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HEALTH ASSESSMENT

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Created by: anuali

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Question	Answer
4 broad goals of professional nurses	to promote health to prevent illness to treat human responses to health or illness to advocate for individuals, families, communities, and population
Health assessment	Gather information analyzing and synthesizing making judgments about nursing interventions evaluating patient care outcomes
primary prevention	avoid from getting anything immunization, washing hands, education
secondary prevention	early identification of illness exams, blood test
tertiary prevention	avoid illness from getting worse preventing from recurrence, take medication on time
subjective and symptoms	what the patient tells you
objective and signs	what you see or notice about patient
3 types of assessment	Emergency Focused Comprehensive
emergency assessment	short, life threatening
focused assessment	based on patients problem
long term care assessment	once a month
intensive care assessment	every min or hr
3 major framework of assessment	functional assessment head to toe assessment body system assessment
general survey	begins when you first meet client physical appearance mental status mobility behavior
vital signs	temp pulse res rate bp O2 pain
BP	systolic: ventricular contraction diastolic: ventricular relaxation
factors affect BP	age gender race diurnal medication personal habits pain emotions obesity
KOROTKOFF sound	phase 1: sharp thuds, start of systolic bp phase 2: blowing sound phase 3: crisp thud phase 4: sounds become muffled phase 5: end of sound, ends at diastolic bp
false high BP measurement	arm above heart level loose cuff narrow cuff deflating very slow re-inflating without deflating completely not waiting 1-2 min before repeat
false low BP measurement	hand below heart level cuff too wide manometer higher than heart deflating to fast not inflating enough pressing firmly on diaphragm
BP in adult	normal 120/80 prehypertensive 120-139/80-89 stage 1 hypertension 140-159/ 90-99 stage 2 hypertension more than 160/100
Temperature	regulated by hypothalamus
factor affect Temp	age diurnal variation: decrease in morning, increase in late afternoon and evening menstrual cycle: decrease exercise: increase stress: increase
sites of temp	axillary: 96.7-98.5 6-9 min oral: 97.7-99.5 2-3 min rectal: 98.7-100.5 2-3 min tympanic: 98.2-100 2-3 sec temporal: 98.7-100.5
Normal HR	adult: 60-100 newborn: 120-170 1 yr: 80-160 3 yr: 80-120 6 yr: 75-115 10 yr: 70-110
orthostatic hypotension	drop in BP as you stand
signs and symptoms of hypertension	HA flushing ringing in the ear nose bleed
sign and symptoms of hypotension	increase HR dizziness cool clammy
hyperthermia	very high fever
hypothermia	very low fever
febrile	fever
afebrile	without fever
factor affect pulse	increase with exercise, fever, and stress decrease with male, age, and athletes
bradycardia	slow pulse
tachycardia	fast pulse
respiration	ventilation: movement of gases diffusion: movement of oxygen and carbon perfusion: distribution of red blood cells
tachypnea	fast respiration
bradypnea	slow respiration
apnea	no respiraiton
dyspnea	difficult breathing
orthopnea	difficult breathing lying down
preinteraction	review of medical record before interviewing the patient
factor affect interview	physical setting nurse behaviors type of questions and how they are asked personality and behavior of clients
active listening	concentrate on clients response don't formulate next question don't make assumptions
facilitation	encourage client to continue talking
clarification	gather more information about conflicting
restatement	repeating what client says using different words
reflection	repeating a phrase client just said to indicate interest
confrontation	inconsistencies between what client reports
interpretation	sharing conclusions
summary	orders data to clarify sequence of events
techniques that diminish data collection	using medical terminology expressing value judgments interrupting the client or changing the subject being authoritarian using why question
symptom analysis	C: characteristics O: onset L: location D: duration S: severity P: precipitating factor A: alleviating/ aggravating factors T: treatment
pruritus	itching
turgor	skin elasticity
edema	accumulation of fluid in intracellular spaces
nail	flat/slightly rounded(convex) nail base angle 160 capillary refill 1-2 sec
cyanosis	blue
pallor	white
jaundice	yellow
erythema	redness
ecchymosis	bruising
telangiectasia	irregular red line caused by dilation of blood vessels
cherry angioma	benign tumor, small slightly raised bright red area on face, neck, and trunk
purpura	reddish purple, non blancheable
petechiae	flat reddish purple, non blancheable
capillary hemangioma	port wine stain, stork bite
vascular spider	telangiectasia with radiating spider legs, blancheable
venous star	telangiectasia, non palpable, flat, bluish star-shaped lesion
assessment of mole melanoma	A: asymmetry B: border irregularity C: color uneven D: diameter > 6mm E: evolved or changed over time F: feeling (itch, tingle, sting)
primary lesions	macule or patch papule or plaque nodule or tumor vesicle or bulla wheal pustule cyst
abnormal nail finding	clubbing hypertrophy thinning/brittleness koilonychia inflammation pitting leukonychia beau's lines
types of headaches	migraine cluster tension post traumatic
migraine headaches	start anytime young females most susceptible 72 hrs unilateral pain photophobia
cluster headaches	painful 30-40 yrs common in men 1/2 to 1 hr repeat daily behind one eye
tension headaches	20-40 yrs bilateral to specific area last for days skeletal muscle of face and jaw tight band around head
post traumatic headaches	secondary to head injury common cause motor vehicle accident days to weeks after injury
hyperthyroidism	graves disease most common cause 20-40 females
hypothyroidism	autoimmune
hydrocephalus	abnormal accumulation of CSF
microcephaly	head is too small genetic, chromosomal, toxic stimuli
macrocephaly	head is too big defective embryonic development or degenerative disease
nasal discharge color	clear: normal white: infection viral yellow, green: infection bacteria
infant mouth	drooling at 3 month or until able to swallow teeth 6-24 month
children mouth	frontal sinuses absent until 7-8 yrs permanent teeth 6 to 18 yrs
allergic rhinitis	inflammation of nasal mucosa
Epistaxis	nosebleed cause by un-control hypertension
candidiasis/thrush	opportunistic infection soft white plaques on tongue, buccal mucosa, posterior pharynx
shape ribs	45 degrees to spine coastal angle less than 90
fine rales/crackles	high pitched crackling collapsed or fluid filled alveoli
coarse rales/crackles	loud, low-pitched bubbling collapsed or fluid filled alveoli
wheezes	high-pitched blocked airway due to inflammation
ronchi	low-pitched, snoring, rattling blocked airway due to inflammation plus fluid
stridor	loud, high-pitched crowing upper airway is blocked
friction rub	low-pitched grating plueral inflammation
infant resp	round thorax nose breathers until 3 months 10-15 sec apnea seesaw breathing
grunting	try of force trapped air out of lungs
acute bronchitis	inflammation of bronchial tree caused by viruses or bacteria
chronic bronchitis	inflammation of bronchial tree productive cough 3 months of 2 successive years
pneumonia	infection of terminal bronchioles/alveoli caused by bacteria, fungi, viruses
tuberculosis	bacterial infectious disease
pleural effusion	fluid in the pleural linning
empyema	purulent/pus in pleural lining
asthma	hyper reactive airway disease
emphysema	abnormal enlargement of air spaces
pneumothorax	air entering plural space
hemothorax	blood in plural space
atelectasis	accumulation of secretions in terminal bronchiole
s1	louder in mitral and tricuspid
s2	louder in aortic and pulmonic
s1 and s2	lub dub
veins	take deoxygenated blood to lungs
artery	bring oxygenated blood back to the heart
apical pulse	point of maximum impulse
homan's sign	to assess DVT
s3	ventricular gallop ken-tuck-y
s4	atrial gallop ten-es-see common in older adult
murmurs	swishing or blowing sound heard at beginning, middle, pr end of the systolic or diastolic phase
strength pulse	0: absent, not palpable 1+: pulse diminished, barely palpable 2+: easily palpable, normal 3+: full pulse 4+: strong, bounding pulse
left side HF	failure of ventricles to pump blood efficiently pulmonary edema precordial movement bilateral pulmonary crackles
right side HF	cell necrosis from infarction blood backs up in right atrium systolic murmur dependent peripheral edema
venous insufficiency	color: normal or cyanotic temp: normal pulse: normal edema: often marked skin: brown pigmentation around ankles
arterial insufficiency	color: pale, dusky red temp: cool pulse: decreased or absent edema: absent or mild skin: thin, shinny
ascities	accumulation of fluids
peptic ulcer disease	lower end of esophagus, stomach, or duodenum
crohn's disease	inflammation mouth to anus, most common terminal in ileum and colon
ulcerative colitis	chronic IBD starts in rectum and progresses through large intestine
diverticulitis	inflammation of diverticula, herniations through muscular wall in colon
viral hepatitis	inflammation of liver
cirrhosis	chronic degenerative liver disease, diffuse destruction/regeneration of hepatic parenchymal cell
cholecystitis with cholelithiasis	inflammation of gallbladder with gallstone
pancreatitis	acute or chronic inflammation resulting from auto digestion of the organ
cystitis	urinary bladder infection
urethritis	urethra infection
pyelonephritis	renal pelvis infection
glomerulonephritis	inflammation of renal glomeruli caused by autoimmune process
nephrolithiasis	formation of stones in kidney pelvis
Barlow-Ortolani maneuver	birth-2 month adduct/abduct test for infants
osteoporosis	genetic one side risk for fracture
rheumatoid arthritis	genetic both side stiffness ulnar deviation swan neck deformity
osteoarthritis	degenerating cartilage joint deformities heberden's bouchard's nodes
gout	increase in serum uric acid tophi: round pea-like deposits
phalen's and tinels sign test	for carpal tunnel syndrome
CN 1-12	1 olfactory 2 optic 3 oculomotor 4. trochlear 5. trigeminal 6. abducens 7. facial 8. auditory 9. glossopharyngeal 10. vagus 11. spinal accessory 12. hypoglossal
plantar test	to assess Babinski response
Glasgow coma scale	assess LOC using 15 points
PERRLA	pupils equal round reactive to light and accommodation
ptosis	dropping
consensual and direct to light	light on left right constrict and light on right left constrict
rosenbaum test	to assess CN 2
infants eyes	peripheral vision developed at birth, central vision at 9-12 month 1 month: can fixate, follow light 2-3 month: tears, may see strabismus 3-4 month: fixate, follow n reach for toy 6-12 month: follow a toy in all direction 8 month: distinguish color
allen picture card test	2.5 to 3 yrs
snellen's E chart test	3 to 6 yrs
snellen's chart test	7 to 8
presbyopia	loss of lens elasticity
cataract	denaturation of lens protein caused by aging blurred vision can also be cause by trauma to eyes
diabetic retinopathy	caused by diabetes mellitus common in 20 to 75 dark spot in vision 2 types background and proliferative
glaucoma	damage retina by intraocular pressure leading cause of blindness in USA center is okay and peripheral is bad 2 types: open and closed angle
Macular degeneration	caused by hypertension common in 65 and up center is bad and peripheral is okay
tinnitus	ringing in ears
vertigo	when the room is moving/spinning
dizziness	when you are moving/spinning
ear is called what	auricle or pinna
helix	the hard part of ear
cauliflower ear are called what	boxers ear
normal tympanic membrane	pearly gray and concave
ear assessment	under 3: pull down over 3: pull up adult: pull up and back