Class 11: Assessment

Question 1

inspection

Answer 1

use of vision and hearing to distinguish normal from abnormal findings. provides valuable clues about a pt health status. Nurses need experience to recognize normal variations among pt of different age groups

Question 2

important points to remember for inspection

Answer 2

• make sure you have adequate lighting
• position so all body parts can be viewed
• compare with other side of body
• do not rush

Question 3

palpation

Answer 3

use of hands to touch body parts to make. sensitive assessments. used to examine all accessible parts of the body

Question 4

percussion

Answer 4

tapping the body with the fingertips to produce a vibration that travels through body tissues

Question 5

auscultation

Answer 5

involves listening to sounds the body make to detect variations from normal usually through stethoscope

Question 6

capillary refill

Answer 6

applying pressure to the nail bed and observing what happens after. will go white then should return to pink within seconds. if this doesn’t happen it indicates circulatory insufficiency

Question 7

cyanosis

Answer 7

bluish discolouration around lips and nail beds

Question 8

edema

Answer 8

areas of skin become swollen or edematous from a build up of fluid in the tissues

Question 9

pallor

Answer 9

paleness may be caused by reduced blood flow and oxygen

Question 10

pruritis

Answer 10

itching of skin, accompanies most rashes

Question 11

dyspnea

Answer 11

difficult or uncomfortable breathing

Question 12

orthopnea

Answer 12

abnormal condition where the person must use multiple pillows when lying down or must sit with arms elevated and leaning forward to breathe

Question 13

hypoxia

Answer 13

inadequate tissue oxygenation at the cellular level

Question 14

CWMS

Answer 14

colour, warmth, movement, sensation

Question 15

diaphoretic

Answer 15

sweating

Question 16

ecchymosis

Answer 16

discolouration of the skin resulting from bleeding underneath (bruising)

Question 17

adventitious breath sounds

Answer 17

abnormal breath sounds

Question 18

crackles

Answer 18

most common in dependent lobes; right and left lung bases. sounds during inspirations

Question 19

wheezes

Answer 19

heard over all lung fields. high pitched, continuous musical sounds like a squeak heard continuously during inspiration or expiration

Question 20

nebulization

Answer 20

process of adding moisture or medications to inspired air by mixing particles of varying size with the air

Question 21

bowel sounds

Answer 21

abdomen is auscultated, normal bowel sounds occur every 5 to 15 seconds and last from 1 second to several

Question 22

anterior

Answer 22

front of body

Question 23

dorsal

Answer 23

back of body

Question 24

inferior

Answer 24

lower parts of body

Question 25

superior

Answer 25

upper parts of body

Question 26

lateral

Answer 26

surfaces farther away from medial plane

Question 27

medial

Answer 27

surfaces closer to the medial plane

Question 28

proximal

Answer 28

located nearest centre of body

Question 29

distal

Answer 29

away from the centre body

Question 30

ipsilateral

Answer 30

on the same side

Question 31

contralateral

Answer 31

on the opposite side

Question 32

superficial

Answer 32

surface wound

Question 33

deep

Answer 33

deeper wound

Question 34

interior

Answer 34

within

Question 35

exterior

Answer 35

outside

Question 36

quick priority

Answer 36

ABC, input/output, pain, safety, LOO, LOC, focused assessment (chief complaint), comprehensive (head to toe)

Question 37

level of consciousness

Answer 37

- confused - delirious - somnolent (sleepy can't open their eyes) - obtunded (decreased alertness) - stuporous (very little activity - waken with stimulation) - comatose (not responding even with yelling)

Question 38

level of orientation

Answer 38

person, place, time, person (state their name), place (state where they are), time(state the date). can use less specific things if too hard

Question 39

comprehensive assessment

Answer 39

- consider all of the patients needs in order to identify actual or potential problems - general survey - vital signs - height and weight - assessment of all organ and body systems including psychosocial domains

Question 40

focused assessment

Answer 40

- modified assessment using knowledge of the patients history and presenting problem (chief complaint) - may yield info that will require assessment of other systems related to chief complaint

Question 41

baseline

Answer 41

pattern of findings identified when client first assessed

Question 42

physical examination

Answer 42

inspection, auscultation, palpation, percussion

Question 43

what part of a physical examination is not in an LPN score

Answer 43

percussion

Question 44

symptom assessment

Answer 44

``` OPQRSTUV O: onset P: provoking/palliating Q: quality R: region/radiation S: severity T: timing (does it happen regularly?) U: understanding (what do you think is happening?) V: values (what do you want to do about this?) ```

Question 45

palliating

Answer 45

what makes it feel better

Question 46

chest assessment

Answer 46

assessing for crackles wheezing rhonchi pleural rub

Question 47

crackles

Answer 47

sounds like rice krispies

Question 48

wheezes

Answer 48

whistling

Question 49

rhonchi

Answer 49

sounds like snoring (rumbling)

Question 50

pleural friction rub

Answer 50

sounds like walking on snow

Question 51

lung field assessment

Answer 51

- back and forth on both sides - sit upright/ lean forward if they can - breath normally - look at skin colour

Question 52

tactile fremitus

Answer 52

vibration

Question 53

abdominal assessment

Answer 53

-can be laying down (preferred, knees bent, lower legs apart) -look for distension 1. inspect 2. auscultate - direction the bowels move (listen for quality and presence) 3. palpate 4. percussion BS x4 NO BOWEL SOUNDS VERY CONCERNING -listen for a full minute in each quadrant before saying there's no bowel sounds (RLQ-RUQ-LUQ-LLQ)

Question 54

peripheral vascular assessment

Answer 54

- CWMS - pain/tenderness - capillary refill (less than 2 seconds) - movement of extremities - compare one side of the body to the ohter - pulse deficit - clubbing - edema

Question 55

edema scale

Answer 55

0+: no pitting edema 1+: mild pitting edema. 2 mm depression that disappears rapidly 2+: moderate pitting edema. 4 mm depression disappears in 10-15 sec. 3+: moderately severe pitting edema. 6 mm depression that may last more than 1 min. 4+: severe pitting edema. 8 mm depression that can last more than 2 mins