Term
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Definition
Health history - subjective data during interview
Physical Assessment (review of systems) and diagnostic test - objective data
part of health assessment process |
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Term
| Components of Health History |
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Definition
Demographic info
source of history
chief concern
history of present illness
past health history/current status
Family history
Social History
Health promotion behaviors |
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Term
| Physical Assessment Order (4) |
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Definition
Inspect, palpate, percuss and auscultate
abdomen: inspect, auscultate, percuss, palpate |
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Term
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Definition
First step, begins with first interaction and throughout
Uses senses of vision, smell and hearing to observe and detect any normal or abnormal findings
Inspects for size, shape, color, symmetry and position. |
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Term
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Definition
touching to determine size, consistency, texture, temperature, location and tenderness of an organ or body part.
Tender areas last
Deeper palpation for abdomen
Hand: Dorsal-temp, ulnar/finger base-vibration, Fingertips-pulsation, position, texture, size, consistency, finger/thumb-grab |
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Term
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Definition
tapping body parts with fingers, fists or small instruments to evaluate size, location, tenderness, and presence or absence of fluid or air in body organs and to detect any abnormalities
direct: striking body to elicit sounds
indirect: placing hand flat on body for surface for sound
fist: tenderness over kidneys, liver and gallbladder |
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Term
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Definition
technique to listen to sounds produced by the body
evaluated for amplitude/intensity, pitch/frequency, duration and quality
diaphragm-high pitched sounds; bell for low pitched |
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Term
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Definition
| occurs during ventricular systole of the heart, when the ventricles force blood into the aorta and represents the maximum amount of pressure exerted on the arteries |
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Term
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Definition
| occurs ventricular diastole of the heart, when the ventricles relax and exert the minial pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries |
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Term
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Definition
Conduction - transfer of heat from body, directly to another surface (immersed in cold water)
Convection - dispersion of heat by air currents (wind)
Evaporation - dispersion of heat through water vapor
Radiation - transfer of heat from one object to another object without contact (cold room) |
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Term
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Definition
Newborns: 36.5-37.5 C (97.7-99.5 F)
older adults (loss of subQ) - 36 C
Temp rises slightly with ovulation and menses
Menopause may increase it up to 4 C
Injury/illness increases body temp. Fever is the bodys infectious/inflammatory response |
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Term
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Definition
Mercury-filled: rare, shake down to 35C prior to use
Disposable for oral and axillary use that are individually wrapped and discarded after 1 use
Electronic uses disposable cover placed on probe prior to insertion; tympanic have a specific device |
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Term
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Definition
Gently place with probe under tongue in the posterior sublingual pocket lateral to center of lower jaw
-Leave till signal or 3 minutes for mercury (not for confused clients or small children who may bite glass)
preferred ages 4 and up
Not appropriate for assessing the temp of a client who breathes through mouth or has face trauma |
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Term
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Definition
Sims position with upper leg flexed, wearing gloves and spread the buttocks
Lubricated thermometer w probe is placed into anus in direction of umbilicus 3.5cm (1.5in) till noise or 3min
Remove if resistance
Clean anal area to remove feces or lubricant and do not use for bleeding precautions or rectal disorders, or 3 months or younger |
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Term
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Definition
less effective than rectal
place thermometer in center of clean dry axilla, lower arm over
Hold arm down till noise or 2 minutes with mercury |
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Term
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Definition
Pull ear up and back for an adult
Pull down and back for child under 3
Snugly into outer ear canal and scan till signal; no infants 3m and under |
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Term
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Definition
Remove camp, wipe lens with alcohol
While pressing scan, hold probe flat again forehead, moving it gently across forehead over the temporal artery and then touch the skin behind the earlobe then release scan |
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Term
| Hyperthermia Interventions (above 39 C) |
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Definition
-Obtain blood culture specimen if ordered then administer antibiotics as prescribed from results
-Assess/monitor WBC, sedimentation rates and electrolytes as ordered
-Avoid shivering
Provide fluids, rest and antipyretecs (aspirin (not adults w viral/chilred=Reye syndrome), tylenol, advil), oral hygiene, dry clothing/linens
-Offer blankets during chills, remove when warm
-Prevent shivering as this increases energy demand
-Keep head covered and maintain environment temp |
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Term
| Hypothermia Interventions (below 35 C) |
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Definition
Provide warm environmental temp, heated humidified oxygen, a warming blankey, friction to extremities, and/or warmed oral and IV fluids
Continuous cardiac monitoring
Keep emergency resuscitation equipment on standby |
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Term
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Definition
Rate,
Rhythm
Strength (0=absent, 1+=diminished, weak, 2+=brisk/expected, 3+=Increased, 4+=Bounding)
Equality-symmetrical in quality and quantity |
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Term
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Definition
| apical rate faster than the radial rate |
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Term
| factors leading to tachycardia |
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Definition
| exercise, fever, meds (epinephrine, beta2-adrenergic agonists), changing from lying down to sitting or standing, acute pain, hyperthyroidism, anemia/hypoxemia, stress/anxiety/fear, hypovolemia, shock, heart failure |
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Term
| factors leading to bradycardia |
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Definition
| long term physical fitness, hypothermia, medications (beta blockers, calcium channel blockers), changing from standing or sitting to lying down, chronic pain, hypothyroidism |
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Term
| Infant pulse rate-->normal |
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Definition
120-160 bpm
12-14 year old average = 80-90 bpm
Expected range 60-100 bpm |
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Term
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Definition
located at fifth intercostal space at the left midclavicular line
For assessing HR of an infant, rapid rates (over 100bpm), irregular rhythms, and rates prior to administration of cardiac medications
Always count a full minute |
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Term
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Definition
Tachycardia - assess/monitor for other signs such as pain, anxiety, restlessness, fatigue, low BP or low O2 sats and potentional side/adverse med effects)
Bradycardia - hypotension, chest pain, syncope, diaphoresis, dyspnea, altered mental status, side/adverse affects) |
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Term
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Definition
Ventilation - exchange of o2 and co2 in the lungs; measure with RR, rhythm and depth
diffusion - exchange of o2 and co2 between alveoli and red blood cells; measure with pulse oximetry
Perfusion - flow of blood to and from pulmonary capillaries; measure with pulse oximetry |
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Term
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Definition
Newborns 30-60
School aged children 20-30
Adult 12-20 |
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Term
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Definition
Place in semi-Fowlers with visible chest
Rest arm across abdomen or place hand on their abdomen
Observe one full RR cycle before countinue for 30s if regular |
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Term
| Hypoxemia Interventions (SAO2 below 90%) |
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Definition
-Confirm probe is place properly
-Correlate with Radial or apical
-Confirm O2 delivery system is functioning
-Deep breathing encouragement, possible suctioning, asses for signs and check for hyperthermia
-Place in semi-->Fowlers |
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Term
| Postural (orthostatic) hypotension |
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Definition
BP falls when client changes position from lying to sitting or standing
dizziness, weakness, fainting
May result from: peripheral vasodilation, med side effect, fluid depletion, anemia, prolonged bedrest
Assess: take BP and HR in supine then sitting or standing, wait 1-5 minutes then reassess BP and HR
SBP decreased more than 20mmHG
DBP decreased more than 10mmHG
HR increased 10-20% |
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Term
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Definition
Normal: 120/80
Prehypertension 120-139/80-89
Stage 1: 140-159/90-99
Stage 2: over or equal 160/100
3 separate occasions over several weeks |
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Term
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Definition
Initially measure BP in both arms after client has rested 5 min
If difference is higher than 10mmHg, use the arm with the higher reading for subsequent measurements (may need to report)
-->Feet flat on floor, arm supported at heart level, in chair, 2minutes apart(more if 5mmHG apart) then measure standing
Apply 2cm above antecubital space with brachial artery in line (lower extremity if not available)
Inflate cuff 30mmHg above palpated estimated systolic pressure (deflated and waited 1m)
Release no faster than 3-2 mmHG |
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Term
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Definition
Cuff width should be 40% of arm circumference
Bladder should cover 80% and 100% in children
-If too large-reading will be too low
DO not measure on side with IV infusion or with mastectomy/shunt of fistula present
Infants, older adults (systolic), morning hours, and hours after exercise may show lower BP readings |
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Term
| Hypertension Interventions |
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Definition
Assess/monitor for tachycardia, bradycardia, pain and anxiety although primarily asymptomatic (renal disease, thyroid disease and meds may cause)
Pharmacologival therapy as prescribes
assess risk factors
encourage lifestyle modification: smoking, DASH-dietary=restrict sodium, cholesterol and saturdated fat, promote potassium, calcium and magnesium to lower)
Weight control, alcohol, physical activity, stress reduction
encourage follow ups |
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Term
| Head and Neck Inspection and Palpation |
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Definition
Head-skull,size, depressions, masses, tenderness, deformities, masses, symmetry
Face-symmetry, involuntary movements
CNV (trigeminal) - motor - palpate massester/temporal muscles/joint as client clenches teeth
CNVII (facial) - test symmetrical movement with smiles, frowns, eyebrows, showing teeth, etc
Neck: symmetical muscles, equal shoulders, ROM (chin to chest flexion, ear to shoulder bilateral flexion, chin up hyperextension), CNXI (spinal accessory) - shrug shoulders against resistance
Lymph nodes - nonpalpable, nontender, not visible, use finger pads and move skin over tissue in circular motion
Trachea-inspect/palpate for deviation-should be midline |
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Term
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Definition
bilobed
First, check lower half of clients neck to see if visible then with a sip of water
Repeat from behind as client tips her head forward, use left hand to displace trachea and place right fingers between sternomastoid muscle and trachae
Feel for movement of gland as it moves up with trachea and larynax
Repeat for both sides
If enlarged, auscultate - presence of a bruit indicates abnormal increase in blood flow |
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Term
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Definition
| Visual acuity, Extraocular movements (EOMs), visual fields, external structures, internal structures |
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Term
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Definition
measures CNII (optic)
Use snellen chart with client 20ft from it-ask to read smallest line possible. First number indicated number of feet away, second is distance a normal sighted would be: normal: 20/20: this is used for myopia (impaired far vision)
Presbyopia (impaired near vision) uses Rosenbaum eye chart 14inches from the face
Ishihara test - color vision |
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Term
| Extraocular movements EOMs |
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Definition
determine coordination of eye muscles with three tests (CNIII, CNIV, CNVI)
1. corneal light reflex
2. Strabismus with cover/uncovertest
3. Six cardinal position gaze with H test watching for nystagmus |
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Term
| Externam Structures Abnormalities |
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Definition
-edema/redness in lacrimal gland
-bulging or crossing of eyes
-ptosis: eyelid covers pupil
-Cloudy lense: cataracts
-Illuminated iris: glaucoma |
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Term
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Definition
External Structures
CN II, CN III
P - pupils should be clear
E- equal in size between 3-5cm
R - Round in shape
R - Reactive to light both directly and consensually when a light is directed into one pupil then the other
A - Accommodation of pupils when they dilate to look at an object far and then converge and constrict to focus near |
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Term
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Definition
-optic disk is light pink or more yellow than surrounding retina
-Retina should be without lesions and color will be dark pink, or light pink with lighter skin
-arteries and veins are found at a 2:3 ratio without nicking
-the macula may not be readily visible with pupil dilation but may be briefly glimpsed when looking directly into light |
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Term
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Definition
| palpate lacrimal apparatus to assess for tenderness and to see if discharge is expressed from lacrimal duct. There should be none noted except tears |
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Term
| Ear/Throat/Nose/Mouth cranial nerves |
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Definition
CNVII (acoustic): hearing
CNI (olfactory): smell
CNVII (facial) and CNIX (glossopharyngeal): taste
CNXII (hypoglossal): tongue movement and strength
CNIX and CNX (vagus): mouth movement of soft palate and gag reflex, swallowing and speech |
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Term
| Ear/Throat/Nose/Mouth cranial nerves |
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Definition
CNVII (acoustic): hearing
CNI (olfactory): smell
CNVII (facial) and CNIX (glossopharyngeal): taste
CNXII (hypoglossal): tongue movement and strength
CNIX and CNX (vagus): mouth movement of soft palate and gag reflex, swallowing and speech |
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Term
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Definition
Whisper test - cover one ear, whisper in other: client should hear clearly 30-60cm away
Rinne Test - tuning form against mastoid bone and have client state when they cant hear it, then do it in front of ear: Air conduction greater than bone 2:1 ratio
Weber test: place tuning fork on top of head, ask which ear/both its heard best:should be heard equal in both |
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Term
| Brest inspection positions |
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Definition
Females:
1. arms at side
2. arms above head
3. hands on hips pressing firmly
4. leaning forward
men: in sitting or lying position with arms at the side only |
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Term
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Definition
wear gloves if skin is not intact
feel for lumps using finger pads of four fingers
best position: lying down with arm up by her head and a small pillow under shoulder of side being examined
Palpate using circular, wedge or vertical strip pattern from sternum to posterior axillary line, and from clavicle to the bra line |
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Term
| posterior thorax palpation |
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Definition
align thumbs parallel along spine at the level of the tenth rib with hands flattened around clients back
instruct to take a deep breath and thumbs should move outward approximately 2in during inspiration |
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Term
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Definition
should result in resonance
abnormal:
dullness - fluid or solid tissue (pneumonia or tumor)
hyperresonance - presence of air (pneumothorax or emphysema) |
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Term
| Thorax normal auscultation sounds |
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Definition
bronchial: loud, high-pitched, longer expiration over trachea
Bronchovesicular: medium pitch/intensity: over large airways: equal I&E
Vesicular: soft, low pitched: I 3x E over peripheral areas of lungs |
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Term
| abnormal thorax auscultation sounds |
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Definition
Crackles/rales-fine-course popping as air passes through fluid
Wheeze-high pitched whistling, musical as air passes through narrow/obstructed airway: louder on E
Rhonchi-course heard on I or E from fluid or mucus
Plueral friction rub - grating sound produced as inflamed visceral and parietal pleura rub against each other |
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Term
| Cardiac Cycle and Heart Sounds |
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Definition
S1: lub: closure of mitral and tricuspid valves, signals beginning of ventricular systole (contraction) best at apex
S2: dub: closure of aortic and pulmoic valves, signals beginning of ventricular diastole (relaxation) best at aortic area
S3: venticular gallop: rapid ventricular filling: normal in children and young adults heard with bell best
S4: strong atrial contraction: normal in older and athletic adults and children: bell |
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Term
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Definition
best heard with bell of stethescope
Blood colume is increased in the hearst or the flow is impeded or altered; a blowing or swishing sound will be heard
systolic murmurs: just after S1
diastolic murmurs: just after S2 |
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Term
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Definition
Aortic - R of S at second ICS
Pulmonic - L of S at second ICS
Erbs point - L of S at third ICS
Tricuspid - L of S at fourth ICS
Apical/mitral (apex) - L midclavicular line at fifth ICS |
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Term
| Three positions for optimal heart sound assessment |
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Definition
1. sitting, leaning forward
2. lying supine
3. turned toward the left side (best position for picking up extra heart sounds or murmurs)
use both diaphragm and bell |
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Term
| peripheral vascular system for bruits |
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Definition
carotid arteries: over the carotid pulse
abdominal aorta: just below the xiphoid process
renal arteries: midclavicular lines above umbilicus on abdomen
Iliac arteries: midclavicular lines below umbilicus
Femoral arteries: over femoral pulses |
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Term
| Blumbergs sign-Rebound tenderness |
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Definition
indication of irritation or inflammation somewhere in abdominal cavity, done in all four quadrants
-apply firm pressure for four seconds with hand at 90 degree angles and fingers extended
-After releaseing pressure, observe clients response to see if pain was elicited and ask
Never deep palpate abdominal mass, tender organs or surgical incisions |
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Term
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Definition
Pallor: loss of color (best noted in face, conjunctivae, nail beds and palms): anemia or lack of blood flow
Cyanosis: bluish (best noted in nail beds, mouth, skin): hypoxia or impaired venous return
Jaundice: yellow-orange of skin, sclera and mucous membranes: liver dysfunction, red blood cell destruction
Erythema: redness (best noted in face, trauma and pressure sore areas): inflammation
shiny/translucent skin without hair on toes and foot is seen with arterial insufficiency |
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Term
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Definition
Macule: nonpalpable, skin color change <1cm - freckle
Papula: palpable, circumscribed, <.5cm - elevated nevus
Nodule/tumor: palpable, circumscribed >.5cm - wart
Vesicle: serous fluid filled < 1cm - blister
Pustule: pus-filled - acne
Wheal: palpable, irregular borders, edematous - insect bite |
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Term
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Definition
Erosion: Lost epidermis, moist surface, no bleeding - ruptured vesicle
Crust: dried blood, serum or pus - scab
Scale: flakes of skin that exfoliate - dandruff
Fissure: linear crack
Ulcer: loss of epidermis and dermis with possible bleeding/scarring - PU |
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Term
| Common spine abnormalities |
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Definition
Kyphosis: exaggerated curbature of the thoracic spine, common in older adults
Lordosis: exaggerated curvature of the lumbar spine; common during toddler years and pregnany
Scoliosis: exaggerated lateral curvature |
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Term
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Definition
Alert – The client is responsive and able to fully respond by opening the eyes and attending to a normal tone of voice and speech. Answers questions spontaneously and appropriately.
Lethargy – The client is able to open the eyes and respond, but is drowsy and falls asleep readily.
Obtundation – The client needs to be lightly shaken to respond, but may be confused and slow to respond.
Stupor – The client requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief
response. The client may not be able to respond verbally.
Coma – There is no response to repeated painful stimuli. |
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Term
| Abnormal Comatose Positioning |
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Definition
Decorticate rigidity – Flexion and internal rotation of upper extremity joints and legs
Decerebrate rigidity – Neck and elbow extension, with the wrists and fingers flexed |
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Term
| Mini-Mental State Examination (MME) |
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Definition
objectively assesses cognitive status
-orientation to time and place
-attention and calculation by counting backwards by 7s
-Registration and recalling of objects
-Language, including naming of objects, following of commands, and the ability to write |
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Term
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Definition
baseline assessment of the client’s level of consciousness for ongoing assessment
This assessment looks at eye, verbal, and motor response, and assigns a number value based on the client’s response. The highest value possible is 15, indicating the client is awake and responds appropriately. A score of 3 indicates the client is in a coma. |
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Term
| Nuerological Screening Exam includes |
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Definition
Mental status examination to test cerebral function
Assessment of cranial nerves
Motor function to test cerebellar function
Sensory function
Reflexes |
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Term
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Definition
Two-point discrimination – Use open paper clips to determine the distance at which the two points are felt as one. Compare bilaterally. Minimal distance will vary depending on the body part being evaluated.
Stereognosis – Use a familiar object (key, cotton ball) placed in the client’s hand, and ask him to identify it.
Graphesthesia – Ask the client to identify a number drawn on his palm with the blunt end of a pencil. |
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Term
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Definition
◯◯ 4+ = Very brisk with clonus
◯◯ 3+ = More brisk than average
◯◯ 2+ = Expected
◯◯ 1+ = Diminished
◯◯ 0 = No response
biceps - flexion of the elbow
brachioradialis - flexion of elbow and pronation of the forearm
triceps - extension of the elbow
patellar - extension of the lower leg
achilles - plantar flexion of the foot |
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