301 Test 1 power points Part 3 Flashcards
assessment type that Gathers system-related data all at once
Systems approach
3 Types of health assessment
Systems approach
Head to toe
Functional pattern approach
Ndx will only include s/s if it’s an ___ problem
actual problem
If you do not know the etiology indicate r/t
”?” Or “unknown”
assessment that focuses on strengths and weaknesses
Functional health pattern
Correct sequence of the 4 techniques used in assessment
Inspection
Palpation
Percussion
Auscultation (except for abdominal assessment: second after inspection)
> 35 inches in women and __ inches in men increases the risk for type 2 diabetes, dyslipidemia, hypertension, and CVD
40
“5th vs”
pain
Thigh BP is ___er than in the arm
higher
coarctation of aorta
narrowing
main relay station for incoming stimuli
Thalamus
part of brain: temperature, sleep, emotions, autonomic activity, pituitary gland
hypothalamus
muscle coordination, equilibrium
Cerebellum
motor neurons, motor and sensory tract
Midbrain and pons
respiration, heart, GI function
Medulla
Any change in mental status requires
escalation of care to the physician
Tactile discrimination
Stereognosis Graphesthesia Two-point discrimination Extinction Point location
brief involuntary twitching of muscle group
Myoclonus
muscle twitch (small area)
Fasciculations
an abnormal involuntary movement disorder
Chorea or Athetosis
Declines associated with normal aging:
Diminished ability to learn ___ information
Delayed __ time
Minor loss of recent __
complex
response
memory
Pathological conditions of impaired cognitive function
3 Ds
Depression
Delirium
Dementia
clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and/or guilt. These symptoms represent a change from usual functioning for the individual that have been present for at least 2 weeks.
Depression
disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly. Evidence of an underlying physiologic or medical condition is generally present.
Delirium
a syndrome of cognitive deterioration that involves memory impairment and disturbance in at least one other cognitive area that results in changes in function (e.g. aphasia, apraxia, or agnosia) and behavior.
Dementias (e.g. Alzheimer’s or vascular)
The most common risk factors associated with delirium are:
Dementia
Male gender
Advanced age
Medical illness
Predisposing factors associated with delirium are:
Poor functional status Alcohol abuse Depression Dehydration Sensory impairment
delirium vs dementia, Short, rapid, hours/days
delirium
delirium vs dementia, Vague symptoms, loss of intellect, agitated, aggressive
dementia
delirium vs dementia, Easily distracted, inappropriate anxiety, labile to apathy
dementia
delirium vs dementia, Labile variable fear/panic, euphoria, disturbed
delirium
easiest colors for old ppl to see are
yellow red orange
Older adults have a decreased ___ of taste buds
number
Put on PPE beginning with
cap
Next put on gown with opening in
back
Gloves go on __ with cuffs of gown tucked into gloves
last
Bathing- wash from fingers to
Axilla
Moving pt: Use __ ppl if pt is more than 200 lbs
3
Risk for injury:
___ conditions interacting with client’s adaptive and defensive resources
Environmental
Risk for thermal injury:
___ impairment, inadequate supervision, developmental level
Cognitive
A client with the Dx Risk for Injury is diagnosed with Ineffective Protection if they are at risk for
bleeding
When it comes to reducing injury, be extra careful with patients on what kind of medication
Blood thinner
you can disconnect IV if it has a
2 way connector
Wash arm with long strokes from __ to __
distal to prox
Dont massages ___ because that cold dislodge a clot causing an embolis
calves
Dont apply lotion between the
toes
A back rub may be contraindicated for pts with
CV disease
Cannot delegate foot care to NAP if pt has foot ulcers or impaired peripheral
circulation
Pts who have DM or impaired circulation require Rx for trimming
nails
During foot care, if pt can’t sit up put in __ __ position
semi fowler position
Soaking feet is contraindicated for pts with __ or __ __ disease
DM or peripheral vascular disease
For oral care, pt should be in chair or in __ __ position
high fowler
Move floss __ and __ instead of back and forth
up and down
oral thermometer tip is what color
blue
immediately report temp if greater than
100
oral temp can be affected by eating, smoking, drinking, and
chewing gum
If pt was lying on her side, do not take __ __ temp on the side that was on the pillow
temporal artery
For ear temp for an adult, pull pinna __ and back
up
If you have trouble getting the brachial pulse you can ask pt to
turn palm downward
pulse site used for CPR for an infant
brachial
Which pulse may be difficult in old ppl
foot
Where do you palpate posterior tibial pulse
ankle
apical HR must be counted for
1 min
digitalis therapy, blood loss, cardiac or resp disease, and other thing that affect oxygenation status may warrant taking a __ __ __ __
apical-radial pulse deficit
The presence of any apical-radial pulse is
abnormal
when taking BP, palm faces
upward
A difference of 10 is normal when comparing BP in
left and right arms
Tuning fork is used to assess
deep sensation
kinesthetic sense is
position
ability to recognize an object by touch
stereognosis
Able to recognize something written on the skin
graphesthesia
Normal deep tendon reflex rating
+2
The MMSE focuses only on ___, not mood or thought process
cognitive
transitioning btwn state of lethargy and stupor
obtunded
normal temp range for adult
96 to 99
oral temp is 1 degree lower than
rectal
HR in older adults is ___er
slower
The romberg assessment tests
balance
most important factor in neuro check
level of consciousness
abnormally low systolic
abnormally low diastolic
