Health Assessment Exam 1

Comprehensive Health assessment

involves a detailed history and physical exam at the onset of care in a primary care setting or in a hospital

Problem based/focused health assessment

involves a history and physical examination that is limited to a specific problem or complaint

Episodic assessment

assessment performed when a patient is following up with a health care provider for a previously identified problem

screening assessment

short exam focused on disease detection

Shift Assessment

assessment done each shift in order to identify and changes from baseline

Subjective data

data collected during the health history interview - verbally stated

objective data

measured data - numeric and descriptive.

Primary prevention

an intervention implemented before there is evidence of a disease or injury

Secondary Prevention

any intervention implemented after a disease has begun but before it is symptomatic

Tertiary Prevention

an intervention implemented after a disease or injury is established

Chief Complaint

the main reason for the patient's visit

OLD CARTS

Onset

Location

Duration

Characteristics

Aggravating factors

Related factors

Treatments

Severity

Standard Precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious. Hand hygiene is the most important

Palpation

use of hands to feel texture, size, shape, consistency, and location of certain parts and identify tender areas

light palpation

1 cm deep, used to assess skin, pulsations, and tenderness

deep palpation

4cm depth of pressure, used to determine organ size and contour

Percussion

a diagnostic procedure designed to determine size, borders, and consistency of a body part by the sound produced by tapping the surface with the fingers

Tympany

percussion sound that is loud, high pitched, and heard over abdomen, meaning liquid filled

Resonance

percussion sound that is heard over normal lung tissue - air sound

Hyperresonance

percussion sound heard in overinflated lungs, as in emphysema

Dullness

percussion sound heard over liver - firm sound

Flatness

Percussion sound over muscles and bones.

Auscultation

Listening with a stethoscope

diaphragm

larger flat surface of stethoscope used to hear high pitched sounds, like breath, bowel, and normal heart sounds

Bell

concave smaller side of stethoscope used to hear soft, low pitched sounds like extra heart sounds of vascular sounds

too small BP cuff

might lead to false high BP

too large BP cuff

might lead to false low BP

Snellen chart

used to measure visual acuity

jaeger chart or Rosenbaum charts

used to evaluate near vision

blood pressure

Force of blood against artery walls.

systolic pressure

the maximum pressure exerted on arteries when ventricles eject blood

diastolic pressure

the minimum amount of pressure exerted on vessels when ventricles of heart relax

Kortokoff sounds

series of sounds that correspond to changes in blood flow through an artery as pressure is released

Heart rate for infant

100-160 bpm

respiratory rate for infants

30-53 breaths per minute

blood pressure for infants

systolic: 72-104 diastolic: 37-56

Heart rate for toddlers

90-140 bpm

Respiratory rate for toddlers

22-37 breaths/min

Blood pressure for toddlers

systolic: 86-106

diastolic: 42-63

Heart rate for school-age children

75-118 bpm

Respiratory rate for school-age children

18-25 breaths/min

blood pressure for school age child

systolic: 97-115

diastolic: 57-76

Heart rate for adolescents

60-100 bpm

Respiratory rate for adolescents

12-20 breaths/min

Blood Pressure for Adolescent

systolic: 110-131

diastolic: 64-83

Heart rate for adults

60-100 bpm

Respiratory rate for adults

12-20 breaths per minute

Blood pressure for adults

systolic:

Trasnduction of pain

movement of impulse from site of stimulation to spinal cord

transmission of pain

conduction of pain message up the spinal cord

perception of pain

occurs at cerebral cortex

Modulation of pain

process by which the sensation of pain is sent back down the spinal cord

A-delta fibers

nerves in charge of quick, sharp pain, faster conduction because they are myelinated

C fibers (pain)

thin, unmylinated axons, conducts pain info slowly and senses dull pain

acute pain

pain that is felt suddenly from injury, disease, trauma, or surgery that is usually self limiting

chronic pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous, tolerance for pain may increase

nociceptive pain

pain from activation of normal neural systems

somatic pain

pain arising from bone, joint, muscle, skin, and connective tissue

visceral pain

arises from stimulation of nerves within the thoracic, pelvic, or abdominal organs

neuropathic pain

occurs from an abnormal processing of sensory stimuli by the central or peripheral nervous system

pain threshold

the point at which a stimulus is perceived as pain

pain tolerance

duration or intensity of pain a person will endure before outwardly responding

limbic system

emotional brain

HITS pneumonic

H - hits or hurts you

I - insults you

T - threaten you

S - scream at you

Major Depression

an abnormal mood state characterized by sense of sadness, hopelessness, helplessness, worthlessness, or despair

Bipolar Disorder

psychotic disorder characterized by episodes of mania, depression, or mixed moods.

Schizophrenia

psychotic disorder characterized by severe disturbance of thought, perception, emotional responsiveness, and social interactions. hallucinations, delusions and thought disorders

Anxiety

The condition of feeling uneasy or worried about what may happen as a response to no specific source or actual object

obsessive-compulsive disorder (OCD)

an anxiety disorder characterized by unwanted repetitive thoughts (obsessions) and/or actions (compulsions)

Post-Traumatic Stress Disorder (PTSD)

an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience

Acute Stress Disorder (ASD)

a disorder resulting from exposure to a major stressor, with symptoms of anxiety, dissociation, recurring nightmares, sleep disturbances, problems in concentration, and moments in which people seem to "relive" the event in dreams and flashbacks for as long as 1 month following the event

Alcohol withdrawal syndrome

The reaction of the body to the sudden stopping of drinking

Dementia

chronic progressive disorder characterized by memory impairment

Delerium

disturbance of consciousness and rapidly developing change in cognition that manifests over a short period of time