Nurse's Role in HA
Biographical info, Hx of present illness, Family Hx, Health and Life Style practices, Review of Systems
What is collecting Subjective data
Appearance, Behavior, Cognition, Thought processes
What are the 4 main Headings of Mental Health Assessment
Bisects center of each clavicle at a point halfway between palpated sternoclavicular and acromioclavicular joints.
What is the Midclavicular Line
Skin changes, leg pain, heaviness, aching, and swelling in the legs and/or feet
What symptoms of peripheral vascular disease
(Flatus, Fluid, Feces, Fetus, Fat/Tumor)
What are the 5 Fs of distention
The process of organizing and relating the information gathered and formulating a nursing diagnosis or problem by organizing data, identifying a pattern, formulating a hypothesis
What is Cluster cues
Concentrates only on cognitive functioning, not on mood or thought processes. Standard set of 11 questions,
What is the Mini Mental State Exam
high-pitched, whistling sounds that are most prominent during expiration.
What is Wheezing
Firmly occlude the ulnar and radial arteries of one hand while the client makes a fist several times, then open the hand Release the ulnar artery. Color should return within 2-5 seconds
What is the Modified Allen test
What organ does Murphy's Sign check?
What is the Gallbladder
Using age appropriate language and techniques to gain cooperation
What are considerations when assessing a pediatric patient
asymmetry, border, color, diameter, elevation and enlargement
What is the ABCDE skin assessment
Palpable vibration felt when a client is asked to say "99" or "Blue Moon"
Tactile fremitus
Firmly depress the skin over the tibia or medial malleolus for 5 seconds and then release
What is assessing for edema
Asking about past injuries, surgeries, or chronic issues like arthritis falls under this part of the history.
Medical History
Used to elicit the client’s feelings and perceptions. They typically begin with the words “how” or “what.”
What is open-ended questions.
Skin loses turgor due to decrease in elasticity and collagen fibers; sagging or wrinkled skin appears in facial, breast, and scrotal areas.
What are older adult considerations for skin assessment
Heart Sound heard at the 5th intercostal space to the lower left sternal border
Tricuspid valve
This non-invasive test, often the first used to diagnose Peripheral Artery Disease (PAD), compares the blood pressure in the ankle to the pressure in the arm.
What is the Ankle-Brachial Index (ABI) test?
Feeling a crackling or grinding sensation in a joint during movement is this assessment finding.
Crepitus
Verify that subjective and objective data are reliable and accurate
Validating
Consists of three-item recall test and clock-drawing test
What is the Mini-Cog Test (screens for cognitive impairment
EKG changes occur as a result of histologic changes in the conduction system
What is changes in the cardiac function of an older adult
The term for pain in the lower legs that occurs with exercise and is relieved by rest, a classic symptom of arterial insufficiency.
Claudication
Evaluating the degree a joint can move (flexion, extension, rotation) tests this.
ROM (Range of Motion
)