health assessment

Start Studying!

Terms

undefined, object

copy deck

hemocrit: identifies volume of red blood cells/liter of blood.

males 40-53% less than 36%

females 36-48% less than 33%
optimal blood pressure: systolic 120 diastolic 80
Tongue Loss of taste: zinc deficiency,

7th cranial nerve defect

certain meds.
tongue strength decrease: defect of the 12th.(hypoglossal) cranial nerve
tongue+ abnormal shortened frenulum: limits movement, tongue tied
tongue long fissures: dehydration
small tongue: malnutrition
atrophied tongue fasciculations: cranial nerve 12 damage
bruxism: grinding of the teeth r/t
stress, tmj, or malocclusion
nasal polyps, what do they indicate: usually from allergies,
most r/t cancer
What is leukoplakia and where is it found???: thick white patches of cells on the ventral side of the tongue.
r/t poorly fitted dentures

requires a M.D. referrral
What is the site for oral cancer?: underneath the tongue
Tongue cancer can most commonly be found where on the tongue?: side of the tongue
What would an abnormal Uvula look like?: bifid.
may be r/t submucous cleft palate
Who would have a Torus Palatinus??: often in females
Eskimos
Native Americans
Asians
Hard/ Soft palate with deep purple, raised or flat lesions, could be ??: Karposi sarcoma
A yellow hard/soft palate could be a sign of ?: jaundice
If the pupils are "Mydriasis" they are: both pupils will be dilated and fixed.

caused by central nerve system injury,circulatory collapse,deep anesthesia
What is anisocoria?: unequal sized pupils
miosis is?: pinpoint pupils, constricted and fixed

r/t narcotic drugs (morphine)
brain damage
perceptive/ sensorineural hearing ?: transmission of sound waves in the inner ear.
cranial nerves assisting with mouth and throat function?: trigeminal

facial

glossopharyngeal

hypoglossal
Innervation of the eye muscles is by what nerves?: occulomotor
trochlear
abducens
anterior chamber is where?: located between the cornea and the lens.
The area between the iris and lens is filled with what type of liquid?: aqueous
THe viterous chamber is where?: the eye, in the area behind the lens to the retina.
Hypopyon eye= abnormal: inflammatory response in which WBC accumulate in the anterior chamber and produce cloudiness in front of the iris
Chalazion EYE abnormal: an infection of the meibomian gland.

may produce extreme swelling of the lid, moderate redness, some pain.
corneal light reflex test: asses parallel alignment of the eyes.

with pen light 12 inches from bridge of the nose, the light should reflect in the same location in each eye. IF not there is a muscle weakness
conductive hearing: transmission of sound through external and middle ear.
a red bulging tympanic membrane is r/t: acute otitis media
a tympanic membrane that is yellowish with bubbles is?: serous otitis media
a blue or dark red tympanic membrane is seen with: blood behind the tympanic membrane r/t
trauma
a scarred tympanic membrane would look like what?: white spots and strikes from infection
what causes a perforated tympanic membrane?: untreated infection
what causes a retracted tympanic membrane??: negative ear pressure
The end result of the nursing assessment is to ?: formulate a nursing diagnosis
An ongoing or partial assessment of a client includes?: a brief reassessment of the client's normal body system
The purpose of a comphrensive assessment is ?: arrive at conclusions about the clients health
After proposing a possible nursing diagnosis the nurse would then ?: check for the presence of defining characteristics
The depth and scope of the nursing assessment has expanded sigificantly primarily due to ?: technology and biomedical advances
empacho: "blocked intestine" a culture-bound syndrome thought to result from a food lump sticking to the intestine wall
Race: a breeding population that mates largely with it group
ethnic group: concerned with learned behavior independent of genetics or nationality
Four types of assessments: initial comprehensive assessment
ongoing or partial assessment
focused or problem-oriented assessment
emergency assessment
initial comprehensive assessment: is needed when the client first enters a health care setting and periodically thereafter to establish baseline information to use against future health changes.
ongoing or partial assessment: consist of data collected after an initial assessment, includes a mini overview of the client's body systems to detect any new problems
focused or problem oriented assessment: when a omprehensive assessment exists for the client but the client arives with a specific health care concern.
example a client has ear pain, the nurse would focus on the pain.
collecting subjective data phases of the interview. introductory phase: explain purpose of interview
discuss the types of questions that will be asked.
assure client confidentiality.
make client comfortable.
develop rapport.
phases of the interview working phase: nurse elicits client's comments about mayor biological data
reasons for seeking health care
history of present illness
past health history
family health history
ROS
lifestyle and health practices
developmental level
Phases of the interview Summary and Closure phase: summarizes information
validates problems and goals
possible plans to resolve problems
nursing and collabrative problems identifed.
ask client if they have any questions.
open ended questions usually beging with?: "How" or "What"
closed ended questions begin with: "When" or "Did"

Start Studying!

Deck Info

Number of cards 53