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