Health Assessment High Yield Review

Vocabulary-style flashcards covering high-yield health assessment topics including cranial nerves, heart/lung sounds, developmental stages, and infection control.

Cranial Nerve I (Olfactory)

Responsible for the sense of smell.

Cranial Nerve II (Optic)

Responsible for vision.

Cranial Nerve III (Oculomotor)

Controls PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation), eyelids, and most eye movement.

Cranial Nerve IV (Trochlear)

Controls down and in eye movement.

Cranial Nerve V (Trigeminal)

Responsible for facial sensation and chewing.

Cranial Nerve VI (Abducens)

Controls lateral eye movement.

Cranial Nerve VII (Facial)

Responsible for facial expression and taste on the anterior tongue.

Cranial Nerve VIII (Vestibulocochlear)

Responsible for hearing and balance.

Cranial Nerve IX (Glossopharyngeal)

Responsible for the gag reflex and swallowing.

Cranial Nerve X (Vagus)

Responsible for voice and swallowing.

Cranial Nerve XI (Accessory)

Allows the patient to shrug shoulders or turn head.

Cranial Nerve XII (Hypoglossal)

Responsible for tongue movement.

Respiratory Rate (RR) Norm

$12-20/\text{min}$.

Oxygen Saturation (SpO2) Norm

$\ge 95\%$.

Crackles

Adventitious lung sound indicating fluid in the lungs.

Wheezes

Adventitious lung sound indicating airway narrowing.

Rhonchi

Adventitious lung sound indicating secretions.

Stridor

Adventitious lung sound indicating upper airway obstruction.

Pleural rub

Adventitious lung sound described as a grating sound.

Signs of Respiratory Distress

Use of accessory muscles, retractions, nasal flaring, tachypnea, cyanosis, restlessness, and low oxygen saturation.

S1 (LUB)

Heart sound representing the closure of the Mitral and Tricuspid valves.

S2 (DUB)

Heart sound representing the closure of the Aortic and Pulmonic valves.

S3 (Kentucky)

Heart sound following $S2$; usually abnormal in older adults and associated with fluid overload or heart failure (HF).

S4 (Tennessee)

Heart sound occurring before $S1$; associated with a stiff ventricle or hypertension (HTN).

Stenosis

A condition where a heart valve will not open correctly.

Regurgitation

A condition where a heart valve will not close correctly.

Systolic Murmur

A murmur occurring between $S1-S2$.

Diastolic Murmur

A murmur occurring between $S2-S1$.

Abdominal Assessment Order

Inspection followed by Auscultation, Percussion, and finally Palpation.

OLD CARTS

Mnemonic for pain assessment: Onset, Location, Duration, Characteristics, Aggravating, Relieving/Radiation, Treatment, and Severity.

Wound Assessment Criteria

Location, length, width, depth, color, drainage (amount/color/odor), wound edges, surrounding skin, signs of infection, pain, and stage (if pressure injury).

Assessing Bruising in Darker Skin

Bruising may appear purple, deep brown, or blue-black; assessment includes palpating for tenderness, swelling, warmth, firmness, or fluctuance and inspecting the sclera, oral mucosa, palms, soles, and nail beds.

Therapeutic Communication Techniques

Open-ended questions, reflection, summarization, silence, and active listening.

Therapeutic Communication Avoidances

Avoid 'why' questions, judgment, and false reassurance.

Donning PPE Order

Gown, Mask, Goggles, Gloves.

Doffing PPE Order

Gloves, Goggles, Gown, Mask.

Contact Precautions

Required for infections such as MRSA and C.diff.

Droplet Precautions

Required for infections such as Influenza and Meningitis.

Airborne Precautions

Required for infections such as TB, Measles, and Varicella; requires an N95 mask.

Vital Sign Norms

BP $\approx 120/80$, Pulse $60-100$, RR $12-20$, Capillary refill $\le 2\text{ seconds}$.

Piaget: Sensorimotor Stage

Age $0-2$; learning through senses and developing object permanence.

Piaget: Preoperational Stage

Age $2-7$; symbolic thinking and egocentrism.

Piaget: Concrete Operational Stage

Age $7-11$; logical thinking about concrete events.

Piaget: Formal Operational Stage

Age $11+$; abstract reasoning and hypothetical thinking.

Erikson: Trust vs Mistrust

The psychosocial stage associated with Infants.

Erikson: Autonomy vs Shame/Doubt

The psychosocial stage associated with Toddlers.

Erikson: Initiative vs Guilt

The psychosocial stage associated with Preschoolers.

Erikson: Industry vs Inferiority

The psychosocial stage associated with School-age children.

Erikson: Identity vs Role Confusion

The psychosocial stage associated with Adolescents.

Erikson: Intimacy vs Isolation

The psychosocial stage associated with Young Adults.

Erikson: Generativity vs Stagnation

The psychosocial stage associated with Middle Adults.

Erikson: Integrity vs Despair

The psychosocial stage associated with Older Adults.

ABCs Framework

Priority setting framework standing for Airway, Breathing, and Circulation.

Maslow's Hierarchy of Needs

Framework consisting of Physiological, Safety, Love/Belonging, Esteem, and Self-Actualization.