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Nursing 101 > Assessment 2 > Flashcards

Assessment 2 Flashcards

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1
Q

Normal range for oral temp

A

98-98.6

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2
Q

Hypertensive Crisis

A

> 180 systolic and/or >120 diastolic

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3
Q

When are vital signs performed?

A

on admission, every shift, before, during and after procedures, to monitor medication effects, changes in pt condition

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4
Q

Assessment order

A

inspection
palpation
percussion
auscultation

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5
Q

Thermoregulation

A

constant body temp = balance between heat production and loss

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6
Q

Core temp range

A

97-100.8

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7
Q

How does your body decrease temp?

A

Sensors in hypothalamus are stimulated and send impulses which causes vasodilation

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8
Q

How does your body increase temp?

A

Sensors in hypothalamus are stimulated and send impulses which causes vasoconstriction

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9
Q

How heat is exchanged between body and environment?

A

Radiation
Convection (transfer of heat to water)
Evaporation (perspirations/breathing)
Conduction (from warm to cool surface by touch)

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10
Q

Do infants shiver?

A

No, use brown fat metabolism. Non-shivering thermogenesis.

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11
Q

Pyrexia oral

A

> 100

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12
Q

Pyrexia rectal

A

> 101

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13
Q

Normal range for rectal temp

A

99-99.6

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14
Q

Normal range for respirations

A

12-20

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15
Q

Normal BP

A

> 120/>80

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16
Q

Hypertension stage 1

A

130-139 systolic/ 80-89 diastolic

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17
Q

Hypertension stage 2

A

> 140 systolic and/or >90 diastolic

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18
Q

Febrile

A

fever

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19
Q

Afebrile

A

without fever

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20
Q

Hyperthermia

A

> 105.8

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21
Q

Normal urine output per hr

A

30 mL

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22
Q

Hypothermia

A

<90

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23
Q

Systole S1

A

lub sound, heart contracts
closing/shutting of tricuspid and mitral valves

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24
Q

Diastole S2

A

dub sound, heart relaxes
aortic and pulmonic valves closing

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25
Q

PMI

A

point of maximal impulse
5th intercostal space mid clavicular line

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26
Q

Radial pulse

A

laterally on anterior wrist

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27
Q

Brachial pulse

A

medially in antecubital space

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28
Q

Carotid pulse

A

between midline and side of neck

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29
Q

Temporal pulse

A

side of forehead

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30
Q

Dorsalis pedis pulse

A

top of foot

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31
Q

Femoral pulse

A

in groin fold

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32
Q

Popliteal pulse

A

behind knee

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33
Q

Apical pulse

A

apex of heart

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34
Q

Bradycardia

A

<60 bpm

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35
Q

Tachycardia

A

> 100 bpm

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36
Q

Pulse quality

A

absent, weak/thready, normal, bounding, bilaterally equal

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37
Q

When the diaphragm goes up

A

you exhale

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38
Q

When the diaphragm goes down

A

you inhale

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39
Q

Kussmals respirations

A

regular but abnormally deep and high rate

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40
Q

Biot’s respirations

A

irregular, variable depth altering w/ periods or apnea

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41
Q

Cheyne stokes

A

gradual high depth, followed by gradual low depth and a period of apnea

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42
Q

Wheezing

A

high pitched, continuous musical sounds, usually on expiration

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43
Q

Rhonchi

A

low pitched continuous sounds caused by secretions in large airways

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44
Q

Crackles

A

sounds like pop rocks

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45
Q

Stridor

A

piercing, high-pitched usually on inspiration

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46
Q

Stertor

A

labored breathing that produces a snoring sound

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47
Q

3 phases of a fever

A

febrile episode; onset
course; flushed/warm to touch
temp drops to normal, pt sweats to lose heat “fever is breaking”

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48
Q

Oxygenation

A

how well the cells, tissues and organs of the body are supplied with oxygen

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49
Q

Perfusion

A

the continuous supply of oxygenated blood through the blood vessels to the vital organs

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50
Q

Vital signs

A

means of assessing vital or critical physiological functions TPR BP

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51
Q

Nonexertional

A

prolonged exposure to an environmental temperature (classic heat stroke)

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52
Q

Cardiac output

A

stroke volume x HR

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53
Q

Dyspnea

A

difficulty/labored breathing

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54
Q

Orthopnea

A

difficulty breathing when laying down

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55
Q

Hypoxia

A

Low oxygen saturation of the body, not enough oxygen in the blood

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56
Q

What is the purpose of a health assessment?

A

establish baseline data, identify nursing diagnoses, collaborative problems or wellness diagnoses, monitor the status of an identified problem and screen for health problems

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57
Q

What does a nurse need for a health assessment?

A

theoretical knowledge, self-knowledge, knowledge about client situation and plan of care review (initial and ongoing)

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58
Q

Preparing the client for a health assessment

A

promote comfort, develop rapport, explain the procedure, and be respectful about cultural differences, always introduce yourself, identify the patient and ask if they would like to use the bathroom before you start

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59
Q

Preparing the environment for a health assessment

A

provide privacy, noise control, use adequate lighting, adjust room temp to make the pt comfortable, and make sure you have the proper equipment

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60
Q

Comprehensive physical exam

A

start with health history and then complete a full head to toe assessment

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61
Q

Focused exam

A

focus on a specific problem

62
Q

System specific exam

A

focusing on a specific body system

63
Q

Ongoing exam

A

performed as needed to assess status, evaluates client outcomes

64
Q

Age modifications for young/middle adults for physical assessment

A

modify in presence of acute or chronic illness

65
Q

Age modifications for older adults for physical assessment

A

special positioning if needed, adapt for vision and hearing, assess for change in physical ability and support system, assess for ability for perform ADL’s, provide rest periods if needed

66
Q

Acronym SPICES is used for who?

A

older adults

67
Q

What does SPICES mean?

A

sleep disorders
problems w/ eating or feeding
incontinence
confusion
evidence of falls
skin breakdown

68
Q

Contusion

A

bruise

69
Q

Petechiae

A

small, pinpoint hemorrhages

70
Q

Mottling

A

usually on a pt who is at EOL, purplish web-like and starts at the toes

71
Q

Hyperhydrosis

A

excessive sweating

72
Q

LOC

A

level of consciousness

73
Q

Arterial impairment

A

not getting blood to the extremities and usually have none/little hair on the extremities

74
Q

Venous issues

A

a lot of blood to extremities, rough leather like skin

75
Q

Nevi

A

moles

76
Q

Striae

A

stretch marks

77
Q

Hirsutism

A

excessive hair growth

78
Q

Finger clubbing cause

A

usually respiratory issues

79
Q

ABCDE for moles

A

asymmetry
boarders
color
diameter
evolving (changes size, shape or color)

80
Q

HEENT

A

head
eyes
ears
nose
throat

81
Q

Periorbital layer

A

outer layer of eye

82
Q

PERRLA

A

pupils
equal
round
reactive to
light
accommodation

83
Q

Anisocoria

A

unequal pupil size

84
Q

What syndromes make ears unaligned?

A

fetal alcohol and down syndrome

85
Q

How many lobes are in the right lung?

A

3

86
Q

How many lobes are in the left lung?

A

2

87
Q

How many spots are there to auscultate the lungs?

A

10 on front and 10 on back

88
Q

Varicosities

A

abnormally enlarged, twisted veins

89
Q

Romberg test

A

eyes closed and maintain a standing position; balance

90
Q

Order for assessing the abdomen

A

LL
UL
UR
LR

91
Q

What are the dietary guidelines for the general population?

A

low fat diet with plenty of fruits and vegetables

92
Q

What are the dietary guidelines for the older population?

A

low sodium options, choose herbs and spices, focus on fluid selection of water, fat free milk and soup, incorporate healthy oil into the diet and incorporate physical activity into the diet

93
Q

Nutrition

A

science of food and it’s relationship to health

94
Q

Why is water an essential nutrient?

A

makes up half of total body weight

95
Q

What are the functions of water in the human body?

A

solvent
transport
body structure and form
temperature
lubricant
catalyst

96
Q

BMR

A

basal metabolic rate

97
Q

What is a BMR?

A

measure of energy used while at rest in a neutral environment

98
Q

Potassium rich

A

peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes

99
Q

Sodium rich

A

eggs, celery, spinach, beets, baking soda and baking powder

100
Q

Phosphorus rich

A

dairy products, beef, pork, sardines, eggs, chicken, wheat bran and chocolate

101
Q

Calcium rich

A

egg yolks, nuts, sardines, dairy products, broccoli and legumes

102
Q

Body composition

A

water
protein
fat/lipids
ash (mineral content in bone)
carbohydrates

103
Q

Carbohydrates

A

primary energy source for the body - sugars

104
Q

Lipids

A

fats; back up energy source for the body- serve as organ insulation and protection

105
Q

Minerals

A

elements found in nature (calcium, iron, sodium etc)

106
Q

Proteins

A

complex molecules made up of amino acids, the structural material of every cell in the body

107
Q

Water

A

aids in essential body functions

108
Q

Vitamins

A

needed for metabolism and preventing a deficiency, fat soluble and water soluble

109
Q

Fat soluble vitamins

A

ADEK

110
Q

Water soluble vitamins

A

C and B complex

111
Q

Digestion

A

takes place in the alimentary canal with the help of accessory organs

112
Q

Mechanical digestion

A

physical breaking down of food into smaller pieces

113
Q

Chemical digestion

A

occurs through hydrolysis- when water and digestive enzymes are used to break down complex molecules

114
Q

Where does absorption occur?

A

small intestine

115
Q

What does the large intestine do?

A

reabsorbs water and forms stool

116
Q

What is considered elimination?

A

stool
urine
gaseous waste
sweat

117
Q

Steatorrhea

A

fat in stools (makes stool float)

118
Q

Enteral tube

A

GI tract

119
Q

Parenteral tube

A

directly in the bloodstream

120
Q

NG tube placement

A

nose

121
Q

G tube placement

A

stomach

122
Q

J tube placement

A

jejunum

123
Q

What must be done immediately after a NG tube placement?

A

chest x-ray

124
Q

Hyponatremia

A

low sodium (135-145)

125
Q

Frail elderly syndrome

A

weight loss, lessened activity and interaction and increasing frailty

126
Q

What is a sign of dehydration in the elderly?

A

confusion

127
Q

Osteoporosis

A

weak and brittle bones

128
Q

Nutritional assessment steps

A

assessment
analysis/diagnosis
planning/intervention
evaluation and documentation

129
Q

Campylobacter

A

caused by undercooked poultry

130
Q

Listeria

A

caused by soft cheeses and deli meats (can grow at refrigerated temp)

131
Q

What does r/t mean?

A

related to

132
Q

Nursing care plan assessment for nutrition

A

mini assessment which screens elderly for a detection of malnutrition

133
Q

ADPIE

A

assessment
diagnosis
planing
implementation
evaluation

134
Q

A in ADPIE

A

assessment
systemic gathering of information

135
Q

Purpose of assessment

A

to obtain data to allow you to help the patient by creating a plan of care

136
Q

Objective data

A

what professionals observe

137
Q

Subjective data

A

what the patient says

137
Q

D in ADPIE

A

diagnosis
when critical thinking skills are used to analyze assessment data

138
Q

Before giving a patient a diagnosis what must you do?

A

verify the problem w/pt

139
Q

Writing a diagnostic statement

A

PES

140
Q

What does PES stand for?

A

problem
etiology
s/s

141
Q

Constipation r/t inadequate intake of fluids and fiber rich foods AEB(as evidence by) painful, hard stool, and bowel movement every 3 or 4 days

A

PES example

142
Q

P of ADPIE?

A

planning
develop a holistic plan of care (mind, body and spirit) that addresses the patient’s unique concerns and health goals
make sure the pt understands when you are explaining to them

143
Q

Maslow’s Hierarchy of Human Needs

A

can be used for prioritizing problems, basic needs must be met before a person can focus on higher needs, most nursing diagnosis fall at the cognitive and lower levels

144
Q

Types of planning

A

initial
ongoing
discharge

145
Q

Initial planning

A

begins with first patient contact and is the stat of the initial care plan

146
Q

On-going planning

A

changes made to the plan as you elevate the patient’s responses to care, obtain new data and diagnosis

147
Q

Discharge planning

A

process of planning for the patient to care for themselves and stay active with their plan of care once leaving the facility

148
Q

SMART goals

A

specific to client problems
measurable’
attainable
realistic
timely

149
Q

Delegation

A

The assignment of new or additional responsibilities to a subordinate

Nursing 101 (1 decks)

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