Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
47 Cards in this Set
- Front
- Back
Four main areas for mental health assessment |
Appearance Behaviour Cognition Thought processes |
|
When assessing radial pulse you should include assessment of which four criteria? |
Measure radial pulse rate Evaluate pulse rhythm Assess amplitude and contour Palpate arterial elasticity |
|
What are you looking for when palpating skin of an adult? |
Texture, thickness, moisture, temperature, mobility and turgor, oedema |
|
Purpose of the health history |
Lays the groundwork for identifying nursing problems and provides a focus for the physical examination. |
|
Areas of questioning during health history of cardiovascular system |
Chest pain and palpations, difficulties breathing, dizziness, oedema, heart burn, heart defect or murmur, hx of heart surgery/interventions, hypertension or other heart diseases, lifestyle |
|
Areas of questioning during health history of both male and female genitalia |
Urination: difficulties, pain, colour, odour, control, blood. Sexual dysfunction: performance, libido, performance. Prior problems, hx of STI, last examination, number of sexual partners, self exams, birth control |
|
Areas of questioning during health history of respiratory system |
Difficulty breathing? Chest pain? Coughing? When and how often? Do you/have you smoked? How much? Hx of respiratory infections? Environmental exposures? |
|
Areas of questioning during health history of breast assessment |
Lumps or swelling, redness, warmth, dimpling, change in size or firmness, pain, nipple discharge, hx of breast cancer, hx of breast disease or surgery. |
|
Areas of questioning during health history of neurological |
Numbness or tingling, seizures, headaches, dizziness, changes in senses, difficulty speaking or swallowing, change in muscle control, memory loss, family hx of hypertension, stroke, Alzheimers, ever had a head or spinal cord injury |
|
Areas of questioning during health history of auditory system |
Changes in hearing, ear drainage, pain, dizziness/feeling unbalanced, hx of ear problems, family hx of hearing loss, lifestyle (noise at work) |
|
Questions during initial pain assessment |
Are you experiencing pain now? Where? Does it radiate or spread? Other symptoms accompanying pain? When did it start? What were you doing? Is it continuous or intermittent? Describe pain in your own words? What relieves/increases pain? Any pain therapy? |
|
Areas of questioning during health history of eyes |
Recent vision changes? Do you see spots or floaters? Blind spots? Eye pain or itching? Excessive watering, eye discharge? Previous eye problems/surgery/treatments? Hx of vision loss in family? Lifestyle? (Exposure to harmful substances etc) |
|
Areas of questioning during health history of abdominal system |
Changes in appetite, dysphagia, food intolerances, abdominal pain, nausea, vomiting, indigestion, constipation, vomiting, changes in bowel habits, past abdo hx, medications, travel |
|
Areas of questioning during health history of head and neck |
Headaches, dizziness/vertigo, neck pain, seizures, surgical hx, swelling, movement limitations, head injury, loss of consciousness, medication |
|
Areas of questioning during health history of mouth and throat |
Sores or lesions, sore throat, bleeding gums, toothache, hoarseness, dysphagia, altered taste, smoking and alcohol consumption, self care behaviours, last dental appt |
|
Areas of questioning during health history of nose |
Discharge, frequent colds, sinus pain, trauma, epistaxis, allergies, altered smell |
|
Areas of questioning during health history of musculoskeletal system |
Recent weight gain, difficulty chewing, joint/muscle/bone pain, past injuries, family hx of arthritis/osteoporosis, exercise pattern, medications, alcohol and smoking, diet, occupation |
|
Areas of questioning during health history of peripheral vascular system |
Changes in skin colour, temperature or texture, pain or cramping in legs, varicose veins, leg ulcers, oedema, swollen glands or lymph nodes, circulation problems, family hx of diabetes, heart disease etc, smoking, exercise |
|
Blood pressure |
Pressure exerted on the walls of the arteries |
|
Systolic pressure |
Pressure of blood in the arteries when ventricles are contracted |
|
Diastolic pressure |
Pressure of blood in the arteries when ventricles are relaxed |
|
Order of joint examination |
Temporomandibular, sternoclavicular, shoulder, elbow, wrist, fingers, thumb, vertebrae, hip, knee, ankle foot |
|
Rationale for performing auscultation of the abdomen before palpation or percussion |
So you do not alter the patients pattern of bowel sounds |
|
COLDSPA |
Character Onset Location Duration Severity Pattern Associated factors |
|
Significant information in the four areas of general survery: physical appearance, body structure, mobility and behaviour |
Physical appearance: skin condition and colour, facial expression, dress and hygiene Body structure: physical development, build, gender and sexual development Mobility: posture, gait, body movements and affect Behaviour:consciousness, speech, apparent age
|
|
Improper size blood pressure cuff |
A cuff that is too small may give a false or abnormally high reading |
|
What needs to be noted when assessing a skin lesion? |
Colour, shape, size |
|
Neurological objective assessment components |
Test cranial nerves, inspect muscle groups for size and involuntary movement, test muscle strength and tone, assess balance gait and rapid alternating movements, assess sensory system (spinothalamic and posterior column tracts), assess deep tendon and plantar reflexes |
|
3 factors that can cause extraneous noise during ausculatation |
Rustling of gown, examiner breathing loudly on stethoscope, patients hairy chest |
|
Guidelines for distinguishing between S1 from S2 |
S1= Lub S2= Dub S1 starts systole, S2 starts diastole. Space between S1 and S2 is short whereas space between S2 and the start of another S1 is much longer. |
|
Explain the statement that normal visual acuity is 6/6 (20/20). |
This means the patient can distinguish what the person with normal vision can distinguish from 6 metres away. |
|
How can you enhance abdominal relaxation? |
Explain each aspect of the assessment, answer any questions, drape genital areas, warm hands |
|
Define and describe the four examination techniques |
Inspection: using senses to observe/detect normal or abnormal findings Palpation: using parts of hand to touch and feel for characteristics Percussion: tapping body parts to produce sound and assess underlying structure Auscultate: use of stethoscope to listen to heart, lung, bowel sounds |
|
Findings that should be noted during abdominal inspection |
Skin: colour, vascularity, scars, lesions, masses Umbilicus: colour and location Abdominal contour, symmetry, pulsations |
|
Define bruit and discuss what it indicates |
An abnormal sound, blowing, swishing or murmuring causes by turbulent flow heard during auscultation. |
|
Name and describe the three types of normal breath sounds |
Bronchial: high pitch, loud, inspiration < expiration, trachea and thorax. Bronchovesicular: moderate pitch and loudness, inspiration=expiration, over major bronchi. Vesicular: low pitch, soft, inspiration > expiration, peripheral lung fields |
|
Describe the tripod position and when is it utilised? |
When patient leans forward and uses arms to support weight and lift chest to increase breathing capacity. Often seen in patients with breathing difficulties such as those with COPD. |
|
Describe 2 tests which can assess cerebellar function |
Rhomberg test: stand with arms at side and feet together with eyes closed 20 s. Evaluates balance Rapid alternating movements: palms up palms down, finger to nose etc, increase speed. Assesses coordination
|
|
The three areas of assessment on the Glasgow Coma Scale |
Motor response (6 grades) Verbal response (5 grades) Eye opening response (4 grades) |
|
Teaching points to include in a testicular self examination |
Easier after shower/bath Check both testes one at a time Use palm of hand to support, roll testis between thumb and fingers to feel for lumps/swelling Feel along epididymis at the back, soft highly coiled tube, check for swelling |
|
How do you assess mood and affect |
Affect: observation of range and appropriateness of patients emotions Mood: describe how patient perceives own mood by asking how they are feeling |
|
Nosocomial infection |
Hospital acquired infection, prevented by use of standard precautions |
|
Standard Precautions |
Hand hygiene, personal protective equipment, patient care equipment and instruments, care of environment, patient placement |
|
Uses of percussion |
Eliciting pain, determining location size and shape, determining density, detecting abnormal masses and eliciting reflexes |
|
Factors that determine level of blood pressure |
Cardiac output, blood volume, blood velocity, blood viscosity |
|
What is the pupillary light reflex |
Causes pupils to immediately constrict when exposed to bright light. A direct reflex when exposed to light, indirect when opposite eye constricts when the other is exposed to light |
|
What is the Hirschberg test |
Tests if eyes are in alignment by shining light at eyes and observing where light reflex is located in reference to the pupil |