Health assessment and physical examination 2022

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Health assessment and physical examination 2022 What is a nursing assessment? - Answer- the systemic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultura... l status of an individual, group, or community What is ADPIE (definition and the acronym) - Answer- It is the process for basic nursing care. Assess, diagnose, plan, implement and evaluate What is the A in ADPIE - Answer- Assess When performing an assessment on a patient, what would you use the acronym PQRST for - Answer- When assessing pain what is PQRST - Answer- an acronym used for assessing pain -P provocative -Q quality -R region / radiation -S severity -T time What is AAO? and what would you ask the patient to confirm this? - Answer- Awake , Alert & Oriented x3 -ask the patient their name, where they are and what day/time What is the glasglow coma scale? - Answer- it is a tool used to measure a persons level on consciousness after a brain injury What is Broca's area? - Answer- motor speech area *left frontal lobe What is Wernicke's area? - Answer- language comprehension What is diaphoresis? - Answer- sweating can we from symptom to disease or side effect to drug What is Juandice? - Answer- yellowing of the skin can be caused because of liver disease, obstruction of bile duct, or excessive breakdown of RBC What is cyanosis? - Answer- a bluish discoloration of the skin can be from poor circulation or inadequate oxygenation of the blood. What is pallor? - Answer- pale skin what is ecchymosis - Answer- a discoloration of the skin resulting from bleeding underneath, typically caused by bruising. what is petechiae - Answer- round spots under the skin from bleeding What is spider angiomas? - Answer- swollen blood vessel below skins surface Whats good, decreased or increased skin turgor ? - Answer- Increased. Decreased indicated that the patient is dehydrated What does the ABCD acronym stand for when assessing the patients skin? - Answer- -Asymmetrical -Border -Color -Diameter What does the acronym PERRLA mean? - Answer- pupils equal, round, reactive to light and accommodation what is a Webers test? - Answer- .Apply vibrating fork to the forehead or on top of the head... does the patient hear in both ears or just one (Lateralization) Lateralization - Answer- cognitive function that relies more on one side of the brain than the other What do crackeling lung sounds sound like - Answer- short popping sounds. can be heard during inhalation, expiration, or both What do wheezing lung sound sound like - Answer- high pitch sounds -can be heard during inhalation or expiration What do Rhonchi lunch sounds sound like - Answer- deep course sounds that have a snoring quality what do frictional rub lung sounds sound like - Answer- a deep harsh or grating donut that is usually heard during inhalation What is S1? - Answer- closure of AV valves, beginning of systole What is S2? - Answer- closure of semilunar valves, end of systole/ beginning of diastolic Dysrythmia - Answer- irregular heart beat Carotid bruit - Answer- abnormal flow of blood through the carotid artery -creates blowing swishing sounds What is lordosis? - Answer- Swayback in the lumbar region (Lumbar, Lordosis) What is kyphosis? - Answer- Humpback in the thoracic area What is scoliosis? - Answer- lateral curvature of the spine what is hypertonicity - Answer- Increased muscle tone (spasticity) -stiff limb, difficulty moving What is hypotonicity? - Answer- diminished tone of the skeletal muscles -floppy limbs/ difficulty standing What is atrophy? - Answer- decrease in muscle size muscle is wasting away Dorsal recumbent position - Answer- lying on the back with the knees flexed Lithotomy position - Answer- lying on back with legs raised and feet in stirrups Semi-Fowler's Position - Answer- lying in bed in a supine position with the head of the bed at approximately 30 degrees. Fowler's position - Answer- a semi-sitting position; the head of the bed is raised between 45 and 60 degrees lateral recumbent - Answer- lying on the side what is clubbing of nails, what is the cause - Answer- nail bed softening with nail flattening; often enlargement of finger tips Cause: chronic lack of oxygen; heart of pulmonary disease What are beau's lines , what is the cause - Answer- transverse depressions in nails indicating temporary disturbance of nail growth cause: systemic illness such as severe infection; nail injury; What is koilonychia (spoon nail), what is the cause - Answer- curving of the nail cause: iron deficiency anemia, syphilis, use of strong detergents What is a splinter hemorrhage, what is the cause - Answer- red or brown linear streaks in nail bed cause: minor trams, subacute bacterial endocarditis What is Paronychia, what is the cause? - Answer- Inflammation of the skin and the base of the nail cause: local infection, trauma What cranial nerves are pure sensory nerves? - Answer- I, II, VIII What cranial nerves are pure motor nerves? - Answer- III, IV, XI, XII What cranial nerves are mixed sensory and motor? - Answer- V, VII, IX, X Glasgow Coma Scale (GCS) >15 - Answer- best response GCS 8 or less - Answer- comatose patient GCS 3 - Answer- totally unresponsive What are the normal breath sounds - Answer- -Vesicular - Bronchovesicular -Bronchial What is the vesicular lung sound - Answer- air moving through smaller airways what is the bronchovesicular lunch sound? - Answer- air moving through large ........ 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