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Q1 nursing > Janie ch 30 > Flashcards

Janie ch 30 Flashcards

0
Q

What does a complete health assessment involve?

A

A nursing history

A behavioral and physical examination

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1
Q

Why are physical assessment skills used for during your pt exam

A

To guide clinical judgments.

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2
Q

The pt condition and response affect the extent of ?

A

Your examination.

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3
Q

What two things will the accuracy of your assessment influence?

A
  1. Choice of therapy

2. Evans of response to those therapies

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4
Q

What are some purposes of physical exams?

A

1- routine ( baseline)
2- emergencies
3- eligibility for health ins. Military, Job
4- to admit pt to hospital or long term care

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5
Q

Physical assessments findings determine what?

A

The cause of the diagnosis

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6
Q

What do you do once you determine the cause of the diagnosis?

A

Enables nurse to individualize a plan of care.

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7
Q

During the evaluation phase what does nurse do when pt achieve their outcomes and goals?

A

Nurse can revise, amend, or doc nursing interventions.

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8
Q

Purpose of physical exams cont

A 
Baseline
Support/ refute data
Identify / confirm nursing diagnose
Making clinical decisions about pt health and management 
Evaluate outcomes
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9
Q

Culture influences a pt what?

A

Behavior

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10
Q

What should be considered for culture sensitivity?

A 
Health beliefs
Use of alternative therapies
Nutritional habits 
Relationships w family
Personal comfort
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11
Q

What should be avoided w culture sensitivity?

A

Stereotyping and gender bias

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12
Q

Why would it be important to be aware of disorders in particular ethnic groups?

A

Increase. Chance to recognize rare conditions.

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13
Q

What 6 preparation for examination?

A 
1 infection control
2 environment
3 equipment
4 pt positioning prep
5 psychological prep for pt
6 assessment of age group
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14
Q

Adventitious sounds

A

Abnormal breathing sounds

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15
Q

Alopecia

A

Hair loss

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16
Q

If there is an enlargements of the aorta from an aneurysm what should you NEVER do?

A

Palpate

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17
Q

How should you organize you organize an exam? 4 steps

A
  1. Assessment of each body system
  2. Follow nursing history
  3. Systematic and organized
  4. Head to toe approach
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18
Q

During an exam what should you compare?

A

Both sides for symmetry

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19
Q

During an exam if pt is seriously ill, what body system do you assess first?

A

The one that is most at risk.

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20
Q

During an exam, when do you perform painful procedures?

A

At end of assessment.

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21
Q

How do you record notes during exam?

A

Use quick notes during exam and complete larger documentation at the end of exam. Duh

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22
Q

What are the 4 techniques of physical assessments?

A
  1. Inspection
  2. Palpating
  3. Percussion ( not really done in nursing any more)
  4. Auscultation
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23
Q

When you get to inspecting the abdomen, what do you do first?

A

Listen for bowel tones before palpating as this tends to wake the bowels up.

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24
What are you doing when you are inspecting?
Carefully looking, listening, and smelling to distinguish normal from abnormal findings.
25
What are 4 things to keep in mind to palate a pt?
1. Use to gather information. 2. Use different parts of hands to detect different characteristics 3. Hands should be warm, fingernails short 4. Start with light palpations, end with deep palpations
26
When do you palmate sensitive areas on a pt?
Last
27
How do you palmate aw helms tumor?
NEVER palmate a tumor!! idiot
28
What are you determining if you find a lump while palpating . 7
1. Position 2. Texture 3. Size 4. Consistency 5. Masses 6. Fluid 7. Crepitus
29
What is crepitus?
Crackling or popping sounds
30
What part of your hand is more sensitive to vibrations?
The Palmer surface
31
Best part of the hand to assess body temp?
Dorsal surface
32
When you grasp body part ( a lump) with 2 fingers what are you measuring for?
Position, consistency, tutor
33
How do you preform percussion and what does it determine?
Tap body w fingertips to produce vibration, the sounds determine location, size, and density
34
What does an abnormal size of an organ suggest?
A mass, air or fluid within it.
35
What are 4 things required to auscultions?
1. To listen to sounds 2. Learn abnormal from normal 3. Good stethoscope 4. Good concentration and practice
36
The bell is what side of stethoscope? What sounds is it best at hearing?
The small side is the bell. Used to hear low pitched sounds.
37
What part of the stethoscope is the diaphragm and what is it used for?
The larger side is the diaphragm, used to hear high pitched sounds
38
What is done in a general survey?
Assess appearance and behavior Assess vital signs Assess height and weight
39
What are 5 things to look for in skin assessment?
1. Color 2. Moisture 3. Temperature 4. Texture 5. Turf or
40
What are all the parts included in integumentary system?
Skin, hair, scalp and nails
41
What is cyanosis?
Bluish discoloration
42
Where should you look for cyanosis on a pt skin?
Lips, nails beds, palpebral conjunctival ( underside of eye lids), palms
43
Where is best place to see jaundice?
Scalar ( yellow or orange discoloration)
44
What does skin changes such as pallor or erythema indicate?
Circulatory changes
45
What is erythema of the skin?
Red discoloration
46
What is pallor of the skin?
Painless, lack of color
47
What does texture of the skin refer to?
Surface of the skin and how deep the layers feel.
48
What's the purpose of inspecting the skin?
To assess oxygenation, circulation,nutrition,damage,hydration
49
Name 3 layers of skin.
Epidermis Dermis Subcutaneous fatty tissue
50
What are ABCD of a discoloration on skin?
Asymmetry Border irregularity Color Diameter
51
What 3 things do you look for on skin assessment?
Vascular it's Edema Lesions
52
What are two common causes of edema?
Direct trauma and impairment of venous return
53
Why palpate edematous areas?
To determine mobility, consistency, and tenderness
54
What is the pit left called when you push a finger into an edema area?
Pitting edema
55
What are you looking for when inspecting hair?
``` Color Distribution Quantity Thickness Texture Lubrication ```
56
Aside of genetics what can hair loss be related to?
Diabetes Thyroid it's Menopause
57
What does condition of nails reflect?
``` General health State of nutrition Occupation Level of self care Age ```
58
What causes lines to form down nails?
Vitamin, protein, electrolyte changes
59
What's included in head and neck assessment?o
``` Head Eyes Ears Nose Mouth Pharynx Neck Lymph nodes Carotid arteries Thyroid gland and trachea ```
60
What techniques are used while assessing head and neck?
Inspecting, palpitation, and auscultation
61
What to look for when assessing eyes.
Visual acuity Extra ocular movements Visual field
62
When examining eyes what all are you looking at?
``` Size Shape Structure Visual acuity Visual fields conjunctiva Sclera Cornea Pupil Iris ```
63
What is nystagmus and how does it occur?
It's an involuntary, rhythmical oscillation of the eye. | Results from local injury of eye muscles and supporting structure or disorder of cranial nerve innervating the muscles
64
Redness in conjunctiva indicates?
Allergies or infection
65
Abnormal drooping of the lids is what?
Ptosis
66
Aside from aging what causes ptosis?
Edema | Or impairment of third cranial nerve
67
What can non symmetrical purples indicate?
Neurological injury
68
What does PERRLA stand for?
Pupils equal, round, reactive to light, and accommodation
69
What pt are in greatest need for eye exam?
Those with diabetes, hypertension, and intracranial disorders

Q1 nursing (27 decks)

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