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