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Health Assessment Quiz 1
assess, general survey, pain
32
Nursing
Graduate
07/01/2013

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Cards

Term
pain scales
Definition
numeric rating scales, Faces Pain Scale-Revised (FPS-R), Oucher Scale
Term
BMI ranges
Definition
under wt <18.5
normal 18.5-24.9
over wt 25-29.9
obese class 1 30-34.9
obese class 2 35-34.9
extreme obesity class 3 > or = 40
Term
Metaboic Syndrome Factors
Definition
WC women > or = 35" men > or = 40"
BP > or = 130 OR 85
FBG > or = 100
HDL women <50 men <40
Triglycerides >150
Term
3 of 5 Metabolic Syndrome Factors lead to
Definition
1. likely to be diabetic
2. risk of sudden cardioembolic death increases
Term
pulse force
Definition
3+ full/bounding - work out/ anxiety
2+ normal - hanging
1+ weak/thready = decreased stroke vol
0 absent
Term
"normal" vitals
Definition
P 60-100
BP 120 AND 80
RR 10-20
Temp 37C (98.6 F) - 35.8 - 37.3 (96.4 - 99.1) rectal measures 1 F higher
Term
factors affecting BP
Definition
age, gender, race, diurnal rhythm
wt, exercise, emotions, stress
Term
level of BP factors
Definition
cardiac output
vascular resistance
volume
viscosity
elasticity of arterial walls
Term
false BP's
Definition
arm above heart - false low
arm below heart - false high
size too narrow - false high
size too loose/uneven - false high
Term
edema 1+
Definition
mild pitting - slight indentation, no perceptible swelling of the leg
Term
edema 2+
Definition
moderate pitting - indentation subsides rapidly
Term
edema 3+
Definition
deep pitting - indentation remains for short time, leg looks swollen
Term
edema 4+
Definition
very deep pitting - indentation lasts a long time, leg is very swollen
Term
edema
Definition
fluid in intercellular space, pigskin or orange-peel look
unilateral - local or peripheral cause
bilateral - central problem - heart or kidney failure
Term
jaundice
Definition
rising amounts of bilirubin in blood
> 2 weeks - biliary tract obstruction
1st day after birth - hemolytic disease
Term
physiologic jaundice
Definition
increased RBC's that hemolyze after birth, hemoglobin in RBC is metabolized by liver and spleen - pigment converted to bilirubin
Term
pallor
Definition
red-pink tones from oxygenated hemoglobin in blood are lost
Term
pallor of impending shock
Definition
presents with rapid pulse rate, oliguria, apprehension and restlessness
Term
abnormal characteristics of pigmented lesions
Definition
ABCDE + discharge
Term
ABCDE + D
Definition
asymmetric
border irregularity
color variation
diameter > 6mm
elevation or enlargement
+ discharge
Term
lesions
Definition
trauma or pathologic change in previously normal structures
Term
evaluate lesions
Definition
color
elevation
pattern or shape
size (in cm)
location and distribution
exudate (not color and odor)
Term
nail shape contour
Definition
normal 160
curved < 160
early clubbing 180
late clubbing >180 with spongy nail base
Term
contusion
Definition
bruise - mechanical injury (blow) hemorrhage into tissues, skin intact
Term
contusion coloring
Definition
1. red-blue or purple (immediately or w/in 24 hrs)
2. blue to purple
3. blue-green
4. yellow
5. brown to disappearing
Term
contusions differ from _________, ____________, & __________ because these are not from blunt trauma
Definition
petechiae, ecchymosis, and purpura
Term
pressure ulcer stage 1
Definition
red/pink skin unbroken
light skin blanches
dark skin - looks darker, doesn't blanch
Term
pressure ulcer stage 2
Definition
partial-thickness, loss of epidermis/dermis, superficial/shallow, open blister, red/pink wound bed
Term
pressure ulcer stage 3
Definition
full-thickness, subcutaneous (like crater) may see subcutaneous fat but no muscle/bone/tendon
Term
pressure ulcer stage 4
Definition
full-thickness/ all skin layers and supporting tissue, exposes muscle/tendon or bone, may show
slough - stringy matter attached to wound bed
or
eschar - bk/ brn necrotic tissue
Term
BMI overestimates
Definition
body fat in very muscular persons
Term
BMI underestimates
Definition
body fat in older adults who have lost muscle mass
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