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Q1 nursing > ch 30 Jess > Flashcards

ch 30 Jess Flashcards

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0
Q

What will your assessment influence

A

The choice of therapies a patient receives, and an evaluation of the response to those therapies

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1
Q

What is included in a complete health assessment

A

A nursing history a behavioral exam and a physical exam

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2
Q

What is the purpose of a physical examination (4)

A

Triage for emergency care
routine screening to promote health and wellness,
to determine eligibility (for health insurance military service new job,)
To admit a patient to hospital or long-term care facility

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3
Q

What do you use physical examination for

A
  • gather baseline data about a patient’s health
  • support or refute subjective data obtained in the nursing history
  • identify and confirm nursing diagnosis
  • make clinical decisions about a patients changing health
  • evaluate the outcomes of care
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4
Q

What is cultural sensitivity

A

Culture influences the patient’s behavior you need to consider health beliefs, using alternative therapies, nutritional habits, relationships with family and personal comfort zone, need to avoid stereotyping and gender bias

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5
Q

Why is it important to be aware of disorders that are more commonly seen in a particular ethnic group?

A

Because you’re more likely to recognize a rare condition unique to each ethnic group which will lead to higher quality care

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6
Q

If a patient is seriously ill, what should you assess first?

A

The body system that is most at risk

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7
Q

When should painful procedures be performed

A

Near the end of the assessment

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8
Q

What do you need to consider in preparation for examination

A

Infection control,
environment,
equipment,
physical and psychological preparation of the patient assessment of age group

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9
Q

What are the four techniques of physical assessment

A

Inspection
palpation
percussion
auscultation

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10
Q

What do you need to remember during inspection

A
  • Use adequate lighting
  • use penlight to inspect body cavities
  • inspect each area for size shape color position and abnormality
  • position and expose body parts as needed so all surfaces can be viewed the privacy can be maintained
  • validate findings with the patient
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11
Q

What senses should you use during inspection

A

Look listen and smell to distinguish normal from abnormal

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12
Q

Why is Teeth/gum health/denture fitting important in the elderly?

A

If they cannot eat due to ill fitting dentures or poor gum health They will not get enough nutrition and will go downhill very quickly

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13
Q

How do you maintain privacy for patients during the physical exam

A

Take off only what’s needed for that moment example remove one piece of clothing at a time then replace it

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14
Q

Explain palpation during a physical exam

A

Used to gather information
– use different parts of hands to detect different characteristics
–hands should be warm
- start with light palpation and with deep palpation

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15
Q

When should you palpate sensitive areas

A

Palpate sensitive areas last

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16
Q

What is percussion

A

Tapping the body with fingertips to produce a vibration sound determines location size and density of structure

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17
Q

What does auscultation involve?

A

– Involves listening to sounds
– learn normal sounds first before identifying abnormal sounds or variations
– requires a good stethoscope
– requires concentration practice

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18
Q

What part of the stethoscope is used to hear low pitch versus high pitch sounds

A

The bell is used to hear low pitch sounds the diaphragm is used for high-pitched sounds

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19
Q

What is the general survey the health assessment

A

Assesses appearance and behavior assess vital signs assessed height and weight

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20
Q

What does the integumentary system include?

A

Skin hair scalp and nails

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21
Q

What are some things you can assess just by looking at your patient

A

Gender and race age signs of distress body type hygiene and grooming body odor speech signs of patient abuse and signs of substance-abuse

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22
Q

Why do you need to obtain a diet history for your patient

A

Because height and weight reflective person’s overall level of health

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23
Q

What do you need to look for when examining the skin

A 
Integument 
color 
moisture 
temperature 
texture 
turgor
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24
Q

What do you need to notice about the color of skin

A

Pigmentation
cyanosis
jaundice
Erythema

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25
Q

What about texture of the skin you need to pay attention to

A

Is it smooth dry scaly rough, or scar issue

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26
Q

What are the ABCD’s of skin

A

A is asymmetry
B border Irregularity
C color
D Diameter

27
Q

What is vascularity of the skin

A

Appears reddened pink or pale occurs in localized pressure Areas
When patients remain in one position

28
Q

What does edema do

A

Separates the surface of the skin from pigmented and vascular layers masking skin color

29
Q

How do you assess degree of putting edema

A

Press the area firmly with the thumb for several seconds and release, the depth determines the degree of edema

30
Q

What is the scale used to measure pitting edema

A 
1+ = 2mm deep 
2+ = 4mm deep
3+ = 6mm deep 
4+ = 8mm deep
31
Q

Where does edema most often occur

A

Feet
ankles.
peri Orbital
sacral

32
Q

What should you notice when looking at hair and scalp

A 
Color
 distribution
 quantity 
thickness 
texture 
Lubrication
33
Q

What does a widening part loss of tails of eyebrows or no hair on toes possibly indicate?

A

Hypothyroidism or poor circulation

34
Q

What is the condition of nails reflect

A 
Gen. health status 
nutrition 
occupation 
level of self self-care 
Age
35
Q

What causes lines or bands to form on the nailbeds

A

Vitamin protein electrolyte changes

36
Q

What does the assessment of head and neck consist of

A

Head

eyes ears nose mouth pharynx neck lymph nodes carotid arteries thyroid gland and trachea

37
Q

What assessment skills should you use for the head and neck

A

Inspection palpation and auscultation

38
Q

Where do lymph nodes normally drain

A

Through the site of infection

39
Q

What should you assess when examining the eyes

A

Size shape structure visual acuity visual fields conjunctiva sclera cornea pupil and iris

40
Q

What is nystagmus

A

And involuntary rhythmic oscillation of the eyes

41
Q

What are some causes of nystagmus

A

Local injury to muscles and supporting structures
intoxication
disorder of the cranial nerves

42
Q

What does the presence of redness in the conjunctiva indicate

A

Allergic or infectious conjunctivitis

43
Q

What is Arcus senilis ?

A

A thin white ring around the margin of the Iris

It is common with aging but is abnormal in anyone younger than 40

44
Q

How many directions of gaze are there

A

6

45
Q

What does PERRLA stand for?

A

Pupils equal round reactive to light, accommodation

46
Q

What is accommodation when doing an eye exam

A

When only one night is covered and then uncovered it is still facing forward or centered

47
Q

What external eye structure do we need to look at

A 
Position and alignment 
eyebrows eyelids 
lachrymal apparatus 
conjunctiva 
Sclerae
 cornea 
pupils and irises
48
Q

What patients are in greatest need of an internal Eye exam

A

Patients with diabetes hypertension and intercranial disorders

49
Q

What do we need to examine on the ears

A

Palpate the auricles for texture tenderness and skin lesions
Look for lesions pain earwax and normal ear color

50
Q

If palpation causes pain what is like

A

An external ear infection

51
Q

If an ear is painful to palpation does not cause additional pain what is likely

A

A middle ear infection

52
Q

If the ear has a foul-smelling yellow or green discharge what does this indicate

A

An infection or foreign body

53
Q

What are the three types of hearing loss

A

Conduction
Sensorineural
Mixed

54
Q

What is conduction hearing loss

A

Interrupt soundwaves as they travel from outer ear to the Cochlea of the inner ear

Causes:
Swelling of the auditory canal and tears in the tympanic member

55
Q

What is sensorineural hearing loss?

A

Involves inner ear auditory nerve or hearing center of the brain sound is conducted through the outer and inner ear structures but the continued transmission of sound becomes interrupted at some point beyond the bony ossicles

56
Q

What population is at risk for hearing loss caused by ototoxicity and why

A

Older adults are more risk from high maintenance doses of antibiotics

57
Q

What is webers test

A

Tuning fork test done for lateralization of sound
Tuning fork is placed on the top middle of the head
A patient with normal hearing or hear the sound equally in both ears

58
Q

What is Rinnes test?

A

Turning fork test test is done for comparison of bone and air conduction
Tuning fork is held behind ear against the mastoid process

59
Q

What should the nose be checked for upon physical exam

A

Excoriation
Polyps
Shape size skin color presence of deformity or inflammation

60
Q

What should you do a swelling or deformity of the nose exists

A

Gently palpate the ridge and soft tissue of nose replacing one finger on each side of the measle arching gently moving the fingers from the nasal bridge to the tip

61
Q

What can the color of nasal discharge indicate about a patient’s condition

A

Pale mucosa with clear discharge indicates allergy

Mucoid discharge indicates rhinitis sinus infection results in yellowish greenish discharge

62
Q

What do you need to examine about lips

A

Color texture hydration contour lesions

63
Q

What does pallor, cyanosis , or cherry red indicate of lips

A
  • Anemia causes Paller of lips
  • respiratory or cardiovascular problems caused cyanosis
  • cherry colored lips indicate carbon monoxide poisoning
64
Q

How do you observe tooth occlusion

A

As the patient to clench the teeth and smile

65
Q

What structures do need to examine inside the mouth

A

Buccal mucosa gums and teeth

66
Q

What you inspect the gums for

A

Color edema retraction bleeding and lesions

Q1 nursing (27 decks)

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