Health Assessment Mod A

  1. Six components to POMR
    • 1.Comprehensive health history
    • 2.Complete physical examination
    • 3.Problem list
    • 4.Assessment and plan
    • 5.Baseline and problem-directed laboratory imaging studies
    • 6.Progress notes
  2. Define Beneficence:
    do good for the patient
  3. Define Nonmaleficence:
    do no harm to the patient
  4. Define utilitarianism:
    the need to consider the appropriate use of resources for the greater good of the larger population
  5. Define fairness/justice:
    recognition of the balance between autonomy and competing interests of family
  6. Define deontological imperatives:
    the duties of care providers established by tradition and in cultural contexts
  7. List the normal structure for a health history:
    • Chief complaint
    • History of present illness
    • Past medical history
    • Family history
    • Personal and social history
    • Review of systems
  8. List the 8 components of the analysis of a symptom (PQRSTU)
    • 1.Location
    • 2.Quality
    • 3.Quantity
    • 4.Timing
    • 5.Setting
    • 6.Aggravating/alleviating factors
    • 7.Associated factors
    • 8.Patient perception
  9. Describe position- Dorsal Recumbent:
    Used for examining genital/rectal areas.

    Pt lies supine with knees bent and feet flat on table
  10. Describe position- Lateral Recumbent:
    Side lying position, with legs extended or flexed.

    May be used to listen to heart sounds
  11. Describe position- Lithotomy:
    Generally used for pelvic exam.

    Begins in dorsal recumbent then stabilize feet in stirrups
  12. Describe position- Sims:
    Used to examine the rectum or obtaining rectal temperature.

    Pt starts in lateral recumbent position. Torso is rolled toward a prone position; the top leg is flexed sharply at the hips and knee and the bottom leg is flexed slightly
  13. Describe position- Fowler's:
    Pt is sitting copletely upright or slightly bent back, legs can be either bent or straight out
  14. Describe position- Trendelenburg:
    Pt i slying supine with legs slightly higher than head
  15. AKA the number of cardiac cycles per minute
    heart rate
  16. Describe- Dyspnea
    difficult and labored breathing w/ shortness of breath
  17. Describe- Orthopnea-
    Shortness of breath that begins or increases when the patient lies down
  18. Describe- Paroxysmal nocturnal dyspnea
    a sudden onset of shortness of breath after a period of sleep
  19. Describe- Platypnea-
    dyspnea increases in the upright posture
  20. Describe- Bradypnea-
    a rate slower than 12 respirations per min, may indicate splendid level of cardiorespiratory fitness
  21. Describe- Hyperpnea-
    Pt is breathing laboriously, as if forced, and deeply
  22. Describe- Kussmaul breathing-
    always deep and most often rapid, the eponym applied to the respiratory effort associated w/ metabolic acidosis
  23. Describe- Hypopnea-
    abnormally shallow respirations
  24. Describe- Cheyne-Strokes-
    periodic pattern of breathing w/ intervals of apnea followed by crescendo/decrescendo sequence of resp; may be pattern for sleep of children and older adults, pattern for seriously ill patients w/ brain damage
  25. Describe- Tachypnea-
    faster than 20 breaths per minute
  26. Describe- Sighing-
    frequently interspersed deeper breathing
  27. Describe- Air trapping-
    the result of prolonged but inefficient expiratory effort
  28. Describe- Biot respiration-
    somewhat irregular resps varying in depth and interrpted by intervals of apnea, but lacking reptitve pattern of periodic resp. associated w/ severe and persistent increased intracranial pressure
  29. Describe Bronchophony-
    "99" or "1,2,3"

    • Normal- sounds muffled
    • Consolidated- sounds clear
  30. Describe Whispered pectoriliquy-
    "99" or "1,2,3" (in a whisper)

    • Normal- sounds muffled
    • Consolidated- sounds clear but louder
  31. Describe Egophony-

    • Normal- sounds like muffled "e"
    • Consolidated- sounds like "a"
  32. Breath sounds- Tracheal
    high pitch/very loud intensity

    I:E 1:1
  33. Breath sounds- Bronchial
    high pitch/ loud intensity

    I:E 1:2
  34. Breath sounds- Broncho-vesicular
    med pitch/ med intensity

    I:E 1:1
  35. Breath sounds- Vesicular
    low pitch, soft intensity

    I:E 2.5:1
  36. Crackles are _________, rhonchi & wheezes are _________
    discontinuous, continuous
  37. Identify:

    Fine high pitched
    popping sounds or noises
    short in duration
    heard more at end of inspiration
    not cleared by coughing
    hear in CHF, asthma, bronchitis
    Fine Crackles
  38. Identify:

    low pitched
    bubbling sounds that start early in inspiration and can extend into expiration
    usually longer in duration
    Course Crackles
  39. Identify:

    low pitched
    loud-like snoring
    primarily heard on expiration
    may clear with coughing
    ex.-bronchitis or pneumonia
  40. Identify:

    high pitched
    musical sound similar to a squeak
    heard during expiration
    often heard in asthma pt's
  41. Identify:

    Like sandpaper
    not cleared by coughing
    heard in both inspiration and expiration
    low pitched, coarse rubbing
    heard in inflammation of pleural spaces
    Pleural friction rub
  42. Describe the physical/developmental changes that occure in the aging client in a respiratory assessment:
    • chest expansion decreased, less able to use the respiratory m.
    • the AP diamter of the chest is increased in relation to the lateral diameter
    • difficulty breathing deep and holding
  43. Functions of the skin:
    • protection
    • proide sensory contact
    • temperature regulation
    • production of vitamin D
    • excretion of sweat, urea, and lactic acid
    • expression emotions
    • repair
  44. Layers of the epidermis:
    _________- basal skin layer; deepest layer, helps to form new skin cells with keratin
    stratum germinativum
  45. Layers of the epidermis:
    __________- outer horny layer of flattened and closly packed dead cells being shead
    stratum corneum
  46. gives skin pigmentation
  47. Sweat glands:
    ______- dilute saline, sweat, help to cool surface of skin and reduce temp
  48. Sweat glands:
    ________- activated in puberty, body order. milky secretion in folds of skin
  49. aka hair loss
  50. normal variations in the skin:
    • striae-stretch marks
    • vitiligo-unpigmented skin
    • freckles- small flat macules
    • mole- a lot of melanin in one area
    • birthmarks- tan, reddish, or brown
  51. usually found on face and neck, bright red raised leasion, doesn't blanch (turn white) with pressure
    strawberry hemangioma
  52. Pallor
    whitish overtone to skin
  53. Erythema
    extreme redness of skin due to excess blood and dilated superficial capillaries
  54. Cyanosis
    Bluish; lack of oxygen
  55. Jaundice
    yellow color; rising amounts of billirubin in blood; liver problem
  56. Caroten
    Orange color; excess orange diet
  57. Normal variations:
    _____- color of cherry found on trunk or neck
    Cherry angioma
  58. Normal variations:
    _________- small red branching, blanch with direct pressure; found on face, neck, arm and upper trunk; cirosis of live
    spider angioma
  59. Normal variations:
    _______- permanent dilation of a group of superficial capillaries and venules; tongue and nose
  60. Abnormal variations:
    _______- small pinpoint lesions
  61. Abnormal variations:
    ________- bruise
  62. Lesions- Patterns or shape

    ______- circular
  63. Lesions- Patterns or shape

    ________- lesions run together (hives)
  64. Lesions- Patterns or shape

    ________- distinct, individual lesions that remain separate (molluscum)
  65. Lesions- Patterns or shape

    ______- clusters of lesions
  66. Lesions- Patterns or shape

    ______- twisted, coiled or snakelike
  67. Lesions- Patterns or shape

    ______- resembles iris of eye with concentric rings of color (erythema multiforme)
  68. Lesions- Patterns or shape

    ______- scratch, streak, line, or stripe
  69. Lesions- Patterns or shape

    ______- annular lesions that grow together (psoriasis)
  70. Lesions- Patterns or shape

    ______- linear arrangement along a nerver route or dermatome (shingles)
  71. AKA hair loss
  72. AKA hair growth
  73. caused by chronic hypoxia, nail bed exceeded 180 degrees
  74. central depression of nail, lateral elevation of nail plate
  75. Primary skin lesions:

    ex- measles
    color change
    <l cm
  76. Primary skin lesions:

    ex- virtiligo
    color change
    may be irregular shape
  77. Primary skin lesions:

    ex- wart, mole
  78. Primary skin lesions:

    ex- psoriasis
    rough lesion with flat top
  79. Primary skin lesions:

    ex- fibroma
    extends into dermis
  80. Primary skin lesions:

    ex- benign tumor
    larger nodule
    solid and soft or firm
    deeper into dermis
    larger than a few cm
  81. Primary skin lesions:

    ex- chicken pox
    serous fluid filled area
  82. Primary skin lesions:

    ex- blister
    vessicle greater than 1 cm
  83. Primary skin lesions:

    filled with purulent fluid(yellow, infectious puss)
  84. Primary skin lesions:

    ex-sebaceous cyst
    fluid-filled cavity in dermis
  85. Primary skin lesions:

    ex- insect bites
    irregularly shaped cutaneous edema
  86. Primary skin lesions:

    coalesced wheals
    caused by allergic reaction
    note pattern or shape
  87. Primary skin lesions:

    described as boil
    localized collection of puss
    inflammation /redness
  88. Secondary skin lesions:

    thickened epidermis
    secondary to persistent rubbing/ itching
    produces tightly packed sets of papules
    looks like moss or lichen
  89. Secondary skin lesions:

    Linear cracks in skin
    ex- chilosis, athlete's foot
  90. Secondary skin lesions:

    thin to thick fibrous tissue that replaaces normal skin following injury or laceration to dermis
  91. Secondary skin lesions:

    elevated scar
    tissue grows beyond the borders of the scar
    higher incidence among blacks
    keloid scar
  92. Secondary skin lesions:

    ex- burn
    loss of epidermis following rupture of vessicle/bulla/pustule
  93. Secondary skin lesions:

    loss of epidermis and dermis
    stasis ulcer, decubitus ulcer
    stasus ulcer- decreased venus return
  94. Staging pressure ulcers:

    intact skin with non-blanchable redness
    stage I
  95. Staging pressure ulcers:

    Partial thickness loss of dermis presenting as a shallow open ulcer
    stage II
  96. Staging pressure ulcers:

    Full thickness tissue loss; subcutaneous fat may be visible
    stage III
  97. Staging pressure ulcers:

    Full thickness tissue loss with exposed bone, tendon or muscle.
    stage IV
  98. Staging pressure ulcers:

    Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
Card Set
Health Assessment Mod A
Health Assessment Module A