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Fundamentals of Nursing Care 1 > Chapter Twenty One > Flashcards

Chapter Twenty One Flashcards

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
Lethargic
Drowsy or mentally sluggish
26
Jaundice
indicative of liver failure, sclera can be yellowish, skin may also be yellow
27
Checking for orientation of consciousness:
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?
28
Erythema
Tissue Redness
29
Cyanotic
Blue
30
Arcus Senilis
Opaque white ring on cornea - normally noted on older adults
31
Ptosis
drooping
32
Anisocoria
When pupils are different sizes
33
Bifurcates
Where the optic nerve divides
34
Consensual Reflex
Stimulation of the nerve by shining the light in either eye should cause both pupils to rapidly constrict simultaneously and equally.
35
Accommodation Response
Measures the eye muscles ability to focus on an image up close and in the distance
36
PERRLA
Pupils Equal Round Reactive to Light and Accommodation
37
Glossitis
Smooth, painful tongue, can be caused by inflammation or a side effect of medication
38
Cheilitis
Inflammation of the lips
39
Circumoral
encircling the mouth area
40
Edentulous
Without teeth
41
Caries
Cavaties
42
Sordes
Dried mucus or food that is caked on the lips or teeth - easily treated with good oral hygiene
43
Aphasia
Without speech - PT may know what they want to say but cannot say the words
44
Dysphasia
Difficulty coordinating and organizing the words correctly in a sentence
45
Neuro Exam
Components of the neurological assessment are performed together as a single assessment
46
Distended
Swell from pressure from inside
47
Dyspnea
Difficulty breathing
48
Orthopnea
Difficulty breathing in the supine position
49
Nonproductive Cough
Dry cough
50
Productive Cough
Wet cough that produces sputum
51
Comprehensive Health Assessment
An in depth assessment of the whole person including the physical mental emotional cultural and spiritual aspects of the pt's health
52
Initial head-to-toe assesment
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
What systems are included in head to toe?
Neuro Cardio Respiratory integumentary gastro genitourinary musculoskeletal
54
What else is included in a head to toe?
Vitals Appearance Speech Safety Risk Factors Tubes and equipment Comfort or complaints Needs
55
Focused Assessment
Less encompassing and involves and examination and an interview regarding a specific body system
56
Excursion
Equal chest expansion
57
Atelectasis
Lung (alveoli) collapse
58
Lordosis
Lumbar concavity is increased
59
Kyphosis
Convexity of the midthorax is increased
60
Scoliosis
Curvature to either the left or right vertebrae
61
Retractions
Chest wall appears depressed or sunken in between the ribs or under the xiphoid process when pt inhales
62
Decreased breath sounds
when there are fewer breath sounds in one area
63
Consolidation
Secretions and exudate from pneumonia that solidify in the lung tissues
64
Absent Breath Sounds
No breath sounds in an area can indicate collapse or blockage of a lung or lobe
65
Adventitious Breath Sounds
Abnormal breath sounds Includes: crackles, rhonchi, wheezes, pleural friction rub, and stridor
66
Crackles
Not continuous, usually heard during inspiration. may be fine or course cannot clear by coughing
67
Rhonchi
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
Wheezes
Continuous melodious, musical, whistling sounds Caused by constriction of airway - heard on inhale or exhale
69
Stridor
Heard with or w/o stethoscope - sign of life threatening upper airway obstruction caused by foreign body, tumor, swelling, or bronchial spasms
70
Anorexia
lack of appetite
71
Peristalsis
Wave like muscular contractions of the intestines that move intestinal contents through the alimentary canal
72
Borborygmus
Stomach gurgling you can hear with out a stethoscope
73
Parasthesia
Numbness or decreased sensation
74
Solar Lentigines
Spots of yellowish-brown discoloration caused by years of sun exposure
75
Diaphoretic
Prespiring
76
Turgor
Elasticity
77
Intact Skin
Has no breaks or openings in the skin
78
Contractures
Tightening and shortening of muscles that prevent full extension of joints
79

Fundamentals of Nursing Care 1 (13 decks)

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