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Nurse 144 Physical Assessment > Comprehensive > Flashcards

Comprehensive Flashcards

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1
Q

What does MDS stand for and when is it utilized?

A

Minimum Data Set used in medicare

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2
Q

1.What are the five steps in hand rubbing *hand hygiene with alcohol based hand sanitizer 2.Duration? Flat Bed Pickups interweave through firetrucks

A

Flat Palms Back of hands interlaced Palms interlaced Interlocked hands *finger pads* Thumbs Fingertips 20 seconds until dry

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3
Q

What is the purpose of a basic complete physical? 2

A
  1. To obtain objective data and interpret it 2. To determine patients status
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4
Q

What is a baseline assessment. When is one taken.

A

A baseline assessment is taken upon the initial meeting with a patient. Whether a new patient at a doctors office or a patient in an emergency situation. The purpose of the baseline assessment is to obtain an initial record of patients status to be compared with later assessments to determine any change in status/condition.

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5
Q

Health assessment data is either ____ or ____

A

Healthy and within defined limits or not (equates to a health problem)

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6
Q

What do continuous, ongoing, and follow-up assessments determine? How?

A

Determine the effects of time and/or nursing care by comparing the most recent assessments with previous ones

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7
Q

What are the possible outcomes of continuous, ongoing, and follow-up assessments

A
  1. patient Condition is stable or stabilizing 2. patient condition is changing or changed
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8
Q

What are the two outcomes if the continuous assessment shows a patients condition is changing or has changed?

A
  1. patient is improving and progressing towards optimum health 2. Patient is worsening
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9
Q

What is the nurses responsibility upon discovering any abnormal finding or change in patient status?

A

To immediately report change to MD or NP

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10
Q

The RN should do what action every-time they interact with the patient

A
  1. Complete a quick assessment at minimum 2. Follow AIDET
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11
Q

Aprox. how many people die in hospitals each year due to medical errors that could have been prevented?

A

44,000 - 98,000

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12
Q

What example did the joint commission used when discussing the importance of constant ongoing assessment?

A

Patients deteriorate 8-12 hours before a cardiac event in clinical settings. Interventions are possible if deterioration is recognized and reported

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13
Q

What are the two main focuses of a physical assessment?

A

1.Subjective data 2. Objective data

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14
Q

Of the two main focuses of physical assessments, which one will be the focus of nurse 144?

A

Objective Data

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15
Q

What is the main difference between a nursing assessment and a Medical Assessment?

A

Nursing assessments have a holistic approach

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16
Q

What are the 5 aspects of holistic patient centered care? PPDSS *for each aspect tell if it is subjective or objective*

A
  1. Psychological-Sub 2. Physiological-Ob 3. Developmental-Ob 4. Sociocultural-Sub 5. Spiritual-Sub
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17
Q

What are the 5 components of a basic complete physical exam. Ruby Has Visits Post Sex

A
  1. Reason for Visit 2. Health history (subjective) 3. Vitals 4. Physical assessment 5. Systematic assessment
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18
Q

What four things must a systematic assessment be? SAS-E

A

Safe, accurate, systematic and efficient

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19
Q

What is the number one consideration above all else in any assessment or procedure?

A

Safety

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20
Q

What 3 things does the RN need to ensure they are respectful of during assessments? Carefully Recognize Emergency’s

A
  1. Culture 2. Ethnicity 3. Religion
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21
Q

The RN should always use what type of communication?

A

Therapeutic Communication

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22
Q

How can the RN become more culturally aware?

A

Through Self-reflection and Elimination of personal biases

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23
Q

What must the RN do when faced with a patient that is expressing values from a different culture that affect the process of assessment?

A

Modify the plan of care and environment to accommodate the patients values and wishes.

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24
Q

Treat others religions with_____ and ____

A

dignity and respect

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25
Q

What are the 4 main types of developmental differences that the RN may need to accommodate for during physical assessments? AIR-I

A
  1. Age (growth and development of children) 2. Impaired or delayed development 3. Regression-trauma 4 impaired cognitive status
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26
Q

What are two main types of impaired cognitive status?

A

1 dementia 2. Brain injury or dysfunction

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27
Q

What 4 things should all assessments be? SAC-E

A

Safe, Accurate, Systematic, Efficient

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28
Q

What are the 4 types of physical assessments? EPCF

A
  1. Emergency ALWAYS NUMBER ONE 2. Pain or primary concern 3. Comprehensive 4. Focused or Targeted
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29
Q

What are the 5 methods of assessment? IPP-AO

A
  1. Inspection 2. Palpation 3. percussion 4. Auscultation 5. Olfaction
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30
Q

Describe supine position

A

lying on the back with the face up.

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31
Q

Describe Prone position

A

lying on the chest with the face down (“lying down” or “going prone”)

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32
Q

Describe Dorsal Recumbent position

A

patient lies on the back with the lower extremities moderately flexed and rotated outward.

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33
Q

Describe lateral recumbent position

A

Patient lies on side with lower extremities moderately flexed

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34
Q

Describe lithotomy position

A

a supine position of the body with the legs separated, flexed, and supported in raised stirrups

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35
Q

Describe sims position

A

It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. Can also be called lateral recumbent

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36
Q

What is the precordium?

A

Front side of the heart against chest wall

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37
Q

What is the pericardium?

A

The double layered membrane that surrounds the heart

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38
Q

What is the mediastinum?

A

The portion of the thoracic cavity that contains the heart and is between the lungs

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39
Q

What is a sinus arrhythmia/dysrhtrhmia?

A

Heart rates that change with breathing

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40
Q

What is a thrombus?

A

A blood clot

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41
Q

What is an embolus

A

A traveling blood clot

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42
Q

What is the carotid sinus?

A

Site of baroregulators in the carotid artery. Do not massage the area or you could drop the heart rate/pressure

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43
Q

What are the three normal breath sounds?

A

Bronchial, Bronchovesicular, vescular

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44
Q

What are adventitious sounds?

A

Abnormal breath sounds

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45
Q

What is stridor, rhonchi?

A

High pitched whistling breath sounds caused by secretions

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46
Q

What is dyspnea?

A

Labored breathing

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47
Q

what are fremitus?

A

Tremors felt during chest palpation-99 mickey mouse

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48
Q

What is a atelectasis

A

full or partial collapsed lung

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49
Q

What is bronchiectasis?

A

Damaged airway

50
Q

Where do you listen for aortic heart sounds What heart sound is most prevalent?

A

the second ICS at the right sternal border S2

51
Q

Where do you listen for pulmonic heart sounds What heart sound is most prevalent?

A

1-3 ICS on left sternal border S2

52
Q

Where do you listen for Erb’s point What heart sound is most prevalent?

A

Third ICS Left sternal border equal S1/S2

53
Q

Where do you listen for murmurs

A

Erbs point

54
Q

Where do you listen for tricuspid heart sounds What heart sound is most prevalent?

A

4th or 5th ICS left lower sternal border S1

55
Q

Where do you listen for Mitral(apical) heart sounds What heart sound is most prevalent?

A

5th ICS on the left MCL S1 Can be palpated

56
Q

What is the main cause for hair loss in older populations lower extremities?

A

Poor circulation

57
Q

What is the duodenum what quadrant?

A

First part of small intestine after the stomach RUQ

58
Q

What is the ileum

A

The third portion of the small intestine between the jejunum and cecum

59
Q

What is the jejunum?

A

The second part of the stomach between duodenum and ileum

60
Q

What is the cecum

A

Pouch connected to the junction of the small and large intestines.

61
Q

What us the ileo-cecal junction?

A

a sphincter valve that connects the ileum and the cecum

62
Q

Where is the suprapubic area?

A

the area above the bladder

63
Q

What is the umbilicus?

A

the belly button

64
Q

What is scaphoid?

A

Concave abdomen

65
Q

What is Ascites?

A

Distended belly caused by edema related to liver disease

66
Q

What are the adenoids?

A

Small glands on roof of mouth behind soft palate

67
Q

What is a facies?

A

A facial expression typical for a specific disease

68
Q

What are some age variations for visual acuity?

A

-Weakened focusing power -senile hyaline plaque -cataracts

69
Q

What are some age variations in the sclera?

A

Yellowing

70
Q

What are some racial variations in the sclera

A

Darker skin can lead to a darker more yellow sclera

71
Q

What are some normal variations in hearing due to age?

A

Reduced hearing due to age- presbycusis

72
Q

What are some age related variations in the ear canal?

A

hard, thick, dry ear wax course hair

73
Q

What are the 3 supplies you will need to assess HEENT?

A

Pen light Gloves Tongue Blade

74
Q

What are two major safety precautions when assessing the GI system

A

-If the is pain don’t palpate -if there is pulsations don’t palpate

75
Q

WHat is a bursa(e)

A

Sac filled with synovial fluid at the synovial joint

76
Q

What is the periosteum?

A

Layer of fibrous connective tissue covering the outside of the bone

77
Q

What is synovial fluid?

A

Lubricating fluid in the synovial joints

78
Q

What is a ligament?

A

Band of collagen rich connective tissues that binds bone to bone

79
Q

What is a tendon?

A

Band of collagen rich connective tissue connecting bone to muscle

80
Q

What is osteoporosis?

A

a degenerative bone disease characterized by loss of bone mass

81
Q

What is Kyphosis?

A

Exaggerated rounding of the back

82
Q

What is lordosis

A

excessive inward curve of the spine

83
Q

What is scoliosis?

A

Lateral curve of the spine

84
Q

What is the romberg test?

A

Test used to examine balance

85
Q

What are DTR’s?

A

Deep tendon reflexes

86
Q

What is the subarachnoid space?

A

Gap between arachnoid space and pia mater filled with cerebral spinal fluid

87
Q

What is paresthesia?

A

Pins and needles

88
Q

What is the function of the frontal lobe?

A

Cognitive function, voluntary muscles, personality

89
Q

What is the function of the parietal lobe?

A

Processes sensory information

90
Q

What is the function of the occipital lobe?

A

Visual processing

91
Q

What is the function of the temporal lobe?

A

Auditory processing

92
Q

What is the somatic nervous systems function?

A

Voluntary muscle movments

93
Q

What is the autonomic nervous systems function?

A

involuntary control and regulation

94
Q

What is CN 1 and its function? Sensory or motor?

A

Olfactory nerve conveys the sense of smell Sensory

95
Q

What is CN 2 and its function?Sensory or motor?

A

Optic nerve Conveys vision Sensory

96
Q

What is CN 3 and its function? Sensory or motor?

A

Ocularmotor nerve -EOM’s Motor

97
Q

What is CN 4 and its function Sensory or motor?

A

Trochelar nerve EOM’s Motor

98
Q

What is CN 5 and its function? Sensory or motor?

A

Trigeminal nerve provide sensation to the skin of the face and also controls the muscles of mastication Both

99
Q

What is CN 6 and its function? Sensory or motor?

A

Abducens nerve EOM Motor

100
Q

What is CN 7 and its function? Sensory or motor?

A

Facial Nerve Facial expressions both

101
Q

What is CN 8 and its function? Sensory or motor?

A

Vestibulocochlear nerve Hearing and Balance sensory

102
Q

What is CN 9 and its function? Sensory or motor?

A

glossopharyngeal nerve Oral sensation, taste, and salivation both

103
Q

What is CN 10 and its function? Sensory or motor?

A

Vagas lots of functions both

104
Q

What is CN 11 and its function? Sensory or motor?

A

Accessory nerve Shoulder elevation and head-turning motor

105
Q

What is CN 12 and its function Sensory or motor?

A

Hypoglossial Nerve Tongue movement motor

106
Q

How would you test CN 2?

A

Visual acuity

107
Q

How would you test CN 3, 4, 6?

A

EOM and Blink response

108
Q

How would you test CN 8?

A

Whisper test and romburg test

109
Q

How would you test CN 10

A

soft palate rise on phonation

110
Q

What is Pain?

A

Unwanted or unpleasant sensation

111
Q

Pain is always _______

A

What the patient says it is

112
Q

Is pain the same as suffering?

A

No

113
Q

IN 1994 the joint commission coined what phrase as a part of their campaign to _____ that is no longer accepted but that directly contributed to current opioid epidemic

A

Improve pain relief Pain is the fifth vital sign

114
Q

What are the two numeric pain assessment tools?

A

-1-10 scale -Visual Analog scale — 1-100 mm line that the patient marks and is measured

115
Q

When a patient uses verbal descriptions of pain how should they be documented?

A

By direct quote in patient chart

116
Q

What does COLDSPA stand for?

A

-Characteristic -Onset -Location -Duration -Severity -Pattern -Aggravating or Alleviating factors

117
Q

What does OLDCARTS stand for?

A

-Onset -Location -Duration -Character -Aggravating or alleviating factors -Related Symptoms -Treatments -Severity

118
Q

What does PQRSTU stand for?

A

-Provocative or Palliative factors -Quality -Region/Radiation -Severity -Timing -How is the pain affecting U

119
Q

What are two other pain assessment tools?

A

-NIPS-Neonatal and infant pain scale -The wong-baker faces pain scale

120
Q

Pain assessment is always _____ data

A

Subjective but objective data is used as clues

Nurse 144 Physical Assessment (6 decks)

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