6410167
Descripción
Fichas por Gwen Paparone, actualizado hace más de 1 año
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Creado por Gwen Paparone
hace alrededor de 10 años
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| Pregunta | Respuesta |
| Health Assessment | systematic method of collecting data about a patient for the purpose of determining the patient’s health status. history, physical exam, and objective assessment |
| Purpose of Health Assessment | Provide a baseline Identify nursing diagnosis and formulate the nursing care plan. |
| Comprehensive Assessment | Very Thorough initial assessment Detailed health history Complete physical exam Examines client’s overall health status |
| Focused Assessment | Problem-Oriented- emergent- chief complaint- primary symptoms- depends on clients condition and the amount of time available |
| Health screening | Helps to determine whether a client has a high probability of having a characteristic of a disease |
| Orientation | Intro And Purpose |
| Working Stage | Gathering Data and Asking questions |
| Termination Stage | "I have two more questions" Anything else you want to tell me about how to take better care of you? |
| Components of Health Hx | Biographical Data Current Health Status Past Health History Family History Review of Systems Psycho social History |
| OLDCARTS | Onset Location Duration Characteristics Associated factors Relieving Factors Timing, Frequency Severity |
| SAMPLE | Signs/symptoms Allergies Medications Past History Last oral intake Events leading up to |
| OPQRTS | Onset Provocation Quality Radiation Severity Time |
| Review of Systems | Organization of symptoms to fit specific systems |
| Doppler | Non invasive ultrasound test used to estimate blood flow through blood vessels. |
| Visual Acuity | Vision Test |
| Otoscope | an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses |
| Opthalmoscope | test that allows a health professional to see inside the fundus of the eye and other structures |
| Nasoscope | an instrument (as an endoscope) for examining the cavities and passages of the nose |
| Transiluminator | A device or instrument that projects light, ultraviolet radiation, etc. through a translucent sample for observation |
| Inspection | General survey- color, shape, size, comparison, symmetry, abnormalities |
| Palpation | Touch- single handed or bi manual |
| Dorsal Aspect Palpation | Best For temperature |
| Balls and ulnar surface of hand Palpation | Best for vibrations |
| Fingertips | Best For fine sensations, texture, shape, size |
| Light Palpation | Surface Characteristics |
| Deep Palpation | Organs, Masses, Tenderness |
| Perceussion | Tapping body with fingers to produce vibrations- abnormal sounds mean mass, air, or fluid |
| Resonance | hollow; normal lung |
| Hyperresonance | Booming: hyper-inflated lung |
| Tympany | Drum, Gastric, Intestinal Air |
| Dullness | Thus, Liver |
| Flat | Flat. Muscle |
| Auscultation | Listening to sounds produced by organs |
| Direct Auscultation | Auscultation Preformed by the unaided ear |
| Indirect Auscultation | Auscultation By use of an aid such as a stethoscope or doppler |
| What are some organs you would auscultate? | Lung, Heart, Vascular sounds, Bowel sounds. |
| What are the descriptors for Auscultation? | Frequency Loudness Quality Duration |
| Olfaction | Sense of smell for use of assessment |
| What sorts of things can Olfaction tell you ? | Cues on cleanliness Cues on disease process Infection |
| Neurological | Level of Consciousness (LOC) Orientation Language Pupils Motor & Sensory Pathways Reflexes Other Neuro functions |
| LOC | Always begin with easiest stimulus (verbal, then tactile, then pain) |
| Levels of Arousal | Alert Lethargic Obtunded Stuperous Semi-comatose Comatose |
| Glasgow Coma Scale | 1- 15 graded scale that rates a Patients LOC 15 being the best score. measures eye response, motor response, and verbal response |
| Response to Painful stimuli can be? | Purposeful or non purposeful or decorticate or decrebrate posturing |
| Decorticate | Arms flexed over chest |
| Decerebrate | Arms twisted away from torso |
| Level of Awareness | Person Place and Time (AO x 3) |
| Aphasia | Inability to speak |
| Sensory Aphasia | Damage to the wernicke's receptive area |
| Motor Aphasia | Damage to the Broca's expressive area |
| PEARLLA | Pearls are equal round reactive to light and accommodate |
| Pupillary response to light is innervated y what cranial nerve? | 3rd cranial nerve |
| Motor Neural Pathways | Voluntary, automatic, coordination, posture |
| Sensory Neural pathway | Sensation |
| Dermatomes | Area of skin innervated by a specific spinal nerve- assesses the effect of spinal anesthesia or Dx of back injury |
| Deep Tendon Reflex | Associated with muscle stretching (eg patella) |
| Superficial Reflex | Reflex created by stimulation of the skin |
| Babinsky Reflex | a reflex action in which the big toe remains extended or extends itself when the sole of the foot is stimulated, abnormal except in young infants |
| Flexor Reflex | Withdrawal reflex (eg from heat) |
| Head Assessment | Hair & scalp Light palpation of sinuses Face: bruising, symmetry, abnormal movements |
| Eyes | Acuity Visual fields Pupils: size, shape, equality Pupillary response: reaction to light, direct and consensual response, accommodation |
| Visual Acuity | Test vision eg with letterboards |
| Visual fields | Measure of central and Peripheral vision |
| Elderly can have what sort of head and eye assessments as regular? | Hair— Grey, white, thinning Eyes— Presbyopia Smaller pupil Yellowing and opacity of lens Distorted depth perception |
| Presbyopia | Inability to Focus Up Close- usually caused by aging |
| Ears, Nose, Throat, Mouth | Cleanliness, positioning Appearance of cerumen in ear Hearing acuity Nasal mucosa Condition of lips, teeth, gums, tongue Gag reflex Tonsils |
| Ways to Assess Hearing Acuity? | Whisper, Hold watch up to patients ear. |
| Cerumen | Earwax |
| Teeth Assessment | Condition of Teeth, Dentures, Proper Fit, missing teeth. |
| Tongue Assessment | Mucosa Color Quality Surface patterns Symmetry |
| Neck Assessment | Inspect distended neck veins Palpate carotid pulse and thyroid gland |
| Chest Inspection | Landmarks, shape of chest and chest excursion |
| Dyspnea | Difficulty Breathing |
| Tachypnea | Rapid Breathing |
| Orthopnea | Shortness of breath |
| Paroxysmal Nocturnal Dyspnea | Waking up in the middle of the night and being unable to breath. |
| Tactile Fremitus | Vibrations that can be felt through the chest on palpation with breath |
| Consolidation | Pneumonia |
| Hyper expanded lungs | COPD |
| Vesicular Breath sounds | Low, soft sound, most of lung |
| Bronchovesicular | medium, mainstream bronchus |
| Tracheal | High, Loud, Trachea. |
| Crackles | Air in the lung space. |
| Rhonchi | Resembles snoring- obstruction or secretion in the larger airways |
| Friction Rub | Grating sound of inflamed pleural spaces rubbing together. |
| Wheezes | Whistling sound that can be heard on inhalation or exhalation- usually allergic reaction. |
| Breath Considerations for the elderly | Decreased breathing capacity; chest wall becomes stiffer (less compliant) Greater chance for collapse of airways Weaker inspiratory and expiratory muscles. Decreased PO2 Increased anteroposterior chest diameter |
| PMI (Point of Maximum impact) | Point where the left ventricular valve collapses- Apical pulse can best be heard from here. |
| Pulse Considerations | Strength, Rate, Symmetry, Deficit, Rhythm |
| Heart sound Considerations | Frequency, loudness, quality, duration |
| S1 sound | "LUB" First sound auscultated Closure of mitral and bicuspid valve at start of systole |
| S2 Sound | "DUB" Second sound auscultated Closure of aortic and pulmonary valve at end of systole. |
| Murmur | "Swish" Flowing of blood, usually through a problematic valve. |
| Pericardial Friction Rub | Audible sign of Pericarditis |
| Other Aspects of cardiac assessment | Blood pressure Respiratory rate Skin color, temperature, edema Capillary refill Neck vein distention |
| Elderly Cardiac Considerations | Softer heart sounds Often irregular beats |
| Breast Exam | Inspection: asymmetry, puckering, dimpling Palpation: 4 quadrants, tail of spence |
| Tail of spence | is an extension of the tissue of the breast that extends into the axilla. |
| How often should breast exams occur? | Monthly |
| Abdomen steps | 1. Inspect for abnormalities 2.Auscultate 4 quadrants 3. Percuss 4. Palpate |
| How long should you auscultate each quadrant? | 5 minutes or until you hear a bowel sound |
| How often should you hear bowel sounds? | Every 5-10 seconds |
| What do you do if bowel sounds are not present? | Avoid Feeding the patient |
| Why do you palpate the abdomen last? | To avoid interfering with the auscultation. |
| Musculoskeletal | Gait & posture Muscle tone ROM Gentle palpation Signs of inflammation Muscle strength 0-5 |
| Kyphosis | Rounded "hutch back" curvature in spine |
| Lordosis | inward lordotic curvature of the lumbar and cervical regions of the spine |
| scoliosis | Lateral curvatures of the spine |
| ADL [Activities of Daily Living] | Everyday necessities the patient can or cannot manage to do at home- brush teeth eat walk etc |
| Skin Considerations | Color, moisture, temperature, texture, vascularity, lesions- moisture- turgor-edema |
| Pallor | Unhealthily pale |
| Cyanosis | Blueish coloring |
| Jaundice | Unhealthy yellow |
| Loss of pigmentation | ... |
| Erythema | Reddness |
| Vascularity | Pressure areas Petechiae (small red spot) Ecchymoses (bruises) Varicose veins |
| Exudate | Excretion from lesion or open wound |
| Warning signs of Melenoma | ABCDE Asymmetry Border Color Diameter Elevation |
| Nails | Shape, angle, texture, color, care |
| Hair | Clean, shiny, evenly distributed No infestation |
| Clubbing | Nail distortion that tilts downward- indicative of heart issues |
| External Genitalia | Inspect for lesions, hemorrhoids, fissures, other abnormalities. Discharge, odor. Masses |
| Data Validation | Compare subjective and objective data Ask client to validate assessment data Use other sources to validate data, such as family members, health- care providers, old records, diagnostic tests |
| Documentation | Accurately Avoid “normal, WNL, usual, general.” Concisely Objectively Record by systems Chart pertinent negatives Institution guidelines |
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