Health History, Physical Assessment, and Vital Signs Review

A comprehensive set of 100 flashcards covering health history, physical assessment techniques, and vital signs based on Chapters 19 and 20 of Fundamentals of Nursing.

What are the three phases of a patient interview?

Orientation, working, and termination

Which factors can affect the success of a patient interview?

Privacy, interruptions, environment, and communication techniques

What does a review of systems typically begin with?

General health status

What are the requirements for the physical environment during a physical assessment?

Privacy, lighting, space, and comfort

How should equipment be arranged for a physical assessment?

In the order it will be used

What steps are taken during patient preparation for a physical assessment?

Verify identity, meet elimination needs, ensure patient is properly dressed and covered, and meet emotional and safety needs

What is the purpose of grouping assessment techniques by position?

To limit position changes for the patient

What is the definition of inspection in assessment?

Using vision and smell to examine characteristics of a whole person and individual body systems

What is the definition of palpation?

Using touch to assess body organs and skin

What assessment technique involves tapping the skin to cause a vibration?

Percussion

What is the definition of auscultation?

Listening to sounds made by body organs or systems

What elements are included in the General Survey?

Age, race, sex and gender identity, sexual orientation, clothing, hygiene and grooming, and affect and mood

Which behavioral and physical indicators are noted in the General Survey?

Safety, alcohol, tobacco, or recreational drug use, speech, gait, vital signs, height, weight, and body mass index

What are seven common skin color alterations?

Absence of pigment, cyanosis, erythema, purpura, jaundice, pallor, and vitiligo

What mnemonic is used to assess skin malignancies?

ABCDE

What characteristics of the skin are assessed through palpation?

Texture, skin temperature, and turgor

What is specifically noted during the inspection and palpation of nails?

Capillary refill

What is assessed during head inspection and palpation?

Head position, skull contour, symmetry, and spasmodic muscular contractions or tics

Which structures are inspected and palpated in the eye assessment?

Alignment, positioning, eyebrows, eyelids, conjunctiva, sclera, clarity of the lens and cornea, lacrimal glands, iris, and pupil

What charts are used to measure visual acuity?

Snellen chart and E chart

Which structures are assessed using an ophthalmoscope?

Optic disc and retinal vasculature

Which types of hearing loss are identified in a hearing evaluation?

Sensorineural, conductive, and mixed

Which tests are used to evaluate hearing?

Weber test and Rinne test

What test is used to evaluate equilibrium?

Romberg test

Which lymph nodes are listed for assessment in the head and neck region?

Preauricular, parotid, postauricular, occipital, retropharyngeal (tonsillar), submandibular, submental, anterior cervical, posterior cervical, and supraclavicular

Which structures in the neck are assessed during physical examination?

Jugular veins, carotid arteries, thyroid gland, and trachea

What is evaluated during the inspection of the chest and breathing?

Shape and configuration, breathing patterns, and abnormal assessment findings

What is assessed during palpation of the chest?

Tactile fremitus and evaluation of chest excursion

What are three clinical findings associated with lung auscultation?

Breath sounds, atelectasis, and adventitious breath sounds

What heart sounds are evaluated during cardiac auscultation?

Heart sounds ($S1$-$S4$)

What are the grades for cardiac murmurs?

Grade 1-Grade 6

What is the scale for intensity or volume of peripheral pulses?

$0$: Absent pulse, $1$: Diminished, $2$: Normal, $3$: Bounding

What test is used during the assessment of radial pulses?

Allen test

Which peripheral pulses are assessed in the physical examination?

Brachial, radial, femoral, popliteal, and pedal pulses

What are the Five Ps assessed for venous and arterial insufficiency?

Pain, Pallor, Pulselessness, Paresthesia, and Paralysis

What skin and hair changes indicate venous or arterial insufficiency?

Lack of hair growth, recurring ulcers, and brittle or thin skin

What are the five levels of reflex responses?

$4+$: Very brisk (hyperactive with clonus), $3+$: Brisker than average, $2+$: Average/normal, $1+$: Sluggish or diminished, $0$: No response

Which nervous systems are included in the neurologic assessment?

Central nervous system and peripheral nervous system

How are the 12 cranial nerves tested?

In numbered order

What is used during a sensory nerve assessment?

Dermatomes

What are the components of a mental status assessment?

Intellect, behavior, language, memory, knowledge, judgment, association, attention, level of consciousness, decision-making, and abstract thinking

What signs are noted during an emotional assessment?

Demeanor, facial expressions, and signs of emotional stress

What specific sounds are assessed during abdominal auscultation?

Borborygmi and bruits

What are the final steps after completing a physical assessment?

Allow time to dress, return exam area to original condition, use PPE/infection control, record in EHR promptly, report abnormalities, and document education

What is the primary use of vital signs assessment?

To monitor body system functioning, detect changes in health status, identify early warning signs of life-threatening conditions, and evaluate intervention effectiveness

What are the four components of vital signs?

Body temperature, pulse, respirations, and blood pressure

How is pulse defined?

The detectable rhythmic expansion of an artery occurring with the pumping action of the beating heart

What is the pulse rate?

The number of heartbeats per minute

How are respirations defined?

The act of breathing

What is the definition of blood pressure ($BP$)?

The measurable pressure of blood in the systemic arteries

What is the purpose of establishing baseline values for vital signs?

To identify changes in patient status and establish patient trends

What is the normal range for core body temperature?

$36.4^\circ$ to $37.6^\circ\,C$ ($97.6^\circ$ to $99.6^\circ\,F$)

What is the average oral temperature?

$37^\circ\,C$ ($98.6^\circ\,F$)

What are the four mechanisms of heat loss?

Radiation, conduction, convection, and evaporation

Which factors can affect body temperature?

Age, recent exercise, hormone fluctuations, circadian rhythms, stress, and environment

What conditions are classified under hyperthermia?

Fever, heatstroke, and heat exhaustion

Where are the common sites for temperature assessment?

Mouth, ear, rectum, forehead, and axilla

What types of thermometers are used in nursing?

Electronic, disposable/temperature-sensitive strips, and noncontact infrared

What data supports a nursing diagnosis of Hyperthermia?

Infectious process and a temperature of $38.89^\circ\,C$ ($102^\circ\,F$)

What data supports a nursing diagnosis of Hypothermia?

Exposure to below-freezing temperature without adequate clothing and a temperature of $93.6^\circ\,F$

What data supports a nursing diagnosis of Impaired Thermoregulation?

Premature infant of $32$ weeks' gestation and inability to maintain temperature within normal range

What factors affect pulse rate?

Age, gender, exercise, fever, medications, fluid volume status, stress, and disease processes

What is the difference between peripheral and apical pulses?

Peripheral pulses are palpated over arteries away from the heart; the apical pulse is central and auscultated over the apex

What is the Point of Maximal Impulse ($PMI$)?

The location over the apex of the heart where the apical pulse is auscultated

What are the pulse rhythm classifications?

Regularity, dysrhythmia, or arrhythmia

What data supports a diagnosis of Impaired Peripheral Tissue Perfusion?

Decreased peripheral circulation, pedal edema, and the need for Doppler ultrasound for pedal pulses

Which findings support a diagnosis of Activity Intolerance related to pulse?

Immobility, shortness of breath with ambulation, and increased pulse rate with activity

Which findings support a diagnosis of Impaired Cardiac Output related to pulse?

Altered contractility of the heart, shortness of breath, peripheral edema, and tachycardia

Where are the respiratory centers located in the brain?

Medulla and pons

Which factors affect respiration?

Age, exercise, respiratory/cardiovascular disease, fluid/electrolyte balance, acid-base disturbances, medications, pain, and emotions

How is respiratory rate measured?

By counting the number of breaths per minute

What is the definition of eupnea?

Normal respiratory rate

What is the difference between tachypnea and bradypnea?

Tachypnea is a rapid rate; bradypnea is a slow rate

What terms describe the depth of respirations?

Hypoventilation and hyperventilation

What terms describe the quality of respirations?

Apnea, dyspnea, and orthopnea

What is $SpO_2$?

Oxygen saturation measured by pulse oximetry

What values are included in Arterial blood gases ($ABG$)?

Carbon dioxide level and $pH$

What data supports a diagnosis of Impaired Breathing?

Increased intracranial pressure from traumatic head injury and hypoventilation

What data supports a diagnosis of Impaired Gas Exchange?

Alveolar changes and oxygen saturation of $89\%$ on room air

What are common interventions for altered respiratory patterns?

Positioning, supplemental oxygen, suctioning, and medications such as bronchodilators

What is systolic blood pressure?

The peak of the pressure wave

What is diastolic blood pressure?

The lowest pressure on arterial walls

How is blood pressure recorded?

As a fraction in millimeters of mercury ($mm\,Hg$)

What is pulse pressure?

The difference between diastolic and systolic pressures

Which system is responsible for short-term regulation of blood pressure?

The autonomic nervous system ($ANS$)

What clinical types of hypertension are there?

Elevated, Stage 1, Stage 2, Primary, and Secondary

Which factors affect blood pressure measurement?

Age, gender, race, medications, weight, circadian rhythm, head injury, blood volume, food intake, emotions, and pain

What are the five phases of sounds heard during blood pressure measurement?

Korotkoff sounds

What is an auscultatory gap?

A period of silence during the auscultation of Korotkoff sounds

What data supports a diagnosis of Risk for Fall related to blood pressure?

Orthostatic hypotension and dizziness, with BP $136/70\,mm\,Hg$ lying and $96/60\,mm\,Hg$ standing

What findings support Impaired Cardiac Output regarding stroke volume?

Altered stroke volume, estimated blood loss of $500\,cm^3$ during surgery, and irregular heart rate

What data supports Fluid Imbalance related to blood pressure?

Renal compromise, increased blood pressure, dyspnea, and orthopnea

What are the three components of hair and scalp assessment?

Inspection and palpation

Which eye structures are assessed for alignment and positioning?

Eyebrows and eyelids

What is cataracts?

A condition affecting the clarity of the lens

Where is the lacrimal caruncle located?

The eye

Which nerve is identified as the Eighth Cranial Nerve ($VIII$) in the ear?

Vestibulocochlear nerve

Which parts belong to the external ear?

Auricle (pinna), lobule, tragus, and external auditory canal

What are the three auditory ossicles in the middle ear?

Malleus, incus, and stapes

What structure separates the external ear from the middle ear?

Tympanic membrane