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118 - INP > Class 11: Assessment > Flashcards

Class 11: Assessment Flashcards

1
Q

inspection

A

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

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2
Q

important points to remember for inspection

A
  • make sure you have adequate lighting
  • position so all body parts can be viewed
  • compare with other side of body
  • do not rush
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3
Q

palpation

A

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

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4
Q

percussion

A

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

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5
Q

auscultation

A

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

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6
Q

capillary refill

A

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

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7
Q

cyanosis

A

bluish discolouration around lips and nail beds

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8
Q

edema

A

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

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9
Q

pallor

A

paleness may be caused by reduced blood flow and oxygen

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10
Q

pruritis

A

itching of skin, accompanies most rashes

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11
Q

dyspnea

A

difficult or uncomfortable breathing

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12
Q

orthopnea

A

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

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13
Q

hypoxia

A

inadequate tissue oxygenation at the cellular level

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14
Q

CWMS

A

colour, warmth, movement, sensation

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15
Q

diaphoretic

A

sweating

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16
Q

ecchymosis

A

discolouration of the skin resulting from bleeding underneath (bruising)

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17
Q

adventitious breath sounds

A

abnormal breath sounds

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18
Q

crackles

A

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

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19
Q

wheezes

A

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

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20
Q

nebulization

A

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

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21
Q

bowel sounds

A

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

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22
Q

anterior

A

front of body

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23
Q

dorsal

A

back of body

24
Q

inferior

A

lower parts of body

25
Q

superior

A

upper parts of body

26
Q

lateral

A

surfaces farther away from medial plane

27
Q

medial

A

surfaces closer to the medial plane

28
Q

proximal

A

located nearest centre of body

29
Q

distal

A

away from the centre body

30
Q

ipsilateral

A

on the same side

31
Q

contralateral

A

on the opposite side

32
Q

superficial

A

surface wound

33
Q

deep

A

deeper wound

34
Q

interior

A

within

35
Q

exterior

A

outside

36
Q

quick priority

A

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

37
Q

level of consciousness

A
  • 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)
38
Q

level of orientation

A

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

39
Q

comprehensive assessment

A
  • 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
40
Q

focused assessment

A
  • 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
41
Q

baseline

A

pattern of findings identified when client first assessed

42
Q

physical examination

A

inspection, auscultation, palpation, percussion

43
Q

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

A

percussion

44
Q

symptom assessment

A 
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?)
45
Q

palliating

A

what makes it feel better

46
Q

chest assessment

A

assessing for crackles
wheezing
rhonchi
pleural rub

47
Q

crackles

A

sounds like rice krispies

48
Q

wheezes

A

whistling

49
Q

rhonchi

A

sounds like snoring (rumbling)

50
Q

pleural friction rub

A

sounds like walking on snow

51
Q

lung field assessment

A
  • back and forth on both sides
  • sit upright/ lean forward if they can
  • breath normally
  • look at skin colour
52
Q

tactile fremitus

A

vibration

53
Q

abdominal assessment

A

-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)

54
Q

peripheral vascular assessment

A
  • 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
55
Q

edema scale

A

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

118 - INP (16 decks)

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