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Q1 nursing > Janie ch 30 > Flashcards

Janie ch 30 Flashcards

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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
Q

What are you doing when you are inspecting?

A

Carefully looking, listening, and smelling to distinguish normal from abnormal findings.

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25
Q

What are 4 things to keep in mind to palate a pt?

A
  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
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26
Q

When do you palmate sensitive areas on a pt?

A

Last

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27
Q

How do you palmate aw helms tumor?

A

NEVER palmate a tumor!! idiot

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28
Q

What are you determining if you find a lump while palpating . 7

A
  1. Position
  2. Texture
  3. Size
  4. Consistency
  5. Masses
  6. Fluid
  7. Crepitus
29
Q

What is crepitus?

A

Crackling or popping sounds

30
Q

What part of your hand is more sensitive to vibrations?

A

The Palmer surface

31
Q

Best part of the hand to assess body temp?

A

Dorsal surface

32
Q

When you grasp body part ( a lump) with 2 fingers what are you measuring for?

A

Position, consistency, tutor

33
Q

How do you preform percussion and what does it determine?

A

Tap body w fingertips to produce vibration, the sounds determine location, size, and density

34
Q

What does an abnormal size of an organ suggest?

A

A mass, air or fluid within it.

35
Q

What are 4 things required to auscultions?

A
  1. To listen to sounds
  2. Learn abnormal from normal
  3. Good stethoscope
  4. Good concentration and practice
36
Q

The bell is what side of stethoscope? What sounds is it best at hearing?

A

The small side is the bell. Used to hear low pitched sounds.

37
Q

What part of the stethoscope is the diaphragm and what is it used for?

A

The larger side is the diaphragm, used to hear high pitched sounds

38
Q

What is done in a general survey?

A

Assess appearance and behavior
Assess vital signs
Assess height and weight

39
Q

What are 5 things to look for in skin assessment?

A
  1. Color
  2. Moisture
  3. Temperature
  4. Texture
  5. Turf or
40
Q

What are all the parts included in integumentary system?

A

Skin, hair, scalp and nails

41
Q

What is cyanosis?

A

Bluish discoloration

42
Q

Where should you look for cyanosis on a pt skin?

A

Lips, nails beds, palpebral conjunctival ( underside of eye lids), palms

43
Q

Where is best place to see jaundice?

A

Scalar ( yellow or orange discoloration)

44
Q

What does skin changes such as pallor or erythema indicate?

A

Circulatory changes

45
Q

What is erythema of the skin?

A

Red discoloration

46
Q

What is pallor of the skin?

A

Painless, lack of color

47
Q

What does texture of the skin refer to?

A

Surface of the skin and how deep the layers feel.

48
Q

What’s the purpose of inspecting the skin?

A

To assess oxygenation, circulation,nutrition,damage,hydration

49
Q

Name 3 layers of skin.

A

Epidermis
Dermis
Subcutaneous fatty tissue

50
Q

What are ABCD of a discoloration on skin?

A

Asymmetry
Border irregularity
Color
Diameter

51
Q

What 3 things do you look for on skin assessment?

A

Vascular it’s
Edema
Lesions

52
Q

What are two common causes of edema?

A

Direct trauma and impairment of venous return

53
Q

Why palpate edematous areas?

A

To determine mobility, consistency, and tenderness

54
Q

What is the pit left called when you push a finger into an edema area?

A

Pitting edema

55
Q

What are you looking for when inspecting hair?

A 
Color
Distribution
Quantity
Thickness
Texture
Lubrication
56
Q

Aside of genetics what can hair loss be related to?

A

Diabetes
Thyroid it’s
Menopause

57
Q

What does condition of nails reflect?

A 
General health
State of nutrition
Occupation
Level of self care
Age
58
Q

What causes lines to form down nails?

A

Vitamin, protein, electrolyte changes

59
Q

What’s included in head and neck assessment?o

A 
Head
Eyes
Ears
Nose
Mouth
Pharynx
Neck 
Lymph nodes
Carotid arteries
Thyroid gland and trachea
60
Q

What techniques are used while assessing head and neck?

A

Inspecting, palpitation, and auscultation

61
Q

What to look for when assessing eyes.

A

Visual acuity
Extra ocular movements
Visual field

62
Q

When examining eyes what all are you looking at?

A 
Size
Shape
Structure
Visual acuity
Visual fields conjunctiva
Sclera
Cornea
Pupil
Iris
63
Q

What is nystagmus and how does it occur?

A

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
Q

Redness in conjunctiva indicates?

A

Allergies or infection

65
Q

Abnormal drooping of the lids is what?

A

Ptosis

66
Q

Aside from aging what causes ptosis?

A

Edema

Or impairment of third cranial nerve

67
Q

What can non symmetrical purples indicate?

A

Neurological injury

68
Q

What does PERRLA stand for?

A

Pupils equal, round, reactive to light, and accommodation

69
Q

What pt are in greatest need for eye exam?

A

Those with diabetes, hypertension, and intracranial disorders

Q1 nursing (27 decks)

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