Exam 1 Flashcards
Explain what is a positive finding
A positive finding indicates that the patient has or has had a particular problem or sign under discussion
(e.g. if the patient with jaundice has an enlarged liver)
Explain what is a negative finding
A negative finding is the absence of a sign or symptom usually associated with a problem
(If a team is not present in a patient with advanced liver disease, specifically know this has no peripheral edema)
List the order of techniques for physical examination
inspection, palpation, percussion, and auscultation.
List the order of techniques for abdominal examination
inspection, auscultation, percussion, and palpation
Performing percussion and palpation of the abdomen before auscultation can alter bowel sounds and produce false findings.
What techniques are used for a musculoskeletal examination
requires only inspection and auscultation
Assessment upon life-threatening conditions is called..
e.g., inhalation injuries, anaphylaxis, myocardial infarction, shock, stroke
Emergency assessment
Detailed assessment of all body systems head-to-toe assessment is called…
Comprehensive assessment
Abbreviated assessment that focuses on one or more body systems that are the focus of care is called…
Focused assessment
Includes an assessment related to a specific problem is called?
(e.g., pneumonia, specific abnormal laboratory findings)
Focused assessment
Identify all three learning styles
(1) visual (reading, pictures)
(2) auditory (listening)
(3) physical (doing things)
This purpose is to exchange points of view about a topic or to arrive at a decision or conclusion
teach back
This purpose is to teach patient and caregiver to perform a skill
show back
Defined as return demonstration; can evaluate patient’s ability to perform skill
show back
Examples of teach back and show back:
teach back- weight loss
show back- dressing change, injection
term for the belief that one can succeed in a given situation
self efficacy
To maximize self-efficacy plan easily achievable goals early in the teaching sessions and proceed from simple to more complex content to create a feeling of success
Purpose of health history
- Contribute to a database that identifies the patient’s current and past health status
- Provide a baseline against which future changes can be evaluated.
- Purpose of nursing assessment is to enable you to make clinical judgments or nursing diagnoses about your patient’s health status.
- The information obtained from the nursing history and physical examination is used to determine the patient’s strengths and responses to a health problem.
Normal range for sodium Na
136-145
Normal range for potassium K
3.5-5.0
Normal range for magnesium Mg
1.3-2.1
Normal range for calcium Ca
9.0-10.5
Normal range for chloride Cl
98-106
Normal range for phosphorus P
3.0-4.5
Normal ranges for HCO3-?
22-26
Normal range for PaCO2
35-45
Normal pH level
7.35-7.45
contraction of facial muscles in response to a tap over the facial nerve in front of the ear
Chvostek’s sign
carpal spasms induced by inflating a BP cuff on the arm
Trosseau’s sign
How do you detect fluid status by skin turgor?
fold of skin, when pinched, will readily move and, on release, rapidly return to its former position
How do you detect edema
Assess edema by pressing with a thumb or forefinger over the edematous area.
what is the significance of daily weight?
- accurate measure of volume status
2. weigh the patient at the same time every day, wearing the same clothes
Common causes of dehydration are?
Exercise, fever, high environmental temperature
Diarrhea
Common causes of hypertonic solution
Fluid excess, Crackles in the lungs, pulmonary edema, peripheral pulses, changes in the urine output
What type of solution has no change; balanced concentration (similar concentration of water and electrolytes to plasma)
What’s an example of this
Isotonic
-Lactated ringers
What type of solution has more salt; less water, cell shrinks. used to treat pt with hyponatremia and trauma with head injury
What is an example of this
Hypertonic
-3% or higher Normal Saline, D5 0.45% Normal Saline, D5LR
What type of solution has more water; less salt, cells swell.
What is an example of this
Hypotonic
0.45% and lower Normal Saline
What is the recommended daily fluid intake for a stable adult?
2000-3000 ml
Name safety considerations for patients with electrolyte imbalances
Pt is at risk for falls because of orthostatic hypotension, muscle weakness, and changes in level of consciousness
- Assess level of consciousness, gait, and muscle strength. Implement fall precautions.
- If orthostatic hypotension is present, teach the patient to change positions slowly when rising from a bed or chair.
- Place alarm monitors on patients who are confused and try to get out of bed without assistance.
What are signs of dehydration?
alterations in mental status (confusion), ranging from agitation, restlessness, confusion, and lethargy to coma.
Which electrolyte imbalances cause dysrhythmias?
Hypo/Hyperkalemia
Name some risk factors associated with Hyponatremia?
- excessive sweating
- diuretics
- wound drainage from GI
- ng tube suction
- decreased secretion of aldosterone
- hyperlipidemia
- kidney disease
- inadequate Na intake = NPO
- hyperglycemia
- low sodium diet
- cerebral salt wasting syndrome
- kidney failure = nephrotic syndrome
- heart failure
- SIADH
What happens to the pulse and BP if the patient has hypovolemia with hyponatremia?
- pulse is bounding, BP is above expected range
Name some signs and symptoms associated with HYPOnatremia
- tachycardia
- RAPID thready pulse
- hypotension
- orthostatic hypotension
- diminished peripheral pulses
- headache/confusion
- lethargy, muscle weakness, fatigue
- decreased DTR
- hyperactive bowel sounds, abdominal cramping, nausea
Name some foods you would encourage for patients with HYPOnatremia
- beef broth, tomato juice
Name signs and symptoms associated with Hypernatremia?
- THIRSTY
- tachycardia
- orthostatic hypotension
- restlessness/ irritable
- muscle twitching
- decreased/ absent DTR
- dry mucous membranes, N/V, occasional diarrhea
Name some risk factors associated with Hypernatremia?
- kidney failure
- Cushing’s syndrome
- Aldosteronism
- water deprivation
- diabetes insipidus
- heatstroke
- hyperventilation
- watery stools
- burns
- excessive sweating
Name some signs and symptoms associated with Hypokalemia?
- low BP
- WEAK THREADY PULSE
- orthostatic hypotension
- altered mental status
- anxiety, lethargy that progresses to acute confusion and coma
- ECG changes
- hypoactive bowel sounds
- N/V, constipation, abdominal distention
- weakness, reduced DTR
Risk factors for HYPOkalemia:
- overuse of diuretics
- Cushing’s syndrome
- N/V, diarrhea, prolonged ng suctioning
- NPO status
- alkalosis
- hyperinsulinism
- hyperalimentation
- TPN
- water intoxication
- increase use of laxatives
Name some signs and symptoms associated with Hyperkalemia?
- slow irregular pulse, hypotension
- restlessness/ irritable
- weakness –> ascending flaccid paralysis, paresthesia
- ECG changes–> peaked T waves, widened QRS
- diarrhea
- hyperactive bowel sounds
Risk factors for HYPERkalemia:
- CLIENTS WHO ARE CHRONICALLY ILL
- overconsumption of high K foods or salt subsitutes
- excessive/ rapid potassium replacement
- RBC transfusions
- adrenal insufficiency
- ACE inhibitors, potassium sparing diuretics
- kidney failure
- acidosis (DIABETIC KETOACIDOSIS)
- tissue damage
- hyperuricemia (high uric acid)
What foods would you recommend to patients with HYPOkalemia?
- Patient has low levels of potassium so recommend them on a high potassium diet
- avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas, juices, melon, lean meats, milk, whole grains, citrus fruits
What electrolyte imbalances are associated with Cushing’s syndrome?
- hypernatremia, hypokalemia
