nursing Health assessment Flashcards

Terms Definitions
oh
Normal BMI
18.9-24.9
pellegra
niacin deficiency
perfusion
circulation of blood
cholesterol
less than 200
lobar pneumonia
consolidated alveoli
which kideney is lower
right
Dr. Davenport Nutrition Lecture:
Complete proteins contain all  ____ Amino Acids
A. Essential
B. Non Essential
Essential
20/? is legally blind?
200
BMI
30-34.9 obese class I
INR
-International Normalized Ratio-only done when taking coumadin-normal .9-1.2
seizures
episodic abnormal electrical discharges of cerrebral neurons
prehension
act of grasping w/fingers
Frontal Lobe
Controls personality, behavior, emotions, and intellectual function.
Anthropomorphic Measures:
Waist-Hip Ratio
 
Abnormal Findings
Waist/Hip Circumference
 
Assesses body fat distribution as indicator of health risk
 
Abnormal Findings
1 >in men or .8> in women - inicates android (upper body obesity) and increased risk for obese related diseases
Purpura
Flat, reddish purple, nonblanchable discoloration; greater than 0.5 cm
 
Caused by infection or bleeding disorders resulting in hemorrhage of blood into skin
 
timing used to describe CC
onsetdurationfrequency
Capillary Refill
<2sec
abnormal- cardiovascular or respiratory dysfunction
What is a comprehensive assessment?
tachypnea
rapid, shallow breathing. Increased rate >24 per minute. Normal response to fever, fear, or exercise.
LDL
-bad cholesterol-lipoprotein found in blood-higher risk for CAD-goals: less than or equal to 70 for ppl with CAD less than or equal to 100 mg/dl for high risk pts-less than 130mg/dl for low risk pts
brain growth
peaks fetus/ early infancy
pulsus paradoxus
weaker amplitude w/respiratory inspiration
organ found in LLQ
sigmoid colon
bronchial normal location
over major bronchus (manubrium)
abdomen exam order
inspection, auscultation, percussion, palpation
Cerebrum
Cerebral cortex is cerebrum's outer layer of nerve cell bodies; is site of highest human functions (thought, memory, reasoning, sensation and voluntary muscles).
Dr. Davenport Nutrition Lecture:
Follicular Hyperkeatosis
Vitamin A Deficiency
 
Excoriation
Loss of epidermis; linear hollowed-out crusted area; abrasion or scratch
 
Darwin tubercle
Small, painless nodule; normal deviation
Rhonchi
Low-pitched, coarse, loud, low snoring or moaning tone; heard primarily in expiration, but also inspiration; coughing may clear
 
Obstruction of trachea or bronchus (chronic bronchitis)
Infant & Children
Wheezing occurs with ...
Airway obstruction
lip color
normal: pink; abnormal: circumstantial pallor (anemia), cyanotic (low oxygen), cherry red (CO poisening, aspirin overdose)
lactose intolerance
American Indians 95%, whites 25%
Petechiae
tiny punctuate hemmorhages 1-3 mm, round and discrete, dark red, purple, or brown in color. caused by bleeding from superficial capillaries; will not blanch.
Serum Creatine
CR-indicator of kidney function-Goal: .7-1.4 mg/dl
Encephalitis
inflammation of brain and spinal cord
darwin's tubercle
congenital, painless nodule of helix
macule
flat skin lesion w/only color change
located on the right side (bowel)
ascending colon
the atrioventricular valves include
tricuspid and mitral valves
friction rub
can be in other organs (heart)
tricuspid auscultory site
4 or 5 ICS LSB
Temporal Lobe
Is the center for auditory reception.
Dr. Davenport Nutrition Lecture:
Fat converts to glucose through ___________.
Gluconeogenesis (Means New)
 
Wasn't glucose before - converts fat to glucose
Visible peristalsis with a distended abdomine indicate ....
intestingal obstruction
Discrete/Singular Lesion
Single lesion; demarcated lesions that remain separate
 
ex. insect bites
Thyroid Cancer
Most common type of endocrine malignancy
 
Usually no symptoms; as tumor grows - changes in voice & problems w/ swallowing or breathing
Cranial Nerve VII (Facial)
Motor branch
 
Corneal reflex (blink)
Tripod Position
Leaning forward with arms braced against their knees, chair, or bed; This gives them leverage so that their rectus abdominis, intercostal and accessory neck muscles all can aid in expiration
Crackles (Rales)
Fluids in small airways (atelectasis); Crackles are a discountinous of sounds; intermittent; nonmusical; brief; heard on inspiration or expiration; popping sounds are created when air is forced through respiratory passages that are narrowed by fluid, mucus or pus; Crackles are associated with inflammation or infection of small bronchi, bronchioles and alveoli; Crackles that don’t produce a cough indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome
P: Provocative/Palliative
what causes it?
What makes it better?
What makes it worse?
nutrients-macronutrients
needed in large amounts-cho, fats abd protiens
What order do you perform "physical exam"?
InspectionPalpationPercussionAuscultation
cherry angiomas
small (1-5mm) smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.
plaques
when papules coalesce to form surface elevation wider than 1cm they are called 
Electrolytes
-substances in the blood that help regulate the proper balance of body fluids-useful in detecting kidney, heart, and liver disease and effects of certain meds
order of sexual maturation in girls
breastpubic hairmenarche
exopthalamus
bulging of eyes anteriorly out of orbit
frenulum
fold of tissue connecting the tongue to floor of the mouth
Apex of heart
PMI; point of maximum impulse
peyronie's disease
painful bending of penis during erection, usually &gt;45 y/o
excess co2
stimulates the rate and depth of respiration
bronchial characteristics
high pitched, loud, less harsh and less tubular than tracheal breath sounds, expiration > inspiration (may be break in between)
what are striae
stretch marks; broken elastic bands due to rapid weight gain/loss
Right hemisphere
Controls things such as imagination & 3D forms.
Dr. Davenport Nutrition Lecture:
Calculate BMI 
KG/m(squared)
 
OR
 
LBS * 705 / Height in Inches (squared)
Inspect the Abdomen:
Umbilicus abnormal findings
Everted (Outward appearance) of Umbilicus with ...
Acites (Fluid accumulation) or Underlying mass
Confluent Lesions
Lesions merge and run together over large areas
older pts
*may require additional time for ? interpretation and pt responses*may need to schedule more time bc pt may have multisystem changes or complaints, a weakened physical condition, or a cognitive impairment.*may be necessary for family or caregiver to assess pt's past and present health or illness status.*speaking loudly and slowly is NOT helpful
Migraine Headaches
Occur at periodic intervals, may last from a few hours to 1-3 days; occurs with menstrual periods
 
Unilateral with throbbing pain; may be accompanied by visual disturbances, nausea, & vomiting
 
Relieved with rest
peripheral pulses and characteristics assessed
radial- strength and regularitybrachial- strength and regularityposterior tibial- presence and strengthdorsalis pedis- presence and strength
Respiration Patterns:
Hypoventilation
Irregular shallow pattern - caused by an overdose of narcotics or anesthetics; occur with prolonged bed rest or conscious plinting of the chest to avoid respiratory pain
Preoperational Stage
Toddlers (2-3)
Thinking is concrete & tangible, cannot reason
Object permanence well-established
Egocentric
Symbolic thought
HDL
greater than 45 males, greater than 55 for females
Android obesity:
greater proportion of fat in upper body
venous lake
A blue-purple dilation of venules and capillaries in a star-shaped linear or flaring pattern
nodule
This is solid, elevated, hard or soft, larger than 1 cm. it may extend deeper into the dermis than a papule
Creatine Kinase
-CK-enzyme found in the heart and muscles-increased levels with heart muscle damage, skeletal muscle injury, strenuous exercise, surgical procedures, and high doses of aspirin-goal: 30-220 U/L-test can be done at any time
conductive hearing loss
reduced transmission of sound to middle ear
What are Deep Tendon Reflex’s?
Spinal cord segmental responses
what is conjuctivitis
inflammation of the bulbar and palpebral conjuctivca(may result from foreign bodies, chemicals, allergins , agents, bacteria, or viruses
episodic database
used for limited time or short-term problem
zosteriform
linear shape of skin lesion along a nerve route
There are
three bronchi on the right and 2 bronchi on the left
the pericardium consists of 3 layers
parietal fibrous-elastic and connective tissue-protects the heartparietal serous layer-next to firbrous layer is seperated from the visceral layer by the pericardial spacepericardial space contains a small amount of fluid-decrease frictionvisceral layer cover the heart and extends to the great muscles
homan's sign
pain in claf and popliteal area on passive dorsiflexion of foot, suggestive of DVT
Dr. Davenport Nutrition Lecture:
Lipid Profile Measures .....
Total cholesteral to evaluate fat metaboslism and assess C.A.D. Risk
 
Norm: 120-200 mg/dL
 
C.A.D. Risk - > 200 mg/dL
 
Compare HDL (good) and LDL (bad) and Triglycerides
Lab Results:
What are non-nutritional factors factors that affect the TLC (Total Lymphocyte Count)?
Metabolic Stress (Trauma, Sepsis, infection, cancer, hypoalbuminemia)
Structure & Function:
Spleen
Where?
Spleen: Mass of Lymphatic tissue on the postlateral wall of the abdominal cativy, under the diaphgragm (LUQ) - 10th rib to the 11th rib
 
Normally not palpable -
If it becomes enlarged, its lower pole moves downward and toward the midline
nursing care plan
combines the elements of the nursing process to document the progress of pt care in a standard fashion.nursing care plans serve as means of communicating pt progress with other health care colleagues and ensuring continuity of care among the nursing staff.
duration
indicates amt of time in which the CC is present.continuous and intermittent are terms used to describe durationwhen possible, the duration of the CC should be stated in specific times such as minutes, hours, days.
Pleural Friction Fermitus
A palpable vibration of the wall of the thorax caused by friction between the parietal and visceral pleura of the lungs.
Thorax & Lungs
Abnormal
Chest wall: A:T=1:1 "barrel chest" & horrizontal ribs in COPD pt
Costal angle:COPD pt is >90 "barrel chest"
Chest expansion:unequal expansion-atelectasis, fractured ribs, or pneumothorax
Percussion:Hyperresonance:-low-pitched booming too much air is present-emphysema, pneumothorax
Hyporresonance: dull, abd. density-pneumonia, atelectasis, tumor
Lung aspices
rise about 4 cm above the first rib
What number would you give a "weak and thready" pulse?
1+
erythemia toxicum
a common rash that appears in the first 3-4 days of life. It consists of tiny, punctate, red macules and papules on the cheeks, trunk, chest back, and buttocks. no treatment is needed.
What governing body do we use for our Pain standards?
JCAHO
water-hammer/ corrigan's pulse
4+, greater force followed by a collapse
The trachea is
10 cm long and 2 cm in diameter
physiological splitting of S2
normal: both components of S2 (aortic and pulmonic) heard during inspiration when auscultating the pulmonic area
Anthropomorphic Measures:
Calculate Body weight as a % of ideal body weight
 
What are abnormal findings?
% of Ideal body weight = (Current weight/Ideal Weight) * 100
 
Abnormal Findings
80-90%: Mild malnutrition
70-80%: Moderate Malnutrition
70%>: Severe malnutrition
Structure & Function:
Four Quadrants: Midline
Aorta (Slightly to the Left)
Uterus (if enlarged)
Bladder (if distended)
Hirshberg's test - Corneal Light Reflex
Light reflections should appear symmetrically in both corneas
 
Asymmetrical reflections - may indicate weak extraocular muscles
What occurs at the Acinus?
Gaseous exchange occurs across the respiratory membrane int he alveolar duct and in the millions of alveoli (Note: Arrangement of interalveolar septa (walls) create a surface area for gas exchange as large as a tennis court - thats crazy!)
waist to hip ratio
indication of risk of unhealthy fat distribution
marked atelectasis, pneumonia, throacic trauma, pneumothorax
What conditions may cause an unequal chest expansion?
List the risk factors for anxiety (3/3)
1. Genetics2. Physical health (sleep deprivation)3. Psychosocial environment (finances, health, school work)a. (****hahahahah ANY NURSING STUDENT AT USF
in what position is the examination of prostate usually conducted
in teh sims position
what does the musculoskeletal system encompass
the muscles, bones and joints
how does liquid conduct heart sounds?
increases audibilty, but large amounts will decrease
Lab Results:
What is the purpose of the hemoglboin test?
To detect iron deficicny anemia
Deep Palpation
Push down 5 - 8 cm - Move counter clockwise & explore the abdoment
 
To overcome reistance of large abdomens, use a bimanual technique
Thoracic Cage Consists of...
Sternum, 12 pairs of ribs, 12 thorcic vertebrae
hip to waist ratio
0.8 women, 1.o men Measure waist at narrowest point, measure hips at largest point
What should a patient remove before being weighed?
Shoes and heavy outer clothing.
What is presbyopia?
Loss of elasticity of the lens of the eye
what is the plantars reflex
the planter reflex, also teh Babinski reflex is superficial, it may be absent in adults without pathology or overriden in voluntary control, use a moderatley sharp objuect, strock the laterla border of the sole of the clients foot, starting at the hell , observe the response
what are the 5 sounds elicited from percussing
Flatness-extremely dull soundproduced by very dense tissue, such as muscle or bone
Dullness-thudlike sound produced by dense tissue such as the liver, spleen or heart
Resonance-hollow sound such as that prodyced by lungs filled with air
Hyperresonnance- not produced in the normal body,it is described as booming and can be heard over an emphysematous lung
Tympany=musical or drumlike sound produced from an air filled stomach
Dr. Davenport Nutrition Lecture:
Fat Soluble vs. Water Soluble Vitamins
Fat Soluble: 4 fat-soluble (A, D, E and K); absorbed through the intestinal tract with the help of lipids. Because they are more likely to accumulate in the body, they are more likely to lead to hypervitaminosis
 
Water Soluble: 9 water-soluble (8 B vitamins and vitamin C); vitamins dissolve easily in water, and are excreted from the body, to the degree that urinary output is a strong predictor of vitamin consumption. Because they are not readily stored, consistent daily intake is important
speech impaired or aphasic pts
*all ?s directed to pt*ask simple ?s w/ yes or no answers*allow additional time for answers*allow pt opportunity to contribute info
Procedure for inspection of internal structures of nose
1. otoscope (avoid chin and septum with handle - away from midline) 2. lift tip of nose before insertion 3. direct speculum posteriorly and up 5. support head
Take an infants VS in the following order:
1. Respiration2. Pulse3. TempTaking the temp may make the infant cry thus falsely elevating the other VS
what is a prone position
lies on abdomen with head turned to the side, with or without a small pillow
Identify the aspects of the physical health examiniation
1.The nursing health history
2 the physical examination
Abnormalities on Palpation of Enlarged Organs:
Aortic Aneurysm
More then 95% are located below the renal arteries and extend to the umbilicus
 
80% are palapble during routine exam
 
Feel like a pulsating mass in upper abdomen to the left of the midline
 
Hear a bruit
 
Femoral pulses will decrease in strength
Unequal Chest Expansion occurs when .....
1. Part of the lung is Obstructed
2. Part of the lung collapsed (Pneumonia)
How is the cardiac output determined?
CO= HR x SVCardiac output= heart rate x stroke volume
A physical examination can be of what type
1 complete assesment2 examination of the body system3 examination of the body area
what type pf adventitious breath can be cleared with a cough
gurgles can be altered when coughing all over adventitious sounds may not be cleared with a cough cracles, wheezing, and friction rub
What is the widtch of the aorta
2.5 -4 cm (if wider- could be aneurysm)
True or false. Recap a used needle before placing it in the sharps container?
False. Never recap a used needle.
List the type of pain for the following descriptions:
· Phantom pain - true pain, produced by stimulation of a nerve · Chronic pain - > 6 months · Referred pain - pain in same spinal cord segment · Acute pain - < 6 months, usually due to tissue damage
describe the normal sounds of the heart
the normal first 2 sounds are produced by closure of the valves of the heart
S1-occurs when the atrioventricualr(av) valves close (lub) these valves close when the ventricles hae been sufficiently filled , after the ventricles close empty their blood into the aorta and pulmonary arteries the semilunar valves close producing the second heart sound
S2=Dub has a higher pitch than s1 and is also shorter these 2 sound occur within a second or less depending on the heart rate
Why should you press gently when listening with the bell?
If you press too hard, the bell will act as a diaphragm and obliterate low pitched sounds
What is the proper degree of ear position and alignment? How else would you measure proper ear alignment?
10o and on a plane with occipit line
You have calculated a BMI of 38 for your patient. What is your next step?
Show the patient where he falls on the BMI table and show recommended weight ranges for his age group.
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Term:
Definition:
Definition:

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