CNUR 107: Health Assessment Techniques

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Questions and Answers

Explain the general survey

The general survey is a quick overall impression of the patient, where the nurse observes the patient's physical appearance, body structure, mobility, and behaviour. It provides an initial assessment of the patient's overall health status.

Explain the 60-second assessment

The 60-second assessment is a rapid assessment that takes approximately 60 seconds to perform. It involves taking the patient's vital signs, which include temperature, pulse, respirations, blood pressure, and oxygen saturation.

Describe the normal posture and body build.

Normal posture is characterized by an upright stance with a balanced distribution of weight. The body build typically refers to the individual's height and weight, along with the relative proportions of their body.

During the general survey part of the examination, gait is assessed. When walking, note the aspects of normal gait.

Normal gait is characterized by a smooth, rhythmic, and coordinated movement. The patient's steps should be smooth and even, with a steady pace and balanced weight distribution. The arms should swing naturally and rhythmically in opposition to the legs, and the head should be held upright. Signup and view all the answers

Describe normal changes in height and in weight distribution for an adult in their 80s and 90s.

As adults age, they may experience a gradual decline in height due to compression of the intervertebral discs and changes in posture. Weight distribution may also shift, with a greater concentration of weight around the abdomen. Signup and view all the answers

Describe the tympanic membrane thermometer, and compare its use to other forms of temperature measurement.

The tympanic membrane thermometer measures temperature by detecting the infrared radiation emitted from the eardrum. Compared to other methods, such as oral or axillary temperature, the tympanic thermometer offers a quick and convenient way to take a temperature, especially for infants and young children. However, it is important to ensure proper technique and to consider potential factors that may affect accuracy, such as earwax buildup or ear infections. Signup and view all the answers

Describe four qualities to consider when assessing the pulse.

When assessing the pulse, consider these key qualities: Rate, rhythm, volume, and equality. Rate refers to the number of beats per minute. Rhythm describes the regularity or irregularity of the pulse. Volume refers to the strength or amplitude of the pulse. Equality refers to whether the pulse is similar in strength and volume between both extremities. Signup and view all the answers

Relate the qualities of normal respirations to the appropriate approach to counting them.

Normal respirations are characterized by an even and regular rhythm, with a rate between 12 and 20 breaths per minute. When counting respirations, observe the patient's chest movement and count the number of breaths for one full minute. It is important to avoid influencing the patient's breathing pattern while counting. Signup and view all the answers

Define and describe the relationships among the terms blood pressure, systolic pressure, diastolic pressure, pulse pressure, and mean arterial pressure.

Blood pressure is the force of blood against the artery walls. Systolic pressure is the highest pressure measured during a heartbeat. Diastolic pressure is the minimum pressure measured between heartbeats. Pulse pressure represents the difference between systolic and diastolic pressure. Mean arterial pressure is the average pressure in the arteries throughout the cardiac cycle. Signup and view all the answers

List factors that affect blood pressure.

Various factors can affect blood pressure, including age, gender, race, genetics, lifestyle, stress, medications, diet, caffeine intake, alcohol consumption, smoking history, and physical activity levels. Signup and view all the answers

Relate the use of an improperly sized blood pressure cuff to the possible findings that may be obtained.

Using an improperly sized blood pressure cuff can lead to inaccurate readings. An overly large cuff will underestimate blood pressure, while an overly small cuff will overestimate blood pressure. Signup and view all the answers

Explain the significance of phase I, phase IV, and phase V Korotkoff's sounds during blood pressure measurement.

Korotkoff's sounds are the audible sounds heard during blood pressure measurement. Phase I corresponds to the first clear tapping sound, which represents systolic pressure. Phase IV is characterized by a softer, muffled sound, indicating diastolic pressure. Phase V represents the point where the sound disappears, marking the end of diastolic pressure. Signup and view all the answers

What instrument is used when there is difficulty in palpating the pulse?

A Doppler ultrasound device is employed when the pulse is difficult to palpate. Signup and view all the answers

List the developmental considerations in an older adult for blood pressure, temperature, pulse, and respirations.

In older adults, blood pressure may naturally elevate due to age-related changes in blood vessels and cardiovascular function. Body temperature regulation may be less efficient with advancing age, leading to fluctuations in temperature. Pulse rate may also tend to increase with age. Respiratory rate may remain within the normal range, but changes in lung capacity and elasticity may occur. Signup and view all the answers

Identify the differences between nociceptive and neuropathic pain.

Nociceptive pain arises from damage to or irritation of tissues, such as pain from a cut, burn, or injury. Neuropathic pain, on the other hand, originates from damage to the nerves themselves, often caused by conditions like diabetes, shingles, or spinal cord injury. Signup and view all the answers

Identify the most reliable indicator of a person's pain.

The most reliable indicator of a person's pain is their self-report. Individuals are the ultimate experts on their own experiences, and their subjective descriptions of pain should be taken seriously. Signup and view all the answers

Recall the OPQRSTUV questions for an initial pain assessment.

The OPQRSTUV questions are a structured approach to assessing pain. They include: Onset (when did it start), Provocation (what makes it worse), Quality (how does it feel), Region (where is it located), Severity (how bad is it), Timing (when does it come and go), Understanding (what do you think is causing it), and Value (how does it affect your daily life). Signup and view all the answers

Describe physical examination findings that may indicate pain.

Physical examination findings that may indicate pain include: guarding, grimacing, agitation, restlessness, decreased or absent movement, increased heart rate and respiratory rate, changes in blood pressure, and muscle tension or spasms. Signup and view all the answers

The pain ______ moves from the spinal cord to the brain.

impulse Signup and view all the answers

Neurons from the brain stem release ______ that block the pain impulse.

neurotransmitters Signup and view all the answers

Match the following terminology with their definitions:

Symmetry = The balance and similarity of body parts on both sides Systolic pressure = The highest pressure measured during a heartbeat Bradycardia = Slow heart rate Bradypnea = Slow breathing rate Diastolic pressure = The minimum pressure measured between heartbeats Korotkoff's sounds = The sounds heard during blood pressure measurement Mean arterial pressure = The average pressure in the arteries throughout the cardiac cycle Pulse pressure = The difference between systolic and diastolic pressure Sinus arrythmia = A type of irregular heartbeat that originates in the sinoatrial node Sphygmomanometer = The instrument used to measure blood pressure Stroke volume = The amount of blood ejected from the left ventricle with each heartbeat Tachycardia = Fast heart rate Tachypnea = Fast breathing rate Signup and view all the answers

Flashcards

General Survey

A general overview of a patient's health status, including physical appearance, body structure, mobility, and behavior.

60-Second Assessment

A rapid, concise assessment of a patient's vital signs within 60 seconds. It often includes temperature, pulse, respirations, and blood pressure.