Health Assessment Exam 1

The nurse demonstrates understanding of the proper use of a stethoscope when making which statement? (Select all that apply)

"When using the bell, apply it lightly to the skin surface." "I will use the bell to hear low frequency sounds"

Skin type VI

- marked constitutional pigmentation - black

Skin type III

- may burn, usually tans - darker skin

Skin type II

- usually burns, sometimes tans - fair skin

Heart position

-Vertically from 2nd to 5th intercostal space (ICS) -Horizontally from right border of sternum to the left midclavicular line (MCL)

Angina

-cardiac chest pain -may also be accompanied by diaphoresis, dyspnea, palpitations, nausea, pallor, tachycardia

Papule

-elevated, palpable, solid mass -circumscribed border -less than 0.5cm

Nodule

-elevated, sold, palpable mass than extends deeper into the dermis than a papule -0.5-2cm circumscribed

Stage 4 ulcer

-full thickness loss with exposed bone, tendon, and muscles -often includes tunneling or undermining

Stage 3 ulcer

-full thickness tissue loss -subcutaneous fat may be seen -you do not see bone, tendon, or muscle

Unstageable ulcer

-full thickness tissue loss in which the base of ulcer is covered with slough or eschar -you cannot see the full picture so cannot stage

Myocardium

-muscular wall of the heart -thickest layer does the pumping

SA node (sinoatrial node)

-pacemaker of the heart -electrical impulse of the heart originates in the right atrium

Stage two ulcer

-partial thickness loss of dermis -shallow open ulcer with red pink wound bed -no slough -not to be used to describe skin tears, tape burns, perineal dermatitis, macerations, or excoriation

Petechia

-round red or purple macule -one to two mm in size

Murmurs

-turbulent blood flow -defects or malfunctions of valves -abnormal chamber openings -increased blood velocity (speed)

Steps of Health Assessment

1. Collection of subjective data 2. Collection of objective data 3. Validation of data 4. Documentation of data

Normal BMI

18.5-24.9

Left lung has how many lobes?

2 lobes

Right lung has how many lobes?

3 lobes

Obese BMI

>30

Vesicle

A membrane bound sac that contains materials involved in transport of the cell.

Culture

A pattern of shared attitudes, beliefs, self-definitions, norms, roles, and values that can occur among those who speak a particular language or live in a defined geographical data

Communication

A process of interaction between two people in which symbols are used to create, exchange, and interpret messages about ideas, emotions, and mind states

Systole

AV valves close > first heart sound = S1

Diastole

AV valves open, ventricles relax and fill the blood

Coping

An ever changing process involving both cognitive means and behavioral actions, in order to manage internal or external situations that are perceived as difficult and/or beyond the individual's current resources

Stress

An internal or external event or demand of life expectancy by the individual that is perceived and appraised for scope and meaning on a continuum to determine whether resources and abilities for management are available, exceeded, or exhausted

Egophony

Ask client to repeat the letter "E" while you listen over chest wall

Use of ABCDE to detect skin cancer

Asymmetry Borders (irregular) Color variations Diameter (diameter exceeding 6mm) Evolution (changes over time)

Check for bruits with

Bell of stethoscope

Cyanosis

Blue discoloration of skin

Swishing sounds indicates

Bruits

CAGE assessment tool

C - Have you ever felt you ought to CUT down on your drinking? A- Have people ANNOYED you by criticizing your drinking? G- Have you ever felt bad or GUILTY about your drinking? E - Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over (EYE-OPENER)? Scoring two "yes" answers indicate a probable alcohol abuse and warrants further assessment.

COLDSPA

C-character O- onset L- location D-duration S- severity P- Pattern A- Associated factors

spinder angioma

Central Red Papule with feeding capillary legs -found on face, neck, arms, and trunk

Annular lesion

Circular lesions

What do ventricles do

Contract and force blood out of the heart

Which concept is defined: "An ever changing process involving both cognitive means and behavioral actions, in order to manage internal or external situations that are perceived as difficult and \or beyond beyond the individual's current resources"

Coping

Apical pulse

Count for 1 minute

Bronchi

Dead space: air travels through it, but no gases are exchanged. Lined with mucous membrane containing cilia

Sinus headache

Deep constant + throbbing (on sinus cavities)

Barrel chest

Diameter is 1:1, uses accessory muscles to breathe, fremetis is non symmetrical and chest expansion is unequal

Types of percussion

Direct, Blunt, Indirect

Orthostatic hypotension

Drop in systolic of >20mm/Hg or increase in pulse of >20 beats with quick change of position

Tension headache

Dull, tight, diffuse (full frontal/forehead)

How do you record electrical impulses that travel throughout the heart?

ECG

Which statement best describes an S4 sound when auscultating heart sounds?

Heard late in Diastole

Kyphosis

Humpback

A geriatric patient comes into the clinic. Which statement by the patient would indicate normal aging process ?

I sweat less than my great grandson

When does temp peak

In the afternoon

Discrete lesion

Individual and distinct lesions

Order of physical exam

Inspect, palpate, percussion, auscultation

Acromegaly

Large head

When palpating a patient's posterior thorax, which sequence is the best practice?

Left to right, down and out

Thoracic cavity consists of

Mediastinum and lungs

Skin type V

Moderate constitutional pigmentation-- Latin American and middle eastern

RR

Number of respirations

OLDCARTS

Onset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Treatment Severity

Purpose of respiration

Oxygenation

A nurse is performing a physical examination on a new client. Which of the four basic physical examination techniques would the nurse perform third?

Percussion

Skin type IV

Rarely burns, always tans Mediterranean

Respiration Rhythm

Regular or Irregular

Documentation/Terminology

Represented by the idea that health IT and health informatics intersect with the science of health practices and serve as an infrastructure to support and promote a continuously learning healthcare system

Semilunar valves closes > second heard sound

S2 in Systole

The nurse palpating for fremitus would give what instructions to the client?

Say the number 99 for me

Respiration Depth

Shallow, regular, or deep

Microcephaly

Small head

Cluster Headache

Stabbing pain (around eye)

When examining a client's coccyx area, the nurse notes a redden area that is NOT blanchable . How would this be documented?

Stage one pressure injury

Endocardium

Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

How do you auscultate the neck/thyroid

Use the bell of the stethoscope, have pt hold her breath

Skin type I

Usually burns, never tans; pale skin red hair, freckles

When examining a client's skin the nurse notes an elevated mass, irregular, with transient borders on the arm. How would this be documented?

Wheal

Reducing the volume of the pleural fluid can cause:

a friction rub between the layers (ex: severe dehydration)

Seborrheic keratosis

a warty or crusty pigmented lesion

Amplitude 0

absent pulse

Tumor related headache

aching, steady, neurological and mental symptoms

Ongoing Health Assessment

also known as a follow-up assessment and is conducted at regular intervals

what is stroke volume

amount of blood pumped with each beat; we feel as the pulse

Inflammation

an immunological defense against tissue injury, infection, or allergy

Both atria contract

and send blood into the ventricles

All People Eat Taco Meat

aortic pulmonic erb's point tricuspid mitral (apical)

peds head circumference

approx. 2cm larger than the chest in newborns + the same in 6 months-2yrs + less > 2 yrs

whispered pectoriloquy

ask client to whisper the phrase "one, two, three" while you auscultate the chest wall

Bronchophony

ask the client to repeat 99

Focused Health Assessment

assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient

sternal angle (angle of Louis)

bony ridge that can be palpated at the point where the manubrium with the body of the sternum

Amplitude 3+

bounding pulse

Comprehensive Health Assessment

broad health assessment that includes a complete health history and physical assessment; it is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments

What happens when you flex the neck

c7 is visible

Cyst

can be semisolid mass, encapsulated fluid filled mass that is located in subcutaneous tissue or dermis

Pulmonary artery

carries blood too lungs

Older adult considerations with chest pain

chest pain related to pleuritis may be absent inn older clients because of age related alterations in pain perception

S1

closure of AV valves (mitral and tricuspid) -lub -usually heard as one sound -loudest over apex

S2

closure of semilunar valves (aortic and pulmonic) -dub -loudest at the base

Nummular lesions

coin shaped lesions

Manubrium

connects laterally with the clavicles and first 2 pairs of ribs

Visceral pleura

covers the external surface of the lungs

Lunula

crescent shaped area located at base of nail

Decreased jugular venous pressure

decreased output from left ventricles or reduced blood volume

Pulse Pressure

difference between systolic and diastolic

Abnormal JVP

distended jugular vein with head of bed at 45 degrees or more

Oral temp

easiest, use sublingual pocket

Nail body

extends over nail bed, pink

dysrhythmias

extra or missed beats (this is common)

Trachea

flexible structure that lies anterior to the esophagus

Eccrine glands

for sweat and thermoregulation, all over body

temporomandibular joint (TMJ)

formed at the back of the mouth where the maxillary and mandibular arches come together

Pigeon chest (precuts carinatum)

forward protrusion of sternum causing adjacent ribs to slope backward

optimal nutrition

getting just the right amount of nutrients

Plaque

greater than 0.5cm coalesced papule with flat top ex: psoriasis

S3

heard easily in diastole after S2 (Ken-tuc-ky)

S4

heard late in diastole just before s1 (Ten-nes-see)

Stethoscope diaphragm

high pitched sounds

suprasternal notch

hollow U-shaped indentation located on the superior border of the manubrium

When is temp the lowest

in the morning

Stage one ulcer

intact skin, nonblanchable redness of localized area, may be difficult to detect with dark skin tones

Wheal

irregular, caused by movement of serous fluid into dermis

Clustered lesion

lesions grouped together

Aging adult

less sq fat, aorta and arteries harden so BP increases

Vesicle

less than 0.5cm not solid

Base of lung

level o the diaphragm

Plueral space

lies between the two pleural layers

parietal pleura

lines the chest cavity

Peripheral Cyanosis

local problem, vasoconstriction

Hematoma

localized collection of blood, trauma

Cutaneous horn

located on ears

Terminal hair

longer (scalp and eyebrows)

Palpate

look for texture, temp, moisture, mobility, consistency, etc

Stethoscope bell

low pitched sounds

Preauricular

lymph node in front of ear

Funnel Chest (Pectus Excavatum)

markedly sunken sternum and adjacent cartilages

Rectal

measures 1 degree higher than oral

Axillary temp

measures 1 degree lower than oral

Breathing is controlled by

medulla oblongata and pons

Migraine

nausea, vomiting, sensitive to light or sound (one sided)

Amplitude 2+

normal pulse

Bulla

not sold greater than 0.5cm

Normal JVP

not visible sitting upright

Sebum

oily substance that waterproofs hair and skin

Pallor

pale with pink undertone

Vellus Hair

peach fuzz; short, pale, fine, and present all over body

Pustule

pus-filled vesicle or bulla

Cutaneous tag

raised papule with a depressed center

Jugular Venous Pulse

reflects function of the right side of the heart

Central cyanosis

result from cardiopulmonary problem; look in oral mucosa

Superior + inferior vena cava

return blood from circulation to heart

Pulmonary veins

return oxygenated blood to heart

Cardiac cycle

rhythmic filling and emptying of heart chambers

Increased jugular venous pressure

right sided heart failure

Ecchymosis

round or irregular macular lesion, larger than petechia

Cherry angiomas

small raised spots typically seen with aging

Confluent lesions

smaller lesions run together to form a larger lesion

Carotid artery palpation

smooth, rapid upstroke and slower downstroke

Apocrine gland

start at puberty, secrete a milky sweat

Arteriosclerosis

stiff arteries

Linear lesion

straight line, scratch

Striae

stretch marks

Crepitus

subcutaneous emphysema; crackling sensation

Older adult considerations with cough

the ability to cough effectively may be decreased in the older client because of weaker muscles and increased rigidity of the thoracic wall

Safety

the healthcare environment should be safe for all patients

Infection

the invasion and multiplication of microorganisms in the body tissues

Affect

the observable response a person has to his or her own feelings

Tissue Integrity

the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes.

Mood

the way a person feels

Percussion purposes

to elicit pain, determine location, size, + shape, determine density, detect abnormal masses, elicit reflexes

Apex of lung

top of the lungs, slightly above the clavicle

Pericardium

tough, fibrous, double-walled sac that surrounds and protects the heart. Contains pericardial fluid

Mediastinum contains

trachea, bronchi, esophagus, heart, + great vessels

emergency health assessment

type of rapid focused assessment conducted when addressing a life-threatening or unstable situation

Health Caring

umbrella for engaging in relationships with others and providing and supporting meaningful exchanges between the person and the nurse; to care or give special attention to

Fremitus

use ball of hands, say 99, assess for symmetry and intensity of vibration

Acanthosis Nigericans

velvety darkening of skin in body folds and creases, especially the neck, groin, and axilla

Amplitude 1+

weak pulse

When do you palpate the thyroid

when the pt swallows, right + left separate

Systolic

when ventricles are contracted

Diastolic

when ventricles are relaxed

Alveoli

where gases exchange and resembles grape clusters

Cuticle

where the nail grows

Jaundice

yellow skin to pumpkin