Download NUR 2092 Health Assessment Final Exam Study Guide and more Exams Nursing in PDF only on Docsity!
NUR 2092 Health Assessment Final Exam Study Guide
- Barriers to communication —the ten traps of interviewing- providing false assurance or reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing, using professional jargon, using leading or biased questions, talking too much, interrupting, using why questions o Blaming, patronizing, false reassurance, failure to listen, changing the subject or topic
- Tips for assessing children under age 5 :
- What occurs in each step of the nursing process : o Assessment o Diagnosis o Outcome identification o Planning o Implementation o Evaluation
- Open ended questions: ask for a narrative response use in following situations: to begin interview, introduce new section of interview, whenever the patient introduces a new topic
- Closed ended questions: ask for apecific information, use in following situations: after opening narrative questions, when you need specific facts about past health problems, to move interview along. These are yes and no questions
- Subjective Data vs objective data:
- Signs vs symptoms: symptoms are subjective sensation person feels from disorder, what a person says is reason for seeking care is recorded and enclosed in quotation marks to indicate persons exact words. Signs are objective abnormally that can be detected on physical examination or in lab reports
- Assessing pulses— is it weak or full, rate and rhythm, force, elasticity, regular, irregular o light pressure, don’t assess pulses on neck at same time
- Terms for respiratory patterns— normal is relaxed, regular, automatic, and silent, orthopenic- shortness of breath when laying down, eupneic- normal good breathing, tachypnea- fast breathing, bradypneic- slow breathing, positional is just allowing for the best chest expansion
- What is included in the family health history--
- Why would you want to ask the clients name and DOB?— helps assess mental status
- Types of nutritional eating disorders: o Anorexia nervosa o **bullemia
- Components of health history vs health assessment--**
- **What are normal lung sounds and where are they found
- What are adventitious lung sounds and where are they found—** o Crackles (rales)- are most commonly heard in dependent lobes: right and left lung bases, random sudden reinflation of groups of alveoli, fine, short, interrupted crackling sounds heard during inspiration, expiration, or both; vary in pitch, high or low, may or may not change with coughing sound like crushing cellophane o Rhonci- primarily heard over trachea and bronchi, if loud enough can be heard over most lung fields, fluid or mucus in larger airway causing turbulence; low pitched, continuous sounds heard more during expiration may be cleared by coughing sounds like blowing air through milk with a straw
o Wheeze- can be heard through all lung fields, severely narrowed bronchus; are high pitched, musical sounds heard during inspiration or expiration, do not clear with coughing o Pleural friction rub- is heard best over anterior lateral lung field, if client is sitting upright, inflamed pleura, parietal pleura rubbing against visceral pleura; grating quality heard best during inspiration, does not clear with coughing
- What are risk factors for breast cancer: gender, age, genetics, family history, weight, race
- What are identifying factors for malignant melanoma: asymmetry, border irregularity, color, diameter ¼ inch or 6mm
- Coordinating function of cranial nerves 3, 4, 6- makes eyes do tricks, oculomoter, trochlear, abducens
- PERRLA— pupils equal, round, reactive to light and accomodate
- Tests to evaluate cerebellar function- Romberg test reflex: a procedure used to evaluate cerebellar function and balance in which the person is asked to stand quietly, with eyes closed, feet together, and hands at side, and to maintain equilibrium while responding to directions. o hand coordination: ask them with eyes closed to raise arms fully extended in front of them; should be able to hold them at equal height in front of them, abnormal would be unleveled hand positions o movement coordination: with eyes still closed and their arms fully extended in front of them ask the patients to make a fist, now ask them to stick out the pinky in both hands, then ask the patient to try to place the tip of their left pinky on the tip of the nose, ask them to do it again with their right pinky, should be able to do this without difficulty, abnormal would be shaky hands, inaccuracy, choppy movements o movement coordination 2: have them open eyes, stick out your index finger in front of them at about arms length, now have them stick out their index finger on each of their hands ask them to touch the tip of their finger to the tip of the nose and then from nose to your outstretched finger, repeat with both hands; abnormal would be shaky or inaccuracy o alternating movement: with the patients eyes open have them extend their arms fully in front of them, ask them to wave both their hands (wave good bye), then ask them to do the same but have them pull their hands inwards so that their hands are next to their chest and their elbows are behind their back , abnormal would be one hand slower than the other and the inability to coordinate
- Spinal curvatures o Lordosis- big dip in on lower back o Kyphosis- hump in top of back o Scoliosis- curved like an S
- BP cuff sizing and placement— the cuff has to be the right size, if it is too big the reading will be low, if it is too small the reading will be high. Should be on the arm and the arm should be at heart level
- IADL ( and what is included): o Personal hygiene (bathing, grooming, oral, nail and hair care), continence management, dressing, feeding, ambulating
o Instrumental Activities of daily living: companionship and mental support, transportation and shopping, preparing meals, managing a persons household, managing medications, communicating with others, managing finances
- Terms for musculoskeletal assessment movements: o Extension, flexion o Abduction is away from the midline, adduction-is opposite direction of the midline o Lateral rotation, medial rotation
- **How do you measure lesions
- S1 and s2 heart sound location and APETM** o S1- beginning of systole, closing of AV valves, loudest at the apex, coincides with carotid artery pulse, coincides with the R segment of QRS complex if patient is on an ECG monitor, lub o S2: loudest at base, dub, end of systole, closing of semilunar (aortic and pulmonic valves) o Aortic- 2 nd-3rd^ right intercostal space o Pulmonic- 2 nd- 3 rd^ left intercostal space o Erbes pointe- 3 rd^ intercostal space, left sternal border o Tricuspid- left sternal border o Mitral valve- apex
- Tonsillitis assessment findings— rated 0- o 1- tonsils hidden within tonsil pillars o 2- tonsils extending to the pillars o 3- tonsils are beyond the pillars o 4- tonsils extend to midline
- Assessing chest movement and lungs- should be symmetrical and smooth, should be relaxed, no effort, no use of accessory muscles
- Adult vs child ear assessment— o Adult : up and back o Child: down and back
- Risk factors for osteoporosis – o Uncontrollable risk factors- being over 50, being female, menopause, family history of osteoporosis, low body weight/being small and thin, broken bones or height loss o Controllable risk factors: not getting enough calcium and vit d, not eating enough fruits and vegetables, getting too much protein, sodium, caffeine, having an inactive lifestyle, smoking, drinking too much alcohol, losing weight
- Heart valve AREAS assessed with APTEM: o Aortic valve o Pulmonic o T-tricuspid o Erbes point, s1,s o Mitral valve
- How do you locate lower leg pulses- o Popliteal, behind the knee o Posterior tibial- inside the ankle **o Dorsalis pedis: top of foot
- How do you assess legs for circulation and blood flow:** warmth, discoloration, pulse ,
- What abnormal signs would you watch for in a casted limb and why— loss of sensation, pain, discoloration, these signs indicate loss of blood flow
- **What is the glascow coma scale and what parameters does it assess
- How do you elicit a patellar reflex? What tricks can help you** o Smack the knee with a thing, have them distracted a little so they aren’t watching to elicit the best response
- Cranial nerve 7 assessment: ask patient to perform these movements, smile, frown, raise eyebrows, show upper teeth, show lower teeth, puff out cheeks, purse lips, close eyes tightly while nurse tries to open them, observe face for flaccid paralysis
- Babinski response— stroke baby foot, toes should move up and out
- **Bp in elderly clients—usually higher with age increase
- Lymph node name around the head and neck**
- Symptoms of arterial insufficiency on the legs— cramping, pain, tired legs or hip muscles that worsens during walking/activity and subsides with rest
- Normal bowel sounds, hyperactive and hypoactive
- Pain assessment tools and lifespan considerations: brief pain inventory: asks patient to rate pain within past 24hrs on graduated scales (0-10), short form McGill pain questionnaire— asks patient to describe pain, intensity, wong baker, oucher, cries
- Staging pressure ulcers ( stage 1, 2, 3)
o Stage 1- non blanchable erythema/purple hue of skin, changes in temperature and sensation o Stage 2- partial thickness skin loss (blister or shallow crater) o Stage 3- full thickness skin loss involving necrosis of subcutaneous tissue o Stage 4- full thickness skin loss with extensive necrosis to tendon, muscle, bone, or joint o Unstageable- ulcer with eschar, wound base cannot be assessed o DTI- purple non blanchable area of intact skin that is mushy or boggy
- Types of fractures o Stable fracture: the broken ends of the bone line up and are barely out of place o Open, compound fracture: the skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture, the bone may or may not be visible in the wound o Transverse fracture: this type of fracture has a horizontal fracture line o Oblique fracture: this type of fracture has an angled pattern o Comminuted fracture: in this type of fracture the bone shatters into three or more pieces
- Deep tendon reflexes- often associated with muscle stretching, used to determine the integrity of the spinal cord and peripheral nervous system, and they can be used to the presence of a neuromuscular disease
- Testicular cancer risks- undescended testicle, family history of testicular cancer, HIV, carcinoma in situ of the testicle, having had testicular CA before, being of a certain race/ethnicity, body size
- Abnormal chest skeleton shapes o Barrel chest o Pectus excavatum (funnel chest) o Pectus carinatum (pigeon breast)
- Tinnitus— ringing of the ears
- Cataracts— clouding of the normally clear lens of the eye
- Lesion types and assessment o Macule: flat, circumscribed area that is a change in color of the skin less than 1cm In diameter, freckles, flat moles, Petechiae, measles, scarlet fever, primary lesion o Papule: elevated, firm, circumscribed area, less than 1 cm in diameter, wart, elevated moles, lichen planus, cherry angioma, neruofibroma, skin tags, primary lesion o Patch: a flaat, non-palpable, irregular-shaped macuole, more than 1cm in diameter, vitiligo, port wine stains, Mongolian spots, café-au-lait spots, primary lesion o Plaque: elevated, firm, and rough lesion with a flat surface, greater than 1 cm in diameter, psoriasis, seborrheic and actinic, keratosis, eczema, primary lesion o Wheal: elevated irregular shaped area of cutaneous edema. Solid transient, variable diameter, insect bites, urticarial, allergic reaction, lupus erythematosus o Nodule: elevated, firm, circumscribed lesion, deeper in dermis than a papule, dermatofibroma, lipomas, melanoma, hemangioma, primary lesion o Tumor: elevated and solid lesion, may or may not be clearly demarcated, deeper in dermis, greater than 2cm, neoplasms, lipoma, primary lesion o Vesicle: elevated circumscribed, superficial, not into the dermis, filled with serous fluid, varicella, herpes zoster, impetigo, primary lesion o Bulla: vesicle greater than 1cm in diameter, blister, pemphigus vulgaris,
lupus, erythematosus, primary lesion
o Pustule: elevated superficial lesion, similar to a vesicle but with purulent fluid, impetigo, acne, folliculitis, herpes simplex, primary lesion o Cyst: elevated, circumscribed, encapsulated lesion in dermis or subcutaneous layer filled with liquid or semisolid material, sebaceous cyst, cystic acne, primary lesion o Scale: heaped-up keratinized cells, flakey skin, irregular, thick or thin, dry or oily variation in size, flaking skin with seborrheic dermatitis following scarlet fever, secondary lesion o Lichenification: rough thickened epidermis secondary to persistent rubbing, itching, or skin irritation often involves flexor of surface extension. Chronic dermatitis, psoriasis, secondary lesion o Keloid: irregular-shaped, progressively enlarging scar, grows beyond boundaries of the wound, following surgery, secondary lesion o Scar: thin- to thick- fibrous tissue that replaces normal skin following injury or laceration to the dermis, healed wound, secondary lesion o Excoriation: loss of the epidermis, linear, hollowed out, crusted area, abrasion or scratch, scabies, secondary lesion o Fissure: linear crack or break from the epidermis to the dermis may be moist or dry, athletes foot, crack at the corner of the mouth, chapped hands, eczema, intertrigo labialis, secondary lesion o Crust: dried drainage or blood, slightly elevated, variable size, variable color, scab or abrasion, eczema, secondary lesion o Erosion: loss of part of the epidermis, depressed, moist, glistening, following rupture of a vessel or bulla, secondary lesion o Ulcer; loss of epidermis and dermis, concave, varies in size, pressure ulcer, statis ulcer, syphilis chancre, secondary lesion o Atrophy: thinning of the skin surface and loss of skin markings, skin appears, translucent and paperlike, aged skin, striae, discord, lupus, secondary lesion o Petechiae: tiny flat, reddish-purple, nonblanchable spots in the skin, appear as tiny red spots pinpoint to pinhead size, vascular lesion o Purpura: flat, reddish-purple, nonblanchable discoloration in the skin, infection or bleeding disorders resulting in hemorrhage of blood into the skin, vascular lesion o Bruise: reddish-purple, nonblachable spot of variable size, trauma to the blood vessel, resulting in bleeding under the tissue, vascular lesion o Angioma: benign tumor consisting of a mass of small blood vessels, can vary in size small to large, cherry angioma, hemagioma,
- **Bruits- the noise a fistula or carotid makes when listening
- Assessing kidneys**
- Primary, secondary, tertiary prevention o Primary prevention: patient can do to prevent, health promotion o **Secondary prevention: could find something you won’t, regular checkups
- Snellen chart-** o Place the Snellen alphabet char in a well it spot at eye level, position the person on a mark exactly 20 ft away, use an opaque card to shield one eye at a time during the test, the bigger the number on the bottom the worse your vision is
- **Religion vs spirituality
- Risks for colon cancer**
o Family history, obesity and diabetes, smoking and alcohol, diet and lifestyle, older people, IBD
- Different hearing tests
- Assessing TMJ— index finger is placed in front of the tragus and the thumb is placed in front of the lower part of the mastoid process. Patient is asked to open his mouth as wide as possible, index finger in front of the tragus can be indented in its space and the thumb can feel the sliding movement of the condyle as the condyle of the mandible slides forward
- Cranial nerve 7, 9 o Cranial nerve 7: facial, mixed motor facial muscles close eye, speech, close mouth, sensory taste( sweet sour salt bitter) anterior 2/ o Cranial nerve 9: glossopharyngeal, mixed motor pharynx, swallowing, sensory taste of posterior 1/3 of tongue, gag reflex
- Terms assessing ankle movement
- Orthopnea— is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair
- Graphesthesia— the ability to recognize writing on the skin purely by the sensation of touch
- Cranial nerve 11, 10 o Cranial nerve 11: spinal accessory, motor movement of trapezius and sternomastoid muscle o Cranial nerve 10: vagus, mixed motor pharynx talking and swallowing, sensory general sensation from carotis body sinus pharynx viscera
- Brochophony— abnormal transmission of sounds from the lungs or bronchi, when you have the patient say “e” and it comes out “a” indicative of pneumonia
- Location of abdominal organs o Left lower quadrant: part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord o Left upper quadrant: stomach, spleen, left lobe of liver, body of pancreas, splenic flexure of colon, transverse and top of descending colon o Right lower quadrant: cecum, appendix, right ovary and tube, right ureter, right spermatic cord o Right upper quadrant: liver, gallbladder, duodenum, head of pancreas, right kidney, hepatic flexure of colon, top of ascending and part of transverse colon
- Left sided heart failure – restlessness, confusion, orthopnea, tachycardia, elevated pulmonary capillary wedge pressure, paroxysmal nocturnal dyspnea, pulmonary congestion, cough, crackles, wheezing , blood tinged sputum, tachypnea
- Right sided heart failure— fatigue, peripheral venous pressure increases, ascites, enlarged liver and spleen, may be secondary to chronic pulmonary problems, distended jugular veins, anorexia and complaints of GI distress, weight gain, dependent edema
- Dietary information— knowing what the patient typically eats, what do they drink, what is their religion, admission nutrition screening tool. Dietary history and clinical information, physical examination for clinical signs. 24 hr recall, food frequency questionnaires, food dietary, during hospitalizations documentation of nutritional intake can be best achieved through calorie counts of nutrients consumed or infused
- Signs and symptoms of different types of headaches
- Heberden and bouchard nodes— swollen, hard and painful finger joints, is the classical sign of DIP and PIP joint osteoarthritis
- Tactile fremitus— tremulous vibration of the chest wall during speaking that is palpable on physical examination, may be decreased or absent when vibrations from the larynx to the chest surface are impeded by COPD, obstruction, pleural effusion, or pneumothorax
- Assessing edema— press on skin over area, then run pads of fingers over the area pressed and note if there is an indentation,
- Signs and symptoms of meningitis o Symptoms: headache, stiff neck, fever and chills, vomiting, extreme sensitivity to bright lights, confusion, seizures, history of recent upper respiratory infection, drowsiness, new rash, joint swelling, localized weakness
- What is a carotid bruit and what does it mean – turbulent blood flow, to screen for stenosis of the artery, although it may not detect all blockages
- Urinate after sex
- Cranberry supplements for UTI prevention
- Wear cotton panties
- Wipe front to back
- Take showers not baths
- Be cautious about spermicides