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H&P Assessment

Health and Physical Assessment HESI Final -SRTC

TermDefinition
mental status exam an inappropriate appearance and poor hygiene may be indicative of depression, manic disorder, dementia, organic brain disease, or another disorder.
physical exam-assessment techniques the first assessment technique, which uses vision and sell senses while observing the client
palpation light palpation is done with 1 hand by pressing the skin gently with the tips of 2 or 3 finders held close together; deep palpation s done by placing 1 hand on top of the other and pressing down with the fingertips of both hands
body systems assessment integumentary system: involves inspection and palpation of skin, hair, and nails
cyanosis check lips and tongue for a gray color; nail beds, palms, and soles for a blue color; and conjunctive for pallor
jaundice check oral mucous membranes for a yellow color; check the sclera nearest to the iris for a yellow color
bleeding look for skin swelling and darkening and compare the affected side with the unaffected side
inflammation check for warmth or a shiny or taut and pitting skin area, and compare with the unaffected side
to test skin turgor pinch a large fold of skin and assess the ability of the skin to return to its place when released. poor turgor occurs in severe dehydration or extreme weight loss
head, neck, and lymph nodes ask the client about headaches, episodes of dizziness (lightheadedness) or vertigo (spinning sensation)
neck to test cranial nerve XI (spinal accessory nerve) to assess muscle strength: ask client to push against resistace applied to side of chin (tests sternocleidomastoid muscle) ask client to shrug the shoulders against resistance ( tests trapezius muscle)
thyroid gland palpate using an anterior-posterior approach(usually the normal adult thyroid cannot be palpated); if it is enlarged, auscultate for a bruit
lymph nodes if nodes are palpated, note their size, shape, location, mobility, consistency, and tenderness
client teaching instruct client to notify HCP if persistent headache, dizziness or neck pain occurs, if swelling or lumps are noted in the head and neck region; or if a neck or head injury occurs
eyes includes inspection, palpation, vision-testing procedures, and the use of an ophthalmoscope
eyes: objective data eyelids for ptosis (drooping); eyeballs for exophthalmos (protrusion) or enophthalmos (recession into the orbit; sunken eye)
eyes: objective data 2 inspect the conjunctiva (should be clear) sclera (should be white), and lacrimal apparatus (check for excessive tearing, redness, tenderness, or swelling)
Snellen eye chart normal visual acuity is 20/20
near vision normal results is 14/14
confrontation test a crude but rapid test used to measure peripheral vision and compare the clients peripheral vision with the nurses
documenting normal findings (PERRLA) P=pupils E=equal R=round RL=reactive to light A=reactive to accommodation
sclera and cornea normal sclera color is white the cornea is transparent, smooth, shiny, and bright
ear includes inspection, palpation, hearing tests, vestibular assessment, and the use of an otoscope
tuning fork tests used to measure hearing on the basis of air conduction or none conduction; includes the weber and rinne tests
fine crackles high-pitched cracking and popping noises (discontinuous sounds)heard during the end of inspiration. not cleared by cough
medium crackles medium-pitched, moist sound heard about halfway through inspiration. not cleared by cough
coarse crackles low pitched, bubbles or gurgling sounds that start early in inspiration and extend into the first part or expiration
wheeze(also called sibilant wheeze) high-pitched, musical sound similar to a squeak. heard more commonly during expiration, but may also be heard during inspiration. coughing may be clear
plural friction rub a superficial, low-pitched, coarse rubbing or grating sound. sounds like 2 surfaces rubbing together. heard throughout inspiration and expiration. loudest over the lower anterolateral surface. not cleared by cough.
breasts assess size and symmetry (1 breast is often the other); masses, flattening, retraction, or dimpling; color and venous pattern; size, color, shape and discharge in the nipple and areola; and the direction in which nipples point
palpation the nurse uses the pads of the first three fingers to compress the breast tissue gently against the chest wall, noting tissue consistency
radius pulse located at the radial side of the forearm at the wrist
ulnar pulse located on the opposite side of the location of the radial pulse at the wrist
brachial pulse located above the elbow at the antecubital fossa, between the biceps and triceps muscles
femoral pulse located below the inguinal ligament, midway between he symphysis pubis and the anterosuperior iliac spine
popliteal pulse located behind the knee
dorsalis pedis pulse located at the top of the foot, in line with the groove between the extensor tendons of the great and first toes
posterior tibial pulse located on the inside of the ankle, behind and below the medial malleolus (ankle bone)
grading the force 4+=strong and bounding 3+=full pulse, increased 2+=normal, easily palpable 1+=weak, barely palpable
lordosis (swayback) increased lumbar curvature
kyphosis (hunchback) exaggeration of the posterior curvature of the thoracic spine
scoliosis lateral spinal curvature
musculoskeletal changes strength and function of muscles decrease. joints become less mobile and bones become brittle. postural changes and limited range of motion occur
nervous system changes voluntary and autonomic reflexes become slower. decreased ability to respond to multiple stimulus occur. decreased sensitivity to touch occurs.
sensory changes decreased vision and lens accommodation and cataracts develop. delayed transmission of hot ad cod impulses. impaired hearing develops, with high-frequency tones less perceptible
genitourinary changes increased nocturia and occurrences of incontinence may occur
anthrax:skin spores enter skin through cuts and abrasions, are contracted by handling contaminated animal skin products. infection starts with itchy bump like mosquito bite that progresses to small liquid-filled sac. become painless ulcer with area of blak dead tissue
anthrax: gastrointestinal infection occurs following the ingestion of contaminated undercooked meat. symptoms begin with nausea, loss of appetite, and vomiting. the disease progresses to severe abdominal pain, vomiting or blood and severe diarrhea
Child Biographical Data name, nickname, address, phone number, parents' names and work #s, age, DOB, birthplace, sex, race, and information on family members in home
Reason for Seeking Care record the parent's spontaneous statement. reasons for health problems may be initiated by the child, parent, or third party.
Health History present or past illness and wellness visits, describe any presenting symptom or sign, using the same format as an adult. considerations: severity of pain, the effect of pain on usual behavior.
Past Health start with an open question. record the mother's use of alcohol, street drugs. or cigarettes, and any x-ray studies taken during pregnancy.
Labor and Delievery (L&D) parity of mother, duration of the pregnancy, name of the hospital, course and duration of labor, use of anesthesia, type of delivery, birth weight, etc
Childhood Illnesses age and any complications of measles, mumps, rubella, chicken pox, whooping cough, strep, and frequent ear infections. any recent exposure to illness
Serious Accidents or Injuries age of occurrence, extent of injury, how the child was treated, and complications of auto accidents, falls head injuries, fractures, burns, and poisonings.
Serious or Chronic Illness age of onset, treatment, complications of meningitis or encephalitis, seizure disorders, asthma, pneumonia, and other chronic lung conditions, rheumatic fever, scarlet fever, diabetes, kidney problems, sickle cell anemia, high blood pressure, & allergies
Operations/Hospitalizations reason for care, age at admission, name of surgeon or primary care providers, name of the hospital, duration of stay, child behavior, complcations
Immunizations immunizations do not start until infant is 6-8wks and bc of this it is important to put on the family to be up to date on vaccines. measles- first dose age 12-15 months; second 4-6 yrs pertussis (whooping cough)- 3-5 yrs
Allergies any drugs, foods, contact agents, and environmental agents to which the child is allergic and the reaction to the allergens. common in childhood-rhinitis, insect hypersensitivity, eczema, and urticaria
Medications any prescription and OTC medications or vtamns that the child takes including the dosage, daily schedule, why the medication is given, and any problems.
Developmental History growth height, and weight at birth, and ages (1, 2, 5, & 10) any periods of rapid gain or loss.
Process of Dentition age of tooth eruption and pattern of loss
Milestones age when child first held head erect, rolled over, walked alone, cut first tooth, said words with meaning, spoke in sentences. normal? compare with siblings and peers
Nutritional History the amount of information needed depends on the child's age. the younger the child the more detailed
Family Hx includes siblings, parents, grandparents. heart disease, hypertension, diabetes, blood disorder, cancer, sickle cell anemia, arthritis, allergies, obesity cystic fibrosis, mental illness, seizure disorder, kidney disease, mental retardation, etc
Review of Systems significant gain or loss of weight, failure to gain or lose weight, frequent illness, ear infections, illnesses, energy level. skin disease
Health promotion use of eyeglasses, date of last vision screening
Adolescent Health Review psycho-social review of symptoms intended to maximize communication with youth. interview alone w/o parents
HEEADSSS method of interviewing focuses on home environment, education and employment, eating, peer-related activates, drugs, sexuality, suicide/depression, and safety.
minimizes adolescent stress bc it moves from expected and less-threatening questions to those that are more personal. It presents the questions in colors. green- essential blue- important if time permits red- in depth per situation Why is HEEADSSS tool used? What are the color codes?
teenagers should get about 9 hours asleep How many hours of sleep a night should an adolescent get?
Orientation the awareness of the objective world in relation to the self. able to name own person, place, and time.
Interpreter clients with language barriers experience many negative health outcomes when interpreter not used & have longer hospital stays.
Pt w/ language barrier at risk for unnecessary testing, discharged without follow-up appointment, more likely to be readmitted to hospital or admitted to hospital.
Keratin epidermis is thin but tough. cells are bound tightly together into sheets that form a rugged protective barrier. it is stratified into several zones. the inner basal layer.
Breast Exam use the pads of our first three fingers and make a gentle rotary motion on the breast. vary your pressure so yo are palpating light, medium, and deep tissue in each location the vertical strip pattern, best way to detect a mass, arrange specific pattern
Organs absent from pain in the brain. pain originating in these organs is referred bc no felt image exits in which to ave pain Pain is felt "by proxy" by another body part that does have felt image heart, liver, and spleen heart may be felt in chest, shoulder and left arm spleen- on the top of the left shoulder
Barrell Chest note equal AP to transverse diameter and that ribs are horizontal instead of the normal downward slope. this is associated with normal aging and also with chronic emphysema and astha as a result of hyperinflation of lungs
Hyperthyroidism also called, MYXEDEMA- a defieciency of thyroid hormone means that the thyroid funace is cold. this reduces the metabolic rate and when severe causes a nonpittig edema or myxedema.
Myedema or Hyperthyroidism puffy, edematous face.. especially in eyes (periorbital edema), puffy hands and feet, coarse facial features; cool, dry skin, and dry coarse hair and eyebrows
Auscultation listening to sounds produced by the body. such as the heart and blood vessels and the lungs and abdomen
BSE (Breast Self Exam) best time to perform this procedure is after a menstrual period when breast are smallest and most congested, menopausal or pregnant women should choose a familiar date as a reminder.
Crepitus a coarse, crackling sensation palpable over the skin surface. it occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue , as after open thoracic injury or surgery
Crepitus irregular bony margins occur with osteoarthritis, pain at joint line, significant, and can occur with degenerative diseases of the knee
Normal Breath Sounds have pt sitting, leaning forward slightly, with arms resting comfortable across the lap. instruct to breathe through the mouth . a little bit deeper than usual, but stop is dizziness occurs
Bronchial (Tracheal) pitch-high amplitude- loud durataion- inspiration < expiration quality- harsh, hollow tubular location- trachea and larynx
Bronchovesic;ular pitch- moderate amplitude- moderate duration- inspiration = expiration quality- mixed location- over major bronchi where fewer alveoli are located
Vesicular pitch- low amplitude- soft duration- inspraion> expiration quality- rustling, like the sound of trees location- over peripheral lung fiels where air flows through smaller bronchioles and alveoli
Allen Test- ulnar artery used to evaluate the adequacy of collateral circulation before cannulating the radial artery.
Created by: Jlewis8775