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Fundamentals of Nursing Care 1 > Chapter Twenty One > Flashcards

Chapter Twenty One Flashcards

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1
Q

Head To Toe Assessment

A

Neurological
Cardiovascular
Respiratory
Integumentary
Gastrointestinal
Genitourinary
Musculoskeletal

Also Includes:

Vitals
Appearance
Speech
Safety risk factors
Tubes & equipment
Comfort & complaints
Needs

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2
Q

Focused Assesment

A

Less encompassing and involves an examination and an interview regarding a specific body system.

Provides a cluster of data about just the one body system that is being assessed.

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3
Q

When is a physical assessment performed?

A

Assessment is an ongoing process,
usually they are done:
-on admission (comprehensive, in depth; generally done by RN)
-at beginning of each shift (shorter, more focused)
-when PT condition changes
-when evaluating the effectiveness of nursing care
-any time things do not feel right

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4
Q

What do you do if you assess a fever of 103?

A

Take immediate action to treat fever and reassess within an hour to see if further intervention is required.

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5
Q

Subjective Data

A

Data the patient provides or says

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6
Q

Objective Data

A

Data that you observe

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7
Q

Signs

A

When you use your four senses to find evidence of illness or injury, and the data is objective and measurable

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8
Q

Symptoms

A

When evidence of illness or injury is only known by what the PT tells you, the findings are subjective and not directly measurable

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9
Q

Interviewing

A

Data obtained during interviewing:
- Personal id and demographics
- details about current conditions
- medical history
- social history
- food/drug allergy
- height/ normal weight
- expectation for hospitalization

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10
Q

Otoscope

A

Lighted instrument used to inspect the lining of the nose tympanic membranes, and ear canals

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11
Q

Opthalmoscope

A

Lighted instrument used to assess or examine the internal structures of the eyes

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12
Q

Palpation

A

Application of your hands to the external surfaces of the body to detect abnormalities of the skin or tissues lying below the skin. Examine by touch or feel.

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13
Q

Things you can detect by touch:

A
  • skin turgor
  • growths on or below the skin
  • edema
  • size and location of body parts
  • distention of bladder or abdomen
  • firmness vs softness of tissue
  • location/strength of pulses
  • pain/discomfort
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14
Q

Palpation is classified according to the depth of tissue compression:

A

1-2cm light palpation
2-3cm moderate palpation
4-5cm deep palpation

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15
Q

Percussion

A

Striking the body parts with the tips of the fingers to
-elicit sounds that can help locate and determine the size of structures beneath the surface
- ID whether the structure is solid or hollow
- detect areas containing air or fluid

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16
Q

Auscultation

A

Listening to the sounds produced by the body

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17
Q

Eructation

A

Sounds that are able to be heard with the naked ear
Examples:
-passing gas
-loud wheezing
-loud bowel noise

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18
Q

Murmurs

A

Abnormal valve sounds (no lub dub, lub swush)

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19
Q

Normal heart sound

A

LUB DUB (s1, s2)

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20
Q

Olfaction

A

using the sense of smell for assesment

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21
Q

Halitosis

A

Bad breath

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22
Q

Smell of ammonia or urine on breath can be a sign of what?

A

Kidney failure

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23
Q

Musty / sweet smell on someones breath can be sign of?

A

Liver disease

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24
Q

Breath that smells like acetone or has fruity/raspberry smell may indicate what?

A

Out of control diabetes

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25
Q

Lethargic

A

Drowsy or mentally sluggish

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26
Q

Jaundice

A

indicative of liver failure, sclera can be yellowish, skin may also be yellow

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27
Q

Checking for orientation of consciousness:

A

Person: whats your name?
Place: Do you know where you are?
Time: Do you know what day of the week it is?
Situation: Do you know why you’re here today?

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28
Q

Erythema

A

Tissue Redness

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29
Q

Cyanotic

A

Blue

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30
Q

Arcus Senilis

A

Opaque white ring on cornea - normally noted on older adults

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31
Q

Ptosis

A

drooping

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32
Q

Anisocoria

A

When pupils are different sizes

33
Q

Bifurcates

A

Where the optic nerve divides

34
Q

Consensual Reflex

A

Stimulation of the nerve by shining the light in either eye should cause both pupils to rapidly constrict simultaneously and equally.

35
Q

Accommodation Response

A

Measures the eye muscles ability to focus on an image up close and in the distance

36
Q

PERRLA

A

Pupils Equal Round Reactive to Light and Accommodation

37
Q

Glossitis

A

Smooth, painful tongue, can be caused by inflammation or a side effect of medication

38
Q

Cheilitis

A

Inflammation of the lips

39
Q

Circumoral

A

encircling the mouth area

40
Q

Edentulous

A

Without teeth

41
Q

Caries

A

Cavaties

42
Q

Sordes

A

Dried mucus or food that is caked on the lips or teeth - easily treated with good oral hygiene

43
Q

Aphasia

A

Without speech - PT may know what they want to say but cannot say the words

44
Q

Dysphasia

A

Difficulty coordinating and organizing the words correctly in a sentence

45
Q

Neuro Exam

A

Components of the neurological assessment are performed together as a single assessment

46
Q

Distended

A

Swell from pressure from inside

47
Q

Dyspnea

A

Difficulty breathing

48
Q

Orthopnea

A

Difficulty breathing in the supine position

49
Q

Nonproductive Cough

A

Dry cough

50
Q

Productive Cough

A

Wet cough that produces sputum

51
Q

Comprehensive Health Assessment

A

An in depth assessment of the whole person including the physical mental emotional cultural and spiritual aspects of the pt’s health

52
Q

Initial head-to-toe assesment

A

Performed at the start of shift when you first see the pt. provides you with a quick overall assessment of the pt’s condition to establish a baseline against which you can compare later assessments to

53
Q

What systems are included in head to toe?

A

Neuro
Cardio
Respiratory
integumentary
gastro
genitourinary
musculoskeletal

54
Q

What else is included in a head to toe?

A

Vitals
Appearance
Speech
Safety Risk Factors
Tubes and equipment
Comfort or complaints
Needs

55
Q

Focused Assessment

A

Less encompassing and involves and examination and an interview regarding a specific body system

56
Q

Excursion

A

Equal chest expansion

57
Q

Atelectasis

A

Lung (alveoli) collapse

58
Q

Lordosis

A

Lumbar concavity is increased

59
Q

Kyphosis

A

Convexity of the midthorax is increased

60
Q

Scoliosis

A

Curvature to either the left or right vertebrae

61
Q

Retractions

A

Chest wall appears depressed or sunken in between the ribs or under the xiphoid process when pt inhales

62
Q

Decreased breath sounds

A

when there are fewer breath sounds in one area

63
Q

Consolidation

A

Secretions and exudate from pneumonia that solidify in the lung tissues

64
Q

Absent Breath Sounds

A

No breath sounds in an area can indicate collapse or blockage of a lung or lobe

65
Q

Adventitious Breath Sounds

A

Abnormal breath sounds
Includes: crackles, rhonchi, wheezes, pleural friction rub, and stridor

66
Q

Crackles

A

Not continuous, usually heard during inspiration.

may be fine or course
cannot clear by coughing

67
Q

Rhonchi

A

Snoring , rattling, gurgling, squeaking, and low-pitched wheezes

Caused by either secretions or partial occlusion of the airways.
Deeper and more rumbling than crackles, heard during expiration.
may clear during coughing

68
Q

Wheezes

A

Continuous melodious, musical, whistling sounds

Caused by constriction of airway - heard on inhale or exhale

69
Q

Stridor

A

Heard with or w/o stethoscope - sign of life threatening upper airway obstruction

caused by foreign body, tumor, swelling, or bronchial spasms

70
Q

Anorexia

A

lack of appetite

71
Q

Peristalsis

A

Wave like muscular contractions of the intestines that move intestinal contents through the alimentary canal

72
Q

Borborygmus

A

Stomach gurgling you can hear with out a stethoscope

73
Q

Parasthesia

A

Numbness or decreased sensation

74
Q

Solar Lentigines

A

Spots of yellowish-brown discoloration caused by years of sun exposure

75
Q

Diaphoretic

A

Prespiring

76
Q

Turgor

A

Elasticity

77
Q

Intact Skin

A

Has no breaks or openings in the skin

78
Q

Contractures

A

Tightening and shortening of muscles that prevent full extension of joints

79
Q
A

Fundamentals of Nursing Care 1 (13 decks)

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