Term
| The purpose of _________is to collect subjective and objective data about a patient to determine his or her overall level of physical, psychological, sociocultural, developmental, and spiritual health. |
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Definition
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Term
| _________ is an integral component of nursing care and the foundation of the nursing process |
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Definition
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Term
| What are the 4 types of health assessment |
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Definition
1. comprehensive
2. ongoing partial
3. focused
4. emergency |
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Term
| this is conducted when a patient first enters a healthcare setting, with information providing a baseline for comparing later assessment |
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Definition
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Term
| Is conducted at regular intervals like at the beginning of each hospital shift or at the beginning of each home health visit |
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Definition
| ongoing partial assessment |
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Term
| is conducted to assess a specific problem. For example if a woman is having abdominal pain the nurse may ask questions about bowel problems |
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Definition
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Term
| is a type of rapid focused assessment conducted to determine potentially fatal situations. For example assessing the airway, breathing, and circulation before beginning cardioulmonary resuscitation. |
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Definition
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Term
| is a collection of subjective data that provides a detailed profile of the patients health status. This is used to identify actual and potential health problems as well as identify sources of strength. |
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Definition
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Term
| What are the components of a health history |
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Definition
1. Biographical data- name address religion, ins.
2. Reason for seeking healthcare
3. History of present health concern
4. Medical history
5. Family history
6. lifestyle |
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Term
| What is the accronym used for risk factors for cancer |
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Definition
C-change in bowel or bladder sounds
A- a sore that does not heal
U-Unusual bleeding or discharge
T-Thickening or lump in the breast or elsewhere
I- Indigestion or difficulty in swalling
O-Obvious change in wart or mole
N- Nagging cough or hoarseness |
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Term
| is the systematic collection of objective information |
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Definition
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Term
| In what sequence is the physical assessment done? |
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Definition
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Term
| What are some of the equipment used in a physical assessment? |
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Definition
1. Stethoscope
2. Ophthalmoscope
3. Otoscope
4. Snellen Chart
5. Nasal Speculum
6. Vaginal Speculum
7. Tuning Fork
8. Percussion Hammer |
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Term
| Used to listen to sounds of the heart, lungs, abdomen, and cardiovascular system. |
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Definition
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Term
| What part of the stethoscope is used to listen to low pitched sounds such as abdominal cardiovascular sounds |
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Definition
| The bell of the stethoscope |
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Term
| part of stethoscope used to listen to high pitched sounds such as normal heart sounds, breath sounds, and bowel sounds |
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Definition
| the diaphram of the stethoscope |
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Term
| lighted instrument used to examine the external ear canal and the tympanic membrane |
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Definition
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Term
| used as a screening test for distant vision and consists of characters in 11 lines of different sized type |
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Definition
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Term
| is used to visualize the lower and middle turbinates of the nose. A penlight or flashlight is used for illumination |
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Definition
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Term
| is a two bladed instrument used to examine the vaginal canal and cervix |
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Definition
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Term
| is a two pronged metal instrument used to rest auditory function and vibratory perception |
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Definition
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Term
| is also known as the reflex hammer and is an instrument with a rubber head used to test deep tendon reflexes |
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Definition
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Term
| What is important to consider during positioning |
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Definition
1. patients age
2. health status
3. mobility
4. physical condition
5. energy level
6. privacy |
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Term
| is the process of performing deliberate, purposeful observations in systematic manner. The nurse observes visually but also uses hearing and smell to gather information during the assessment |
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Definition
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Term
| During an inspection what should you inspect each part of the body for? |
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Definition
1. size
2. color
3. shape
4. positioning
5. symmetry |
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Term
| During palpation which surfaces of the hands are used for gross measure of temp |
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Definition
| the dorsum (back) surface |
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Term
| During palpation which part of the hand is used to assess texture, shape, fluid, size, consistency, and pulsation |
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Definition
| the palmar (front) surfaces of the fingers and finger pads |
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Term
| Which part of the hand best palpates vibration |
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Definition
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Term
| is the act of striking one object against another to produce sound. Used to assess the location, shape, size, and density of the tissues |
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Definition
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Term
| What are the 4 characteristics of sound that are assessed by auscultation |
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Definition
1. pitch (ranging from high to low)
2. loudness ( ranging from soft to loud)
3. quality (gurgling or swishing)
4. duration ( short, medium, or long) |
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Term
| What is the first component of the physical assessment that includes observations about the patients overall appearance and behavior, taking vital signs and measuring height and weight |
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Definition
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Term
| are measured to establish a baseline for the database and to detect actual or potential health problems |
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Definition
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Term
| is the overall assessment of health, hydration status, and nutrition |
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Definition
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Term
| This includes assessing the skin, nails, hair, and scalp |
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Definition
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Term
| this assessment provides information about the patients overall health status, as well as clues to local or systemic health problems. It also provides data about self-care activities to maintain health hygiene and nutrition. |
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Definition
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Term
| This is redness of the skin. it is often seen in the face and neck. It is associated with sunburn, inflammation, fever, trauma, and allergic reactions |
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Definition
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Term
| Bluish or grayish discoloration of the skin in response to inadequate oxygenation |
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Definition
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Term
| is a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia and hemolysis |
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Definition
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Term
| paleness of the skin often results from an inadequate amount of hemoglobin, causing inadequate oxygenation of the body tissues |
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Definition
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Term
| skin is normally warm and dry in increase in skin temp and moisture can indicate ___ |
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Definition
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Term
| an excessive amount of perspiration such as when the entire skin is moist is called |
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Definition
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Term
| is the fullness or elasticity of the skin and is usually assessed on the sternum or under the clavicle. |
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Definition
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Term
| when testing turgor if the skin folds return to its shape when it is released then the patient has normal turgor if it doesnt and returns slowly what is the diagnosis |
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Definition
| dehydration or it could be normal for older adults |
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Term
| Difficulty in lifting a skin fold may indicate |
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Definition
| edema- excess fluid in the tissue |
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Term
| Edema is graded on a 1 through 4 scale explain |
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Definition
0 none
1 trace 2 mm
2 moderate 4 mm
3 deep 6 mm
4 very deep 8 mm |
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Term
| What are some abnormal findings for nails |
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Definition
1. indentations called beau's lines
2. infection
3. painless separation of the nail plate from the nail bed called onycholysis
4. increased brittleness or thickness from anemia or iron deficiency
5. clubbing from long term lack of oxygen |
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Term
| What are some abnormal findings for hair and scalp |
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Definition
1. alopecia- balding
2. hirsutism- excessive amounts of hair on the face and body |
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Term
| What does assessment of the head and neck include |
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Definition
| skull, face, eyes, ears, nose and sinuses, mouth, pharynx, trachea, thyroid gland lymph nodes |
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Term
| The skull should be palpated and inspected for size and shape what are some abnormal findings |
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Definition
1. lack of symmetry
2. unusual size or contour
3. tenderness |
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Term
| what should the face be inspected for |
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Definition
color
symmetry
distribution of hair
involuntary facial movements |
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Term
| What does the thorax comprimise |
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Definition
the lungs
rib cage
cartilage
intercostal muscle |
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Term
| When inspecting the thorax an increased anteroposterior diameter as seen in chronic lung disease is described as__ |
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Definition
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Term
| Abnormal findings when assessing the thorax include |
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Definition
increase chest size
increase contour
abnormal breathing patterns
unequal chest expansion
abnormal respiration |
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Term
| When assessing the thorax auscultation is used for what |
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Definition
| to detect airflow within the respiratory tract |
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Term
| What do Cardiovascular and peripheral vascular assessment include |
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Definition
| the heart and the extremities |
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Term
| What does peripheral vascular assessment include |
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Definition
measuring the blood pressure
assessing peripheral pulses and perfusion |
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Term
| Auscultation is used to determine the heart sounds caused by closure of the heart valves. Systematic auscultation should be used beginning and ending where |
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Definition
aortic area
pulmonic area
Erbs point
tricuspid area
Mitral are |
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Term
| What should the extremities be inspected for |
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Definition
| color,temp, continuity, lesions, venous patterns, and edema |
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Term
| When inspecting the abdomen you should inspect what |
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Definition
the skin color
surface characteristics
the umbilicus
contour
symmetry
peristalsis
pulsations
masses |
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Term
| the abdomen can be aucultated for what sounds |
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Definition
| bowel and vascular sounds |
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Term
| What are the primary structures of the musculoskeletal system |
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Definition
| bones, muscles, cartilage, ligaments, tendons, and joints |
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Term
| Abnormal findings when assessing the musculoskeletal system include |
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Definition
deformity
crepitus
limited ROM |
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Term
| Muscle groups are observed for______ and palpated for____ |
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Definition
| muscle groups are observed for tone and strength and palpated for tenderness |
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Term
| what are abnormal findings when palpating the muscles |
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Definition
atrophy- decrease in size
tremors-involuntary movements
flaccididty- without tone
loss of strength and tone
decreased ROM
Uncoordinated movement
swelling
pain |
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Term
| What does a mental status assessment include |
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Definition
level of awareness
level of consciousness
behavior and appearance
memory, abstract reasoning, and language |
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Term
| How is motor or sensory function evaluated |
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Definition
| Evaluate Motor by assessing balance, gait, and coordination. Evaluate sensory by assessing sensory discrimination of pain, light touch, and vibrations |
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Term
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Definition
| by having the patient walk across the room on the toes, on the heels, and heel to toe. Observe posture, balance, arm, and leg movement |
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