Health Assessment Final Exam

What is the nursing process?

Assess

Diagnose

Planning/Outcome

Implementation

Evaluation

What is Primary Prevention?

Immunizations, education

What is Secondary Prevention?

screening, diagnoses

What is Tertiary Prevention?

avoid long term effects

What is nonmaleficence?

do no harm

What does beneficence mean in client ethics?

the act to promote the good of the client

What is client autonomy?

The right to make a decision, informed consent

What is justice?

treating everyone fairly

What is confidentiality?

respecting the privacy of the patient

What are some social determanants of health?

access and quality education and healthcare

neighborhood/environment

social and community context

economic stability

What is subjective data?

health history, what the patient tells you

What is objective data?

physical exam, what you say/do

What is ISBARR communication?

Identify (yourself/ the pt)

Situation (confirm details)

Background (pt history)

Assessment

Recommendation

Read Back Order

What are the components of a health history interview?

Opening: introduction

Discuss: plans/goals

Closing: summarize

What is therapeutic communication?

builds trust

What is a direct question?

close ended, yes/no

What is a non direct question?

open ended, explanation

What is considered nonverbal communication?

facial expressions, eye contact, body language

What are the parts of a health history?

biographical data

reason for seeking care

history of present illness

past medical history

family history

psychosocial

review of systems

What are the components of biographical data?

name

DOB

address

phone number

gender, race, religion

primary/secondary language

marital status

emergency contact

OLDCARTS

Onset

Location

Duration

Characteristics

Alleviates/Aggravates

Related Symptoms

Treatments

Severity

What are the components of past medical history?

allergies

immunizations

childhood illness

chronic illness

accidents/injury

surgeries

hospitalizations

mental illness

sexual/obstetrical

Whos family health history do we need to know for a patient?

grandparents

siblings

parents

ROS

head-to-toe

what are some Psychosocial factors?

education

housing

occupation

finances

safety

exercise

sleep

stress

tabaco

alcohol

illicit drugs

support systems

domestic violence

functional assessment

spirituality

What are we looking for in a general survey?

signs of distress

appearance

sexual development

abnormal skin

movement/ symmetry

facial features

level of consciousness

what are we assessing in appearance

emotional state

eye contact

level of consciousness

skin

What are we assessing in behavior

speech

mood

personal hygiene

What are we assessing for in body structure?

posture

overall build

mobility

ROM

What are some involuntary movements?

spasticity

rigidity

fasciculation

myoclonus

tic

tremor

What is visceral pain?

deep organ, cramps

What is somatic pain?

musculoskeletal

What is referred pain?

Felt in one area, originating from somewhere else

What is acute pain?

pain that occurs related to illness or injury

What is chronic/persistent pain?

Lasts 6 months

What is reoccurring pain?

keeps happening

What sounds do you hear from the diaphragm of the stethoscope?

High pitch

What do you hear from the bell of the stethoscope?

low pitch

What are expected skin variations?

hyper/hypo pigmentation

What are some unexpected skin variations?

cyanosis

ecchymosis (bruise)

erythema

jaundice

pallor

What are expected skin textures and moisture?

acne

wrinkles

scars

What are some unexpected skin texture/moistures?

velvety skin

roughness

dryness

flakiness

diaphoresis

What are some unexpected skin integrities?

lesions

petechiae

ecchymosis

purpura

What is a stage 1 pressure injury?

slightly red

What is a stage 2 pressure injury?

epidermis and dermis

What is a stage 3 pressure injury?

Epidermis, dermis, sub Q

What is a stage 4 pressure ulcer?

past sub Q

What makes an unstageable pressure injury?

Eschar

What should skin temperature be like?

warm

hand and feet might be colder

What are some environmental factors that change skin temperature?

Cold environment

What is hyperthermia?

>100.4

What is hypothermia?

<97

What do we expect when testing skin turgor

no tenting, skin should go down immediately

What are some unexpected nail findings?

yellow- jaundice

cyanosis- blue

brown streak- mole/cancer

damage- anemia

clubbing- circulation issue

delayed cap refill

What are normal head finidings?

skull should be rounded, skin should be uniform, and intact, free of nodules and pain

What are some unexpected head findings?

lumps

protrusions

sunken areas

lesions

redness

edema around eyes

tense facial expression

lice

facial hair on women

What are some unexpected nose findings?

pale mucosa and clear discharge

mucoid discharge/ bright red mucous

yellow/green discharge

unilateral watery discharge with recent head injury

What are some unexpected mouth findings?

smooth/dark red swollen tongue

gum swelling

yellow discoloration

lesions

edema

swelling

ulcers

thrush

blood

What are normal neck findings?

symmetric

trachea midline

skin color is the same

no lumps/bruises

good ROM

What are some abnormal neck findings?

visible lymph nodes

difficulty swallowing

What are some expected variations in elderly peoples eyes?

ectropion: lower eyelid turns outward

entropion: lower eyelid turns in, eyelashes and skin rub against cornea

psuedoptosis: upper eyelid droop

What are some unexpected outer eye variants?

Exophthalmos: protrusion of eyeballs

strabismus: eyes point in different direction

eyebrows not extended beyond eye

unable to move eyebrow

scalling or flaking of skin

redness of eyelid

edema of eyelid

drooping of eyelid

What are some unexpected eye findings

inability to close eyelid: lagophthalmos

yellow/green sclera: jaundice

sunconjunctival hemorrhage

Conjunctivitis: red, itchy, watery, crusty eye

unequal pupil size

cloudy pupils

pupils dilated >7mm

pinpoint pupils <3mm

What are some unexpected ear findings?

eczema

redness

bright blood/watery drainage

frequently repeating questions

How often should someone get a vision screening?

yearly

How often should a person undergo a hearing screening

every 3 years after 50 if hearing loss is noted

what is the physiology of the lungs?

high to low concentration then to the inside of the body

trachea- right and left bronchi- bronchioles-alveoli-exchanges in capillary w/ CO2

What is the Tripod position?

when the patient is folded into a forward leaning position, typically in patients with COPD

What do nurses need to watch for to indicate breathing problems?

watch muscles of the neck/throat

intercostal muscle use

What is unexpected in a patients level of consciousness?

anxious, agitation, confusion (resp depression)

frequent sighing (hyperventilation)

What are some characteristics of the anterior chest?

transverse is smaller than anterior and posterior

What are some anterior chest unexpected variations?

barrel chest

funnel chest (pectus excavatum)

pigeon chest (pectus carintum)

blue mucosa= not enough CO2

How many lungs are in the left lobe?

2 lobes

How many lobes in the right lobe?

3

Where should the sternal line be?

midline

Where is the midclavicular line

through the nipple

where are the axillary lines located?

through both armpits

What are some unexpected chest expansion variations?

tachypnea = >20

bradypnea = <12

hypoventilation = slow breaths

hyperventilation = >24, rapid and shallow, panic attacks

Ataxic: brain injury, periods of apnea

Cheyne Stokes: periods without breaths

What is expected in the posterior and lateral chest?

equal scapulas and spine midline

What are some posterior and lateral chest expected variations?

COPD: AP and transverse= similar

scoliosis: spine not aligned

kyphosis: hump of neck

What are some unexpected posterior/lateral chest variations?

unequal expansion

pneumonia/inflammation

What do we do when auscultating the lungs?

ladder pattern

full breaths at each location

watch for light headedness

listen laterally as well

do not listen over clothes

abnormal sound- make pt cough and listen again

get over inner costal spaces

What are some normal breath sounds?

tracheal: over trachea

bronchial: down from trachea

vesicular: alveolar sounds

bronchovescular: out from bronchi

What are some unexpected breath sounds

Stridor: upper airway obstruction

wheezing: asthma, musical

crackles: popping

pleural friction rub

Ronchi: deep snore

decreased breath sounds

What are some different lung palpation techniques?

bronchphany (vibration), tactile fremitus- 99

chest expansion: pinch (symmetry)

egofany: “E”

How do we percuss the lungs

testing for resonance

test cva tenderness

without gloves

What tools do we use with cardiovascular system?

stethoscope

doppler

clock

penlight

What is the anatomy and physiology of cardiovascular system

deoxygenated blood- inferior vena cava- right atrium- tricuspid valve- right ventricle-pulmonary artery- lungs (oxygenated)- pulmonary artery- left atrium- mitral valve- left ventricle- aortic valve- aorta- body

Explain the dual pumping system

mechanical pumping: pushing blood through

electrical pumping: nodes send electrical pulses

4-6 L blood every minute

What is expected in the extremities?

consistent temperature

even color

symmetrical hair

What is unexpected in the extremities?

twisted veins, change in skin tone, lack of hair, thin, shiny skin, thick skin, ulcers asymmetry

Name all peripheral pulses

radial

brachial

femoral

popliteal

posterior tibial

dorsalis pedis

What order do we assess the abdomen?

Inspect at eye level, auscultate, palpate, then percuss.

What are we expecting to see on the abdomen area?

moles, healed scars, silver striae

What is unexpected to see on the abdomen?

lesions, brusing, dilated veins, purple striae, rashes, yellow coloring, glistening/ taut skin

What are some expected symmetry/masses found on the abdomen?

thin frame

buldge

What are some unexpected symmetry/mass abdomen variations?

localized bulging

visible masses

asymmetry of movement

visible intense pulsations

visible GI peristalsis w/ distended abdomen

What are some expected shape and contour variations of the abdomen?

frame and weight

older adults

What are some unexpected shape and contour variations of the abdomen?

Term

abdominal distention

marked concavity

What expected umbilicus variations?

piercings, extraversion, obesity