Chapter 30 - Health Assessment

7/29/2019 Chapter 30 - Health Assessment

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A Papanicolaou specimen is used


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A Papanicolaou specimen is used

test for cervical and vaginal canc


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A(n) ________ is the blowing

sound caused by turbulence in

narrowed section of a blood vess


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A bruit is the blowing sound caus

by turbulence in a narrowed sect

of a blood vessel


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An occlusion is _______.


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An occlusion is a blockage of a

vessel (Artery or vein)


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Assessment of the skin reveals t

patient's health status related to:


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a. Oxygenationb. Circulation

c. Nutrition

d. Local tissue damagee. Hydration


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Atherosclerosis is indicated by

________.


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Atherosclerosis in indicated by

diminished or unequal carotid

pulsations


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Benign (fibrocystic) breast diseas

characterized by:


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Benign (fibrocystic) breast diseascharacterized by bilateral lumpy

painful breast, sometimes withnipple discharge


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Briefly describe the following

abnormalities of the nail bed.

Beau lines


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Beau lines are transverse

depressions in the nails


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Clubbing


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Clubbing is a change in the anglebetween the nail and nail base,

including softening, flattening, anenlargement of the fingertips


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Koilonychia


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Koilonychia are concave curve


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Paronychia


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Paronychia is inflammation of th

skin at the base of the nail


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Splinter hemorrhages


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Splinter hemorrhages are red o

brown linear streaks in nail bed


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Briefly describe the followingprimary skin lesions and give a

example of each.Atrophy


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Thinning of skin with loss of normskin furrow, with skin appearing

shiny and translucent; varies in si(e.g. arterial insufficiency)


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example of each.Macule


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Flat, non palpable change in sk

color; smaller than 1 cm (e.g.

freckle, petechiae)


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example of each.Nodule


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Elevated solid mass, deeper an

firmer than papule; 1-2 cm (e.g

wart)


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example of each.Papule


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Palpable, circumscribed, solid

elevation in skin; smaller than 1

(e.g. elevated nevus)


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example of each.Pustule


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Circumscribed elevation of skinsimilar to vesicle but filled with p

varies in size (e.g. acne,staphylococcal infection)


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example of each.Tumor


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Solid mass that extends deep

through subcutaneous tissue; lar

than 1-2 cm (e.g. epithelium)


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example of each.

Ulcer


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Deep loss of skin surface thatextends to dermis and frequently

bleeds and scars; varies in size (e

venous stasis ulcer)


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example of each.

Vesicle


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Circumscribed elevation of skinfilled with serous fluid, smaller th

cm (e.g. herpes simplex,

chickenpox)


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example of each.

Wheal


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Irregularly shaped, elevated are

superficial localized edema; varie

size (e.g. hive, mosquito bite)


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Briefly explain the two types o

aphasia.

Expressive


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A person understands written anverbal speech but cannot write

speak appropriately when

attempting to communicate


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Briefly explain the two types o

aphasia.

Receptive


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A person cannot understand writ

or verbal speech


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Chancres are:


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Chancres are syphilitic lesions

which appear as small, open ulce

that drain serous material


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Chest excursion is normally________ Reduced chest

excursion may be caused by

_______.


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Symmetrical, separating thumbsto 5 cm; reduced chest excursio

may be caused by pain, postura

deformity or fatigue


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Complete the following table by

listing the signs of venous andarterial insufficiency.

Assessment Criterion: Color

Venous: ?

Arterial: ?


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Venous: Normal or cyanoticArterial: Pale; worsened by

elevation of extremity; dusky re

when extremity is lowered


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Assessment Criterion: Edema

Venous: ?

Arterial: ?


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Venous: Often marked

Arterial: Absent or mild


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Assessment Criterion: Pulse

Venous: ?

Arterial: ?


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Venous: Normal

Arterial: Decreased or absent


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Assessment Criterion: Skin chang

Venous: ?

Arterial: ?


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Venous: Brown pigmentationaround ankles

Arterial: Thin, shiny skin; decrea

hair growth; thickened nails


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Assessment Criterion: Temperatu

Venous: ?

Arterial: ?


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Venous: Normal

Arterial: Cool (blood flow blocked

extremity)


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Define acromegaly


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Acromegaly is a condition that

causes enlarges jaws and facia

bones in adults


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Define auscultation


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Auscultation is listening to the

internal sounds the body make


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Define hydrocephalus


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Hydrocephalus is the buildup o

cerebrospinal fluid in the ventric


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Define inspection.


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Inspection is looking, listening, a

smelling to distinguish normal fr

abnormal findings


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Define murmur


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A murmur is a sustained swishingblowing sound heard at the

beginning, middle, or end of the

systolic or diastolic phase


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Define palpation


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Palpation involves using the han

to touch body parts.


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Define pigmentation.


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Pigmentation is skin color. It i

usually unifrom over the body


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Define the following common ey

and visual abnormalities.

Cataract


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A cataract is an increased opacity

the lens


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Glaucoma


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Glaucoma is intraocular structur

damage resulting from increase

intraocular pressure


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Hyperopia


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Hyperopia is a refractive error

causing farsightedness


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Macular degeneration


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Myopia


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Myopia is a refractive error causi

nearsightedness


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Presbyopia


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Presbyopia is impaired near visiin middle-age and older adults

caused by loss of elasticity of th

lens


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Define the following common eyand visual abnormalities.

Retinopathy


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Retinopathy is a noninflammatoeye disorder resulting from chan

in retinal blood vessels


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Define the following common eyand visual abnormalities.

Strabismus


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Strabismus is a congenital conditin which both eyes do not focus

an object simultaneously


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Define the following normal breasounds heard over the posterio

thorax.

Bronchial


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Bronchial sounds are loud and higpitched with a hollow quality that

are related by air moving through

trachea close to chest wall


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thorax.

Bronchovesicular


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Bronchovesivular sounds are

blowing sounds that are mediumpitched and of medium intensity

that are created by air movingthrough large airways


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thorax.

Vesicular


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Vesicular sounds are soft, breezand low pitched that are created

air moving through smaller airwa


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Define the following terms relatto muscle tone and strength.

Atrophied


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Atrophied muscled are reduced

size; they feel soft and boggy


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Hypertonicity is increased musc

tone


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Define the following terms relatto muscle tone and strength.

Hypotonicity


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Hypotonicity is a muscle with lit

tone


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Define the following terms relatto the abdomen.

Aneurysm


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An aneurysm is a localized dialat

of a vessel wall


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Distention


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Distention is swelling by intestingas, tumor, or fluid in the abdomi

cavity


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Hernias


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A hernia is a protrusion ofabdominal organs through the

muscle wall


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Peristalsis


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Peristalsis is movement of contenthrough the intestines, which is

normal function of the small an

large intestine


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Striae


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Striae are stretch marks


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Define the following terms relatto the external eye.

Conjunctivitis


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Conjunctivitis is the presence oredness, which indicates an aller

or an infection


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Entropion


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An entropion is an eyelid margi

that turn in


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Exophthalmos


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Exophthalmos is a bulging of the


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Ptosis


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Define the following terms tharelate to the nose.

Excoriation


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Define the following terms tharelate to the nose.

Polyps


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Polyps are tumor-like growths


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Define the following terms tharelate to the oral cavity.

Exostosis


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Exostosis is extra bony growth

between the two palates


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Leukoplakia are thick white patch


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Leukoplakia are thick white patch

that are often precancerous lesion

seen in heavy smokers and peopl

with alcoholism.


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Define the following terms.

Cherry angiomas


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Cherry angiomas are ruby-red

papules


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Edema


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Goniometer


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Indurated


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Indurated means hardened


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Kyphosis


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A kyphosis is a hunchback, andexaggeration of the posterior

curvature of the thoracic spine


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Lordosis is a swayback, an increa

lumbar curvature


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Scoliosis


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Scoliosis is a lateral spinal curvat


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Senile keratosis is a thickening

the skin


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Turgor


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Define vocal or tactile fremitus


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Delirium is characterized by:


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Describe how you would assess f

phlebitis.


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Inspect the calves for localizedredness, tenderness, and swellin

over vein sites.


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Describe the sounds auscultatedthe following murmurs.

Grade 2

l l d bl b


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clearly audible but quiet

ib h d l d


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Describe the sounds auscultatedthe following murmurs.

Grade 3


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l d i h i d h ill


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loud with associated thrill


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l d h d ith t t th


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louder; heard without stethosco

E i ti f th i l d


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Examination of the eye includeassessment of five areas. Name

them (5)


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E l i h t f th Ri


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Explain how to perform the Rintest. (6)

1. Place the stem of the vibrating tuning fork against the

patient's mastoid process

2. Begin counting the interval with your watch

3. Ask the patient to tell you when he or she no longer hea

sound; not the number of seconds


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sound; not the number of seconds4. Quickly pace still0vibrating tines 1 to 2 cm from ear can

and ask the patient to tell you when he or she no longer h

the sound

5. Continue counting time the sound is heard by air condu6. Compare the number of seconds the sound is heard by b

conduction versus air conduction


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Deep palpation involves depress


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Deep palpation involves depressthe area 4 cm to assess the

conditions of organs.

Explain the difference between


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Explain the difference betweenLight palpation


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0.5- to 1-cm crusted lesion that is for raised and has a rolled, somewh

scaly border


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scaly border

Frequently appearance of underlyi

widely dilated blood vessels withinthe lesion


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0.5- to 1-cm brown, flat lesion; appearssun-exposed or nonexposed skin;

variegated pigmentation, irregular

borders and indistinct margins


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borders, and indistinct margins

Ulceration, recent growth, or recent

changes in long-standing mole areominous signs

Explain the following skinli i


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Explain the following skinmalignancies.

Squamous cell carcinoma

Occurs more often on mucosal surfaces

and nonexposed areas of skin than basa

cell


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cell

0.5- to 1.5-cm scaly lesion sometimes

ulcerated or crusted; appears frequentland grows more rapidly than basal cell


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Explain the following terms relat

to assessment of the heart


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to assessment of the heart.

S2


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Explain the following terms relat

to assessment of the heart


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to assessment of the heart.

S3


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Explain the steps the nurse wou


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Explain the steps the nurse wouuse to assess venous pressure. (

1. Place the patient in semi-Fowler position

2. Expose the neck; align the head

3. Lean the patient back into a supine positio

the level of venous pulsations begins to rise a


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p gpatient reaches 45-degree angle

4. Use two rulers to measure

5. Repeat the same measurement on the otheside

For each skin color variation, identify tmechanism that produces color change

common causes of the variation, and th

optimal sites for assessment:


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pColor: Cyanosis

Condition: ?

Causes: ?Assessment Locations: ?


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optimal sites for assessment:


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pColor: Erythema

Condition: ?


Condition: Increased visibility ofoxyhemoglobin caused by dilation or

increased blood flow

Causes: Fever, direct trauma, blushing,


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galcohol intake

Assessment Locations: Face, area of

trauma, sacrum, shoulders, other commsites for pressure ulcers


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Condition: Increased deposit of

bilirubin in tissues

Causes: Liver disease, destructiond bl d ll


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,red blood cells

Assessment Locations: sclera,

mucous membranes, skin


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Condition: Vitiligo

Causes: Congenital or autoimmun

condition causing lack of pigment


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condition causing lack of pigment

Assessment Locations: Patchy are

on skin over face, hands, arms


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Condition: Reduced amount of oxyhemoglobinCauses: Anemia

Assessment Locations: Face, conjunctivae, nail b

palms of hands

Condition: Reduced visibility of oxyhemoglobin


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Condition: Reduced visibility of oxyhemoglobin

resulting from decreased blood flow

Causes: Shock

Assessment Locations: Skin, nail beds, conjuncti

lips



optimal sites for assessment:C l T b


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Color: Tan-brown

Condition: ?


Condition: Increased amount of

melanin

Causes: Suntan, pregnancyA t L ti A


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p g yAssessment Locations: Areas

exposed to sun: face, arms, areola

nipples


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Identify the 12 cranial nerves. (1


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Identify the appropriate sites fo

inspection and palpation of thefollowing


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following.

Aortic area


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Fifth intercostal space just to the

of the sternum; left midclavicul


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line




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following.

Pulmonic area


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following.

Second pulmonic area


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Common symptoms include a

painless enlargement of one testi

and the appearance of a palpable

ll h d l h id f h


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small, hard lump on the side of th

testicle

Identify the correct range of mot

for the following terms.

Abd i


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Abduction


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Add ti


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Adduction

toward the midline


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D ifl i


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Dorsiflexion


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increasing angle between twoadjoining bones


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for the following terms.External rotation


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External rotation

rotation of the joint outward


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for the following terms.Hyperextension


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Hyperextension


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for the following terms.Internal rotation


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Internal rotation

rotation of the joint inward


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bending of toes and foot downwa


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for the following terms.Pronation


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Pronation

that the frontal or ventral surfacface downward


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for the following terms.Supination


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p

front or ventral surfaces face upw


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Identify the functions of thecerebellum.


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The cerebellum controls muscul

activity, maintains balance andequilibrium, and helps to contr

t


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posture

Identify the guidelines to achiev

the best results during inspectio(6)


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( )

a. Adequate lighting is available

b. Use direct light source

c. Inspect each area for size, shape, colo

symmetry, position, and abnormalityd. Position and expose body parts as

needed maintaining privacy


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needed, maintaining privacy

e. Check for side-to-side symmetryf. Validate findings with the patient

Identify the internal eye structur

that you would examine with aophthalmoscope. (6)


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p p

a. Retinab. Choroids

c. Optic nerve discd. Macula

e Fovea centralis


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e. Fovea centralis

f. Retinal vessels

Identify the key landmarks of thchest. (6)


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a. Patient's nipplesb. Angle of Louis

c. Suprasternal notchd. Costal angle

e Clavicles


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e. Clavicles

f. Vertebrae

Identify the physical findings of t

skin that are indicative of substanabuse. (8)


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a. Diaphoresis

b. Spider angiomas

c. Burns (especially on fingers)

d. Needle markse. Contusions, abrasions, cuts, scars

f. "Homemade" tattoos


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g. Vasculitish. Red, dry skin

Identify the principles to follow

keep an examination well organiz(7)


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a. Compare both sides for symmetry

b. If a patient is ill, first assess the systems of the body pmost at risk

c. Offer rest periods if the patient becomes fatigued

d. Perform painful procedures near the end of the

examinatione. Record assessments in specific terms in the record

f. Use common and accepted medical terms and


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abbreviations

g. Record quick notes during the examination to avoiddelays

Identify the questions related to

following acronym.CAGE


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C: Have you ever felt the need to cut down on

your use?

A: Have people annoyed you by criticizing yo

use?

G: Have you ever felt bad or guilty about youuse?

E: Have you ever used or had a drink first thi


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E: Have you ever used or had a drink first thi

in the morning as an "eye opener" to steady ynerves or feel normal?

Identify the structures of the

external eye that you would inspe(7)


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a. Position and alignmentb. Eyebrows

c. Eyelids

d. Lacrimal apparatuse. Conjunctivae and sclera

f C


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f. Corneas

g. Pupils and irises

Identify the three parts of the ea

canal and list the structures witheach. (3)


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a. External ear (auricle, outer ear canal, and tympanic membr

b. Middle ear (three bony ossicles)c. Inner ear (cochlea, vestibule, and semicircular canals)


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Identify the three systematic

approaches to palpation of thebreast. (3)


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a. Clockwise or counterclockwis

b. Vertical technique

c. Center of the breast in radia

fashion


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fashion

Identify the three types of hearin

loss. (3)


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a. Conduction

b. Sensorineuralc. Mixed


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Identify the two types of norma

reflexes and provide an exampleeach. (2)


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a. Deep tendon reflexes (biceps

triceps, patellar, Achilles)

b. Cutaneous reflexes (plantar

gluteal, abdominal)


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g , )

In a patient with pneumonia, the nurse

hears high-pitched, continuous musica

sounds over the bronchi on expiration.

These sounds are called:

1. Rhonchi

2. Crackles


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3. Wheezes

4. Friction rubs

3. High-velocity airflow through

severely narrowed or obstructeairway


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List at least 12 specific observatio

of the patient's general appearan

and behavior that should be

reviewed. (12)


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a. Gender and race

b. Agec. Signs of distress

d. Body type

e. Posture

f. Gait

g. Body movements

h. Hygiene and grooming

i. Dress

j Body odor


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j. Body odor

k. Affect and moodl. Speech

List seven variations in the nurs

individual style that are appropriwen examining older adults. (7


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a. Do not stereotype about aging patients's level of cogn

b. Be sensitive to sensory or physical limitations (more

c. Adequate space is needed

d. use patience, allow for pauses, and observe for detaile. Certain types of information may be stressful to give

f. Perform the examination near bathroom facilities

g. Be alert for signs of increasing fatigue


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g. Be alert for signs of increasing fatigue

List seven variations in the nurs

individual style that are appropriwhen examining children. (7)


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a. Gather all or part of the histories of infants and children fro

parentsb. Perform the examination in a nonthreatening are and provi

time for play

c. Offer support to the parents during the examination and do

pass judgment

d. Call children by their first names and address their parents

and Mrs.

e. Use open-ended questions to allow parents to share more

information


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f. Treat adolescents as adultsg. Provide confidentiality for adolescents; speak alone with the

List the five nursing purposes fo

performing a physical assessmen(5)


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a. Gather baseline data about the patient's hestatus

b. Support or refute subjective data obtained

the nursing history

c. Confirm and identify nursing diagnoses

d. Make clinical judgments about a patient's

changing health status and management


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changing health status and management

e. Evaluate the outcomes of care

List the principles related to th

nurse performing daily physicaexaminations. (4)


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a. A head-to-toe assessment is required dailyb. Reassessment is performed when the patie

condition changes as it improves or worsens

c. The environment, equipment, and patient properly prepared

d. Safety for confused patients should be a

i it


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priority

List the risks for skin lesions in

hospitalized patients. (9)


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A. Exposure to pressure during immobilizati

b. Various medicationsc. Neurologic impairment

d. Chronic illness

e. Orthopedic injuryf. Diminished mental status

g. Poor tissue oxygenation

h Lo cardiac output


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h. Low cardiac output

i. Inadequate nutrition

List the sequence for assessing t

nodes of the neck (6)


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1. Occipital nodes ar the base of the sku

2. Postauricular nodes over the mastoid

3. Preauricular nodes at the base of the

skull

4. Retropharyngeal nodes at the angle

the mandible

5 Submandibular nodes


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5. Submandibular nodes

6. Submental nodes

List the six factors to consider wh

assessing a murmur. (6)


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a. Auscultate all valve areas for placement in the cardiac cycle

(timing), where best heard (location), radiation, loudness, pitc

quality

b. Distinguish between systolic and diastolic murmurs by

determining if they occur between S1 and S2 (systolic) and S2

(diastolic)

c. The location is not necessarily over the valvesd. listen over areas besides where the murmur is heard best to

for radiation

e. Feel for thrust or intermittent palpable sensation at the

auscultation site in serious murmurs and rate the intensity


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auscultation site in serious murmurs and rate the intensity

f. Low-pitched murmur best heard with the bell of the stethoschigh-pitched murmur is best heard with the diaphragm

List three actions that should b

taken to ensure accurate weigh

measurement of a hospitalized

patient. (3)


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a. Weigh patients at the same tim

of day

b. Weigh patients on the same scc. Weigh patients in the same

clothes


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Name the three types of lice. (3


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a. Pediculus humanus capitis (he

lice)

b. Pediculus humanus corporis(body lice)

c. Pediculus pubis (crab lice)


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p ( )

Proper preparation for examinati

should include: (5)


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a. Infection controlb. Environment

c. Equipment

d. Physical preparation of the patie

e. Psychological preparation of the


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patient

Sound: Crackles

Site Auscultated: ?

Cause: ?

Character: ?


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Site Auscultated: Are most common in dependent lobes: right

left lung bases

Cause: Random, sudden reinflation of groups of alveoli; disru

passage of air through small airways

Character: Fine crackles are high-pitched fine, short; interrup

crackling sounds heard during end of inspiration; usually not

cleared with coughing.

Medium crackles are lower; moister sounds heard during midd

inspiration; not cleared with coughing.


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Coarse crackles are loud, bubbly sounds heard during inspiratnot cleared with coughing.

Sound: Pleural friction rub

Site Auscultated: ?

Cause: ?

Character: ?


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Site Auscultated: Heard over anterior laterallung field (if patient is sitting upright)

Cause: Inflamed pleura; parietal pleura rubb

against visceral pleura

Character: Dry, rubbing, or grating quality isheard during inspiration or expiration; does

clear with coughing; heard loudest over lowe


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lateral anterior surface.

Sound: Rhonchi (sonorous whee

Site Auscultated: ?

Cause: ?

Character: ?


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Site Auscultated: Are primarily heard over

trachea and bronchi; if loud enough, able to bheard over most lung fields

Cause:Muscular spasm, fluid, or mucus in la

airways; new growth or external pressurecausing turbulence

Character: Loud, low-pitched, rumbling coar

sounds are heard either during inspiration or


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g p

expiration; sometimes cleared by coughing.

Sound: Wheezes (sibilant wheez

Site Auscultated: ?

Cause: ?

Character: ?


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Site Auscultated: Heard over all lung fiCause: High-velocity airflow through

severely narrowed or obstructed airway

Character: High-pitched, continuousmusical sounds are like a squeak heard

continuously during inspiration or


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expiration; usually louder on expiration

Structures examined during

assessment of the neck include:


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a. Neck musclesb. Lymph nodes of the head and n

c. Carotid arteries

d. Jugular veins

e. Thyroid gland


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f. Trachea

Syncope is caused by _______


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Syncope is caused by a drop in he

rate and blood pressure


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The American Cancer Society

(2010) recommends the followin

guidelines for early detection obreast cancer. (6)


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a. Monthly BSE for women in their 20s

b. Women ages 20 years and older need to report any bchanges

c. Women need to have a clinical breast examination ev

years (ages 20-40 years) and yearly after the age of 40 y

d.Women with a family history need a yearly examinate. Asymptomatic women need a screening mammogram

age 40 years. Women older than age 40 years need an

annual mammogram

f. For women with increased risk, additional testing sho


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, g

be discussed with the health care provider

The component that should receive thehighest priority before a physical

examination is:

1. Preparation of the equipment2. Preparation of the environment

3. Physical preparation of the patient


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4. Psychological preparation of the pati

4. A thorough explanation of thepurpose and steps of each

assessment lets patients know whto expect and what to do so they c

cooperate.


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The following are sounds that a

described when auscultating. Ple

explain each one.Amplitude


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Amplitude describes the loudne

soft to loud


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explain each one.Duration


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Duration describes length of tim

that sound vibrations last


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explain each one.Frequency


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Frequency indicates the number

sound wave cycles generated pesecond by a vibrating object


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explain each one.Quality


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Quality describes sounds of simi

frequency and loudness


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The normal tympanic membran

appears:


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The normal tympanic membran

appears translucent, shiny, andpearly gray


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The nurse assesses the skin turgor of the pati

by:

1. Inspecting the buccal mucosa with a penlig

2. Palpating the skin with the dorsum of the h

3. Grasping a fold of skin on the back of theforearm and releasing

4. Pressing the skin for 5 seconds, releasing,

ti h ti t f d th


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noting each centimeter of depth

3. Normally, the skin lifts easily asnaps back immediately to its

resting position; the back of thehand is not the best place to test f

turgor


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The purpose of digital examinati

is:


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Digital examination is used to det

colorectal cancer in the early stagand prostatic tumors


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The purpose of the Glasgow Com

Scale is to:


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The Glasgow Coma Scale provid

an objective measurement of

consciousness on a numerical scover time


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The purpose of the Mini-Menta

State Examination is to measur


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The Mini-Mental State Examinat

measures orientation and cognitfunction


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The second heart sound (S2) occurs wh

1. Systole begins

2. There is rapid ventricular filling

3. The mitral and tricuspid valves close

4. The aortic and pulmonic calves close


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4. After the ventricle empty,ventricular pressure falls below th

in the aorta and pulmonary arteryallowing the valves to close and

causing the second heart sound


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The sensory pathways of the cent

nervous system conduct what tyof sensations? (5)


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a. Painb. Temperature

c. Positiond. Vibration

e. Crude and finely localized tou


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When assessing the patient's thorax, the nurs

should:

1. Complete the left side and then the right sid

2. Compare symmetrical areas from side to s

3. Begin with the posterior lobes on the rightside.

4. Change the position of the stethoscope betw

inspiration and expiration


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inspiration and expiration.

2. Use systematic pattern whencomparing the right and left sides

You need to compare lung sounds

one region on one side of the bodwith sounds in the same region o

the opposite side of the body


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When palpating abnormal masse

the breast, you should note: (7


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a. Location in relation to the quadran

b. Diameter

c. Shape

d. Consistency

e. Tenderness

f. Mobility

g. Discreteness


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While examining Mr. Parker, the nurse notes

circumscribed elevation of skin filled with ser

fluid on his upper lip. The lesion is 0.4 cm in

diameter. This type of lesion is called a:

1. Macule2. Nodule

3. Vesicle

4. Pustule


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3. Circumscribed elevation of sk

filled with serous fluid, smaller th

1 cm


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Chapter 30 - Health Assessment

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Transcript of Chapter 30 - Health Assessment