Exam 1 Flashcards
Complete database
- a complete health history and full physical exam. It describes the current and past health state and forms a baseline against which all future changes can be measured. Yields the first diagnosis. Often completed in a primary care setting.
Focused or problem-centered database
Used for a limited or short-term problem; concerns mainly one problem, one cue complex, or one body system. Used in all settings, hospitals, primary care, long-term care.
Follow-up database
Used in all settings to monitor progress of short-term or chronic health problems.
Emergency database
Rapid collection of the database, often compiled concurrently with lifesaving measures.
What makes up a general survey
o The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. It is an introduction to the physical exam that will follow. It includes: Physical appearance- Age, sex, LOC, skin color, facial features, overall appearance Body structure- Stature, nutrition, symmetry, posture, position, body build/contour Mobility- range of motion Behavior- facial expression, mood and affect, speech, speech pattern, dress, personal hygiene Measurement- Weight, height, BMI, waist circumference Vital signs- temp, pulse, RR, BP, pulse ox, pain, HR
When weighing a patient, what are good practices to ensure accuracy?
-Ensure that the patient is wearing the same amount of clothing as the previous day -Weight at the same time every day -Record weight in Kg
Palpation
Follows and often confirms points that you noted during inspection. Applies your sense of touch to assessing these factors: temp, moisture, organ location and size, swelling, vibration and pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness and pain
Percussion
Tapping on the persons skin with short, sharp strokes to assess underlying structures.
Auscultation
Listening to sounds produced by the body , such as the heart, blood vessels, and the lungs and abdomen.
Diaphragm
-high-pitched sounds- breath, bowel, normal heart sounds
Bell
soft, low-pitched sounds- extra heart sounds or murmurs
Resonant sound
medium-loud, low, clear, hollow, duration moderate
Hyperresonant sound
Louder, lower, booming, longer duration
Tympany sound
Loud, high, musical and drumlike, sustained longest duration
Dull sound
soft, high, muffled thud, short duration
Flat sound
very soft, high, a dead stop of sound absolute dullness
Proficient nurse
The Proficient nurse perceives situations as wholes rather than in terms of chopped up parts or aspects. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The Proficient nurse learns from experience what typical events to expect in a given situation and how plans need to be modified in response to these events. The Proficient nurse can now recognise when the expected normal picture does not materialise. This holistic understanding improves the Proficient nurse’s decision making; it becomes less laboured because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones.
Expert nurse
The Expert nurse has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The Expert operates from a deep understanding of the total situation. His/her performance becomes fluid and flexible and highly proficient. Highly skilled analytic ability is necessary for those situations with which the nurse has had no previous experience.
Subjective info
what the person says about himself or herself during history taking
Objective info
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical exam
Afebrile
Not feverish
Hypothermic
Abnormally low body temp
Brady cardia
- In an adult a resting heart rate less than 50 beats/min
Tachycardia
A rapid heart rate of over 95-100 beats/min
Hypertension
Abnormally high blood pressure
Hypotension
Abnormally low blood pressure
Hyperthermia
Fever
Best ways to obtain temp
Rectal temp is the most accurate route to obtain temp.
The dorsum of the hand should be used to take temperature
Temperature variances amongst different ages.
