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HEALTH ASSESSMENT

QuestionAnswer
4 broad goals of professional nurses to promote health to prevent illness to treat human responses to health or illness to advocate for individuals, families, communities, and population
Health assessment Gather information analyzing and synthesizing making judgments about nursing interventions evaluating patient care outcomes
primary prevention avoid from getting anything immunization, washing hands, education
secondary prevention early identification of illness exams, blood test
tertiary prevention avoid illness from getting worse preventing from recurrence, take medication on time
subjective and symptoms what the patient tells you
objective and signs what you see or notice about patient
3 types of assessment Emergency Focused Comprehensive
emergency assessment short, life threatening
focused assessment based on patients problem
long term care assessment once a month
intensive care assessment every min or hr
3 major framework of assessment functional assessment head to toe assessment body system assessment
general survey begins when you first meet client physical appearance mental status mobility behavior
vital signs temp pulse res rate bp O2 pain
BP systolic: ventricular contraction diastolic: ventricular relaxation
factors affect BP age gender race diurnal medication personal habits pain emotions obesity
KOROTKOFF sound phase 1: sharp thuds, start of systolic bp phase 2: blowing sound phase 3: crisp thud phase 4: sounds become muffled phase 5: end of sound, ends at diastolic bp
false high BP measurement arm above heart level loose cuff narrow cuff deflating very slow re-inflating without deflating completely not waiting 1-2 min before repeat
false low BP measurement hand below heart level cuff too wide manometer higher than heart deflating to fast not inflating enough pressing firmly on diaphragm
BP in adult normal 120/80 prehypertensive 120-139/80-89 stage 1 hypertension 140-159/ 90-99 stage 2 hypertension more than 160/100
Temperature regulated by hypothalamus
factor affect Temp age diurnal variation: decrease in morning, increase in late afternoon and evening menstrual cycle: decrease exercise: increase stress: increase
sites of temp axillary: 96.7-98.5 6-9 min oral: 97.7-99.5 2-3 min rectal: 98.7-100.5 2-3 min tympanic: 98.2-100 2-3 sec temporal: 98.7-100.5
Normal HR adult: 60-100 newborn: 120-170 1 yr: 80-160 3 yr: 80-120 6 yr: 75-115 10 yr: 70-110
orthostatic hypotension drop in BP as you stand
signs and symptoms of hypertension HA flushing ringing in the ear nose bleed
sign and symptoms of hypotension increase HR dizziness cool clammy
hyperthermia very high fever
hypothermia very low fever
febrile fever
afebrile without fever
factor affect pulse increase with exercise, fever, and stress decrease with male, age, and athletes
bradycardia slow pulse
tachycardia fast pulse
respiration ventilation: movement of gases diffusion: movement of oxygen and carbon perfusion: distribution of red blood cells
tachypnea fast respiration
bradypnea slow respiration
apnea no respiraiton
dyspnea difficult breathing
orthopnea difficult breathing lying down
preinteraction review of medical record before interviewing the patient
factor affect interview physical setting nurse behaviors type of questions and how they are asked personality and behavior of clients
active listening concentrate on clients response don't formulate next question don't make assumptions
facilitation encourage client to continue talking
clarification gather more information about conflicting
restatement repeating what client says using different words
reflection repeating a phrase client just said to indicate interest
confrontation inconsistencies between what client reports
interpretation sharing conclusions
summary orders data to clarify sequence of events
techniques that diminish data collection using medical terminology expressing value judgments interrupting the client or changing the subject being authoritarian using why question
symptom analysis C: characteristics O: onset L: location D: duration S: severity P: precipitating factor A: alleviating/ aggravating factors T: treatment
pruritus itching
turgor skin elasticity
edema accumulation of fluid in intracellular spaces
nail flat/slightly rounded(convex) nail base angle 160 capillary refill 1-2 sec
cyanosis blue
pallor white
jaundice yellow
erythema redness
ecchymosis bruising
telangiectasia irregular red line caused by dilation of blood vessels
cherry angioma benign tumor, small slightly raised bright red area on face, neck, and trunk
purpura reddish purple, non blancheable
petechiae flat reddish purple, non blancheable
capillary hemangioma port wine stain, stork bite
vascular spider telangiectasia with radiating spider legs, blancheable
venous star telangiectasia, non palpable, flat, bluish star-shaped lesion
assessment of mole melanoma A: asymmetry B: border irregularity C: color uneven D: diameter > 6mm E: evolved or changed over time F: feeling (itch, tingle, sting)
primary lesions macule or patch papule or plaque nodule or tumor vesicle or bulla wheal pustule cyst
abnormal nail finding clubbing hypertrophy thinning/brittleness koilonychia inflammation pitting leukonychia beau's lines
types of headaches migraine cluster tension post traumatic
migraine headaches start anytime young females most susceptible 72 hrs unilateral pain photophobia
cluster headaches painful 30-40 yrs common in men 1/2 to 1 hr repeat daily behind one eye
tension headaches 20-40 yrs bilateral to specific area last for days skeletal muscle of face and jaw tight band around head
post traumatic headaches secondary to head injury common cause motor vehicle accident days to weeks after injury
hyperthyroidism graves disease most common cause 20-40 females
hypothyroidism autoimmune
hydrocephalus abnormal accumulation of CSF
microcephaly head is too small genetic, chromosomal, toxic stimuli
macrocephaly head is too big defective embryonic development or degenerative disease
nasal discharge color clear: normal white: infection viral yellow, green: infection bacteria
infant mouth drooling at 3 month or until able to swallow teeth 6-24 month
children mouth frontal sinuses absent until 7-8 yrs permanent teeth 6 to 18 yrs
allergic rhinitis inflammation of nasal mucosa
Epistaxis nosebleed cause by un-control hypertension
candidiasis/thrush opportunistic infection soft white plaques on tongue, buccal mucosa, posterior pharynx
shape ribs 45 degrees to spine coastal angle less than 90
fine rales/crackles high pitched crackling collapsed or fluid filled alveoli
coarse rales/crackles loud, low-pitched bubbling collapsed or fluid filled alveoli
wheezes high-pitched blocked airway due to inflammation
ronchi low-pitched, snoring, rattling blocked airway due to inflammation plus fluid
stridor loud, high-pitched crowing upper airway is blocked
friction rub low-pitched grating plueral inflammation
infant resp round thorax nose breathers until 3 months 10-15 sec apnea seesaw breathing
grunting try of force trapped air out of lungs
acute bronchitis inflammation of bronchial tree caused by viruses or bacteria
chronic bronchitis inflammation of bronchial tree productive cough 3 months of 2 successive years
pneumonia infection of terminal bronchioles/alveoli caused by bacteria, fungi, viruses
tuberculosis bacterial infectious disease
pleural effusion fluid in the pleural linning
empyema purulent/pus in pleural lining
asthma hyper reactive airway disease
emphysema abnormal enlargement of air spaces
pneumothorax air entering plural space
hemothorax blood in plural space
atelectasis accumulation of secretions in terminal bronchiole
s1 louder in mitral and tricuspid
s2 louder in aortic and pulmonic
s1 and s2 lub dub
veins take deoxygenated blood to lungs
artery bring oxygenated blood back to the heart
apical pulse point of maximum impulse
homan's sign to assess DVT
s3 ventricular gallop ken-tuck-y
s4 atrial gallop ten-es-see common in older adult
murmurs swishing or blowing sound heard at beginning, middle, pr end of the systolic or diastolic phase
strength pulse 0: absent, not palpable 1+: pulse diminished, barely palpable 2+: easily palpable, normal 3+: full pulse 4+: strong, bounding pulse
left side HF failure of ventricles to pump blood efficiently pulmonary edema precordial movement bilateral pulmonary crackles
right side HF cell necrosis from infarction blood backs up in right atrium systolic murmur dependent peripheral edema
venous insufficiency color: normal or cyanotic temp: normal pulse: normal edema: often marked skin: brown pigmentation around ankles
arterial insufficiency color: pale, dusky red temp: cool pulse: decreased or absent edema: absent or mild skin: thin, shinny
ascities accumulation of fluids
peptic ulcer disease lower end of esophagus, stomach, or duodenum
crohn's disease inflammation mouth to anus, most common terminal in ileum and colon
ulcerative colitis chronic IBD starts in rectum and progresses through large intestine
diverticulitis inflammation of diverticula, herniations through muscular wall in colon
viral hepatitis inflammation of liver
cirrhosis chronic degenerative liver disease, diffuse destruction/regeneration of hepatic parenchymal cell
cholecystitis with cholelithiasis inflammation of gallbladder with gallstone
pancreatitis acute or chronic inflammation resulting from auto digestion of the organ
cystitis urinary bladder infection
urethritis urethra infection
pyelonephritis renal pelvis infection
glomerulonephritis inflammation of renal glomeruli caused by autoimmune process
nephrolithiasis formation of stones in kidney pelvis
Barlow-Ortolani maneuver birth-2 month adduct/abduct test for infants
osteoporosis genetic one side risk for fracture
rheumatoid arthritis genetic both side stiffness ulnar deviation swan neck deformity
osteoarthritis degenerating cartilage joint deformities heberden's bouchard's nodes
gout increase in serum uric acid tophi: round pea-like deposits
phalen's and tinels sign test for carpal tunnel syndrome
CN 1-12 1 olfactory 2 optic 3 oculomotor 4. trochlear 5. trigeminal 6. abducens 7. facial 8. auditory 9. glossopharyngeal 10. vagus 11. spinal accessory 12. hypoglossal
plantar test to assess Babinski response
Glasgow coma scale assess LOC using 15 points
PERRLA pupils equal round reactive to light and accommodation
ptosis dropping
consensual and direct to light light on left right constrict and light on right left constrict
rosenbaum test to assess CN 2
infants eyes peripheral vision developed at birth, central vision at 9-12 month 1 month: can fixate, follow light 2-3 month: tears, may see strabismus 3-4 month: fixate, follow n reach for toy 6-12 month: follow a toy in all direction 8 month: distinguish color
allen picture card test 2.5 to 3 yrs
snellen's E chart test 3 to 6 yrs
snellen's chart test 7 to 8
presbyopia loss of lens elasticity
cataract denaturation of lens protein caused by aging blurred vision can also be cause by trauma to eyes
diabetic retinopathy caused by diabetes mellitus common in 20 to 75 dark spot in vision 2 types background and proliferative
glaucoma damage retina by intraocular pressure leading cause of blindness in USA center is okay and peripheral is bad 2 types: open and closed angle
Macular degeneration caused by hypertension common in 65 and up center is bad and peripheral is okay
tinnitus ringing in ears
vertigo when the room is moving/spinning
dizziness when you are moving/spinning
ear is called what auricle or pinna
helix the hard part of ear
cauliflower ear are called what boxers ear
normal tympanic membrane pearly gray and concave
ear assessment under 3: pull down over 3: pull up adult: pull up and back
Created by: anuali