hypoactive, normoactive, hyperactive and absent bowel sounds? | Listening to bowel sounds. Hypo <5/min, Normoactive 5-35/min, Hyper >35/min. Absent needs to be auscultated for 5 min in all 4 quadrants |
| At what age and how often should a male perform a self testicular exam? | 15 yo and monthly |
| Name 2 urinary signs and symptoms of an enlarged prostate. | Frequency and incontinence |
| Define the levels of consciousness (LOC) | Alert, Lethargic, Obtunded, Stuporous, Semi-comatose, Comatose |
| What is the Glascow Coma Scale (GCS)? | Objective masurement of consciousness on neurological scale |
| Which cranial nerve controls smell? | Olfactory |
| Which cranial nerve controls Pupil Reaction? | Optic |
| Which cranial nerve controls facial expression? | Facial |
| Which cranial nerve controls hearing and taste? | Auditory |
| Define Romberg's test | Testing balance. Ask client to stand with ceet at comfortable distance apart, arms at sides and eyes closed. Expected finding: the client should be able to stand with minimal swaying for at least 5 sec |
| Define Ataxia | Neurological sign and symptom consisting of gross lack of coordination of muscle movements |
| Define DTR | Deep Tendon Reflexes - Using a reflex hammer, assess DTRs bilaterally and compare results for symetry. Grading is done on scale of 0-4. |
| What level is expected on DTR? | Expected = 2+ |
| Define Contracture | Shortening of a muscle in response to continued hypertonic stress exerted on that muscle or tendon. Seen in pts with Spastic Cerebral Palsy |
| Define Muscular atrophy | A decrease in muscle size due to disuse |
| Define Aphasia | Acquired language disorder in which there is an impairment of any language modality |
| Define Atelectasis | Collapse of alveoli, preventing normal respiratory exchange of O2 and CO2 |
Created by:
mcwilliams05
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