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nur330L > midterm > Flashcards

midterm Flashcards

1
Q
  1. Oral nutrition( feeding a patient) /Intake and output measurement-2 questions
  2. Drug dosage calculations- “desired over have method” style questions-3 questions
  3. Turning and repositioning- 1 question
A
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2
Q

purpose of personal hygeine

A

promotes physical and mental health
provides an opportunity to discuss health care concerns and establish a relationship

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3
Q

principles of personal hygeine

A
  • maintaining skin integrity by promoting circulation and hydration
  • cognitive issues or dementia involves applying physical, emotional, and environmental factors to promote safe and acceptable and comfortable hygeine process
  • maintain pt privacy and comfort, encourage participation
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4
Q

best time to perform skin assessment

A

during bed bath

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5
Q

chlorhexidine gluconate (CHG) bathing

A

daily bathing with 2% CHG reduces patients cutaneous microbial burden
effective against wide spectrum of gram-positive and gram-negative bacteria
reduces health care associated infections

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6
Q

use of CHG solution for preoperative skin antisepsis is

A

associated with fewer surgical site infections

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7
Q

CHG reduces

A

central line associated bloodstream infections and reduces HAI exposure to infected or colonized roomates and prior room occupants

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8
Q

continenece issues pose threats to a patients

A

skin integrity
increase risk of falls
increase social isolation

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9
Q

use clean gloves when

A

there is likely contact with drainage, secretions, excretions, or blood

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10
Q

safety of bathing

A
  • hygeine products within reach
  • test waters temp to prevent burn injuries
  • assess and evaluate pt before and after care to assess unexpected outcomes
  • coagulation studies and meds before admin of oral care/shaving to prevent bleeding
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11
Q

can a bed bath be delegated

A

skill of bathing can be but assessment, no
instructs UAP to not massage reddened areas, contraindications to soaking patients feet, reporting any signs of impaired skin integrity, and proper positioning for MS limitations or a cathether

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12
Q

areas of excessive dryness, rashes, irritation, or pressure injury appear on skin

A
  • CHG soap
  • limit frequency of complete baths
  • complete pressure injury assessment
  • ensure patient is not positioned over pressure points
  • institute turning and positioning measures
    obtain special bed surface as needed
  • notify HCP and/or obtain wound consult
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13
Q

if patient becomes tired

A
  • reschedule bathing when more rested
  • pt w cardiopulmonary conditions and breathing difficulties require pillow or elevated head of bed during bathing
  • notify HCP about changes in fatigue
  • perform hygiene measures in stages between scheduled rest periods
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14
Q

restless or complaints of discomfort

A
  • use less stressful method such as disposable bath
  • consider analgesia before bathing
  • schedule rest before
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15
Q

perineal care

A

cleaning around patients external genitalia and surrounding skin
provided during complete bed bath
provided more frequently for patients at risk for infection (IAD (defibrilator), incontinence, indwelling cathether, postpartum, recovering from rectal or genital surgery)

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16
Q

instruct UAP during perineal care to

A

avoid physical restriction that affects proper positioning of patient
properly position pt with catheter
inform nurse of any perineal drainage, excoriation, or rash

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17
Q

CHG cloths

A

disposable washclothes impregnanted with CHG
reduces risk of HAIs and multidrug resistant organisms

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18
Q

daily oral hygeine

A

brushing, flossing, and rinsing

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19
Q

head of bed should be raised to

A

30-45 degrees

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20
Q

muscosa dry and inflamed tongue has thick coating

A

increase pt hydration
increase frequency of oral care, focusing on tongue brushing

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21
Q

cheilosis

A

dry cracked lips
apply moisturiiing lubricant to pt lips

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22
Q

gum margins are retracted with localized inflammation, bleeding occurs around gum margins

A

report findings because pt may have underlying bleeding tendancy
switch to softer bristle brushes
avoid rigorous brushing and flossing

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23
Q

muscosa becomes inflmaed from repeated chemo administration and a leasion from sloughing of tissue develops

A

determine best practice for mucositis and stomalitis
ex. flouride toothpaste
rine 4-6x/day with salt and baking soda, saliva subs as ordered

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24
Q

xerostomia

A

dry mouth
if occurs, additional rinses to increase moisture may be used

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25
Q

denture care

A

removes food and debris from and around dentures
reduces risk of gingival infection

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26
Q

UAP on dentures

A
  • don’t use very hot or cold water
  • inform if any cracks in dentures
  • inform if pt has oral discomfort
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27
Q

unconscious or debilitated patients

A

more susceptible to infection
have either reduced or absent gag reflex and must be protected from choking and aspiration

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28
Q

secretions or cursts are on muscosa tongue or gums

A

provide more frequent oral hygeine

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29
Q

localized inflammation or bleeding of gums or mucousa is present

A

provide more frequent oral hygeine with toothpaste sponges
water based mouth moisturizer
chemo and radiation can cause mucositis, room temp saline rinses, bicarbonate and sterile water rinsess decrease severity and duration of mucositis

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30
Q

patient aspirates secretions

A

suction oral airway as secretions accumulate to maintain airway patency
elevate HOB
if aspiration is suspected notify HCP, prepare pt for chest xray

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31
Q

instruct patients to (foot)

A

protect feet from injury
keep feet clean and dry
wear appropriate footwear

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32
Q

disorders that put patients at risk for developing serious foot problems

A

peripheral neuropathy
peripheral vascular disease (PVD)
DM

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33
Q

morse fall scale

A
  1. history of falling; immediate or within 3 months (yes = 25)
  2. secondary diagnosis (yes= 15)
  3. ambulatory aid ie., bed rest/nurse assisst (0), crutches/cane/walker (15), furniture (30)
  4. IV/heparin lock (yes=20)
  5. gait/transferring ie, normal/bedrest/immobile (0), weak (10), impaired (20)
  6. metal status ie, oriented to own ability (0), forgets limitations (15)
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34
Q

risk level MFS

A

0-24 = no risk
25-50= low risk
>51 = high risk

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35
Q

dvt

A

deep vein thrombosis
clot in a deep vein (leg, pelvis, or arms)

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36
Q

risk factors for DVT

A

bedrest
post-op
fractures
pregnancy
heart disease
obesity
sitting for long periods
limited mobility

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37
Q

prevention of DVT

A

early ambulation
intermittent sequential compression devices (SCDs)
compression stockings
foot pumps

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38
Q

signs of DVT

A

edema
red or hot skin
calf pain
signs of allergic reaction

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39
Q

assistive device

A

any device that is designed, made, or adapted to help a person perform a particular task or function
includes: canes, crutches, and walkers

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40
Q

assisting with use of cane walkers and crutches

A

have pt dangle following lying in bed
immediately return pt to bed or chair if he or she is nauseated, dizzy, pale, or diaphoretic
apply safe, nonskid shoes on patient and ensure clear environment

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41
Q

pt unable to ambulate out of fear of falling, physical discomfort, upper body muscles that are too weak to use ambulation device, or lower extremities are too weak to support body

A

consult PT to strengthen muscles or alternative methods for ambulation
provide analgesics for discomfort
discuss pt fears or concerns about walking using assistive device

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42
Q

pt sustains injury

A

notify HCP
return pt to bed if injury stable otherwise have lift team transfer to bed
document

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43
Q

immobilization devices

A

increase stability of bones and joints
support an extremity
reduce load on weight bearing structures
ex. splints, slings
can cause medical device-related pressure injuries

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44
Q

7 rights of medication administration

A

right med
right dose
right patient
right route
right time
right documentation
right indication

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45
Q

3 checks of med administration

A
  1. pulling meds out of pyxis
  2. before entering pt room
  3. when giving med
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46
Q

safety guidelines for med administration

A
  • use 2 ID before admin and check against the MAR
  • double check dosing calculation
  • assess pt sensory function, sight, hearing, touch, and physical coordination, and dexterity
  • evaluate each med for potential drug-drug or drug-food interactions
  • always assess allergies
  • evaluate if pt can take PO meds w food
    review order for pt name, drug, dosage, route, and time
  • use correct equipment for admin of all meds
  • gather pertinent info to drugs ordered: purpose, normal dosage, route, common side effects, time of onset and peak, contraindications, and nursing implications
  • determine if nursing interventions are needed prior to administration
  • check expiration dates
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47
Q

common routes of nonparenteral meds

A
  • oral
  • sublingual
  • buccal
  • topical (direct application to skin or mucosa)
  • nasal/opthalmic/otic
  • direct application of liquid (nasal spray, inhaler)
  • inhalation of dry powder
  • rectal/vaginal
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48
Q

oral meds

A
  • liquids absorbed faster
  • some oral meds are absorbed in intestines
  • notfiy HCP for adverse effects
  • assess vitals
  • hold further doses
  • urticaria, rash, pruritis, rhinitis, and wheezing may indicate allergic rxn
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49
Q

never crush or split an

A

enteric coated med

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50
Q

if pt refuses meds

A

ask why
provide further instruction
dont force meds
notify HCP

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51
Q

pt unable to explain drug info

A

further assess pt or family caregiver knowledge of medications and guidelines for drug safety
further instruction or different approach necessary

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52
Q

meds through feeding tube

A
  • keep head of bed at minimum of 30-45 degrees for 1 hr after med administration
  • report immediately to nurse if coughing, choking, gagging, or drooling of liquid
  • report occurance of side effects
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53
Q

topical meds

A
  • applied locally to skin, mucous membranes, or tissues
  • lotions, patches, pastes, and ointments primarily produce local effects but can create systemic effects if absorbed through the skin
  • never apply new meds over a previously applied med
  • always clean the skin or wound thoroughly before applying new dose
  • report immediately any skin irritation, burning, blistering, or increased itching
  • do NOT apply any dressing over topical meds unless instructred
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54
Q

opthalmic meds

A
  • commonly in drops, ointments, intraocular discs
  • pt should learn correct self admin
  • potential temporary burning or blurring of vision after admin
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55
Q

pt complains of burning or pain or experiences local side effects of eye meds

A

dim lights to reduce glare and discomfort
notify HCP for possible adjustment in med and/or dosage

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56
Q

systemic effects from eye drops

A

notify HCP
remain w pt
assess vitals
withhold further doses

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57
Q

pt unable to explain drug info or steps for taking eyedrops or manipulating dropper

A

repeat instructions and include family caregiver

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58
Q

ear (otic) meds

A
  • usually drops
  • admin at room temp
  • precautions: use sterile drops and solutions in case ear drum is ruptured, do not occlude ear canal with a medicine dropper
  • potential dizziness or irritation after admin
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58
Q

patients hearing acuity does not improve

A

notify HCP
cerumen may be impacted required ear irrigation

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58
Q

ear canal remains inflammed, swollen, tender to palpation, drainage is present

A

hold next dose
notfiy HCP for changes in dose and med

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58
Q

nasal mucosa remains inflammed and tender with discharge from nares

A

consider alternative therapy

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58
Q

pt complains of sinus headache, remains congested

A

consider alternative therapy, nasal irrigation

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58
Q

sprays, drops, tampons

A

report bloody nasal drainage

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59
Q

pt unable to breathe through nasal passages

A

stop med use
notify HCP for possible alternative therapy

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60
Q

metered dose inhalers (MDIs)

A
  • small handheld device
  • disperses medication into the airways through an aerosol spray or mist by activation of a propellant
  • requires coordination during breathing cycle
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61
Q

pt with poor coordination may need

A

spacer or BAI

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62
Q

patient respirations rapid and shallow, breath sounds indicate wheezing

A

evaluate VS and RR
notify HCP
reassess type of med and delivery

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63
Q

pt needs bronchodilator more than every 4 hrs

A

reassess type of med and delivery methods needed
notify HCP

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64
Q

pt experiences cardiac dysrythmias (light headed, syncope) especially if receiving beta-adrenergic medications

A

withold all further doses of meds
evaluate cardiac and pulmonary status
notify HCP

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65
Q

dry powdered inhaled medications

A
  • holds dry powder
  • creates an aerosol when pt inhales through a resovoir that contains the medications
    contains no propellant
  • does not require spacer
  • report paroxysmal coughing, audible wheezing, and pt report of breathlessness or dyspnea
66
Q

nebulization

A

process of adding meds or moisture to inspired air by mizing particles of various sizes with air
small volume nebulizers convert drug solution into mist which is then inhaled by pt into bronchial tree
effects are designed to be local, but can be systemic if absorbed into bloodstream by alveoli

67
Q

pt respirations are rapid and shallow; breath sounds indicate wheezing and peak flow reading is below target

A

reassess type and delivery
notify HCP

68
Q

pt experiences paroxysms of coughing, aerosolized aprticles can irritate posterior pharynx

A

reasess type of med and delivery
notify HCP

69
Q

administering vaginal meds

A
  • foam, jelly, cream, suppository, irrigation, duche
  • oval shaped, individually wrapped
  • refrigerated, melt at body temp
  • allow pt to self admin if preferred
  • report any changes in comfort or new or increased vaginal discharge or bleeding to nurse
70
Q

rectal suppository

A

local or systemic effects
thinner and more bullet shaped
placed past internal anal sphincter and against the rectal mucosa
improper placement can result in expulsion of med

71
Q

nurse instructs AP to notify what w/ rectal suppositories

A

fecal discharge
bowel movements
side effects of meds
informing nurse of rectal pain or bleeding

72
Q

steps of med admin

A
  1. hand hygeine
  2. obtain med from med unit
  3. read label and compare w/ MAR
  4. calculate dosage
  5. check expiration date
  6. place med in cup (DO NOT OPEN)
  7. do 2nd check against MAR
  8. take med and MAR to pt
  9. wash hands
  10. introduce self
  11. ID pt w 2 ID (name, DOB)
  12. scan bracelet
  13. use picture if posted
  14. perform necessary assessment (BP, pulse, labs)
  15. 3rd check (pt, dose, time, route, purpose, med)
  16. educate pt on med in brief easy to understand terms
  17. remain w/ pt till swallowed
  18. document
73
Q

parenteral medications

A

injected w/ needle
more quickly absorbed
used when pts are vomiting, cannot swallow, or are restricted from taking oral fluids or require IV meds

74
Q

four routes of parenteral meds

A

subq
intramuscular
intradermal
IV injection or infusion

75
Q

subcutaneous injection

A

just under dermis

76
Q

intramuscular injection

A

into a muscle

77
Q

intradermal injection

A

injection just under the epidermis

78
Q

IV injection or infusion

A

injection into vein

79
Q

principles of parenteral injections

A
  • use sharp beveled needles of shortest length and smallest gauge
  • change needle if liquid med coats the shaft of the needle
  • position and flex pt limbs to reduce muscular tension
  • divert the pt attention away from injection
  • apply vapocoolant spray or topical anesthetic to an injection site before giving a med when possible or place wrapped ice on site minute before injection
80
Q

subq technique

A
  • select injection site where there is a body area where 1 inch or 2.5 cm of subcutaneous fat can be pinched
  • pediatric patients will require different needles and lengths based on age
  • if pt is receving small dose (less than 5 units) of insulin, pen injector should not be used as there is a 50% change of dose errors
81
Q

guidelines for subq technique

A
  • do NOT aspirate injection; hold needle in place for several seconds, especially important with insulin pens to prevent leakage of meds
82
Q

best site for insulin injection

A

abdomin

83
Q

safe medication admin guidelines

A
  • inject medication slowly but smoothly
  • hold syringe steady once needle is in the tissue to prevent tissue damage
  • withdraw needle smoothly at same angle used for insertion
  • gently apply antiseptic pad or dry sterile gauze
  • apply gentle pressure at injection site unless administering anticoagulation med
  • rotate injection sites to prevent formation of indurations and abscesses
84
Q

what angle should subq injections be given

A

45 degrees-90degrees

85
Q

what angle should intramuscular injections be given

A

90 degrees

86
Q

what angle should intradermal injections be given

A

5-15 degrees

87
Q

syringes

A

single use, disposable, leur-lok, or non leur-lok
available in many sizes
tuberculin and insulin

88
Q

needles

A

disposable, usually stainless steels
parts: hub, which fits on tip of syringe; shaft which connects to the hub; and the bevel or slanted tip

89
Q

ampules

A

single dose of injectable liquid med
made of glass with a constricted, prescored neck that is snapped off to allow access to med
use filter needles to prevent glass from being drawn into syringe
replace filter needle with appropriate sized needle after withdrawing medication

90
Q

vials

A

single dose or multidose of liquid or dry med
made of plastic or glass with rubber seal
protective metal or palstic cap
some vials have two chambers separating dry meds and diluent; roll vial to mix do not shake

90
Q

air bubbles remaining in syringe

A

expel air from syringe and add medication to it until correct dose is prepared

90
Q

selection of correct needle

A

dependent on pt body mass and tissue site of injection

90
Q

subq injection administration

A
  • deposits med into loose connective tissue underlying dermis
  • contraindicated by conditions that impair blood flow
  • use for small volumes (1.5mL or less, 0.5 mL for children)
91
Q

incorrect dose of med prepared

A

discard prepared dose
pepare correct new dose

92
Q

subq injection sites

A
  • outer aspect of upper arms
  • abdomen from below costal margins to the illiac crests
  • anterior aspects of the thighs
  • bilateral upper back
  • bilateral upper buttocks
  • bilateral arms (posterior)
93
Q

special considerations for admin of insulin

A
  • anatomical site rotation not needed
  • rotation occurs within same region
  • timing of injections critical
  • plan insulin jection times based on blood glucose levels and when a patient will eat
  • know peak action and duration of insulin
  • ONLY insulin syringes
  • release skin if pinched with insulin injections
  • do NOT aspirate
94
Q

what needle size should be used for insulin injections

A

1/2 or 5/16 inch (28-31 gauge)

95
Q

IM injection route

A

deposits meds into deep muscle tissue
faster absorption than subq
use clinical judgment to determine site, depth, needle, volume

96
Q

angle of IM

A

90 degrees

96
Q

IM injection sites

A

ventrogluteal
vastus lateralis
deltoid

97
Q

during injection of IM, blood is aspirated…

A

immediately stop injection and remove needle
prepare new syringe of medication for administration

98
Q

childer, older adults, and thin pts tolerate only

A

2 mL of an IM injection depending on sitee

99
Q

do NOT give more than 1 mL IM to and do NOT give more than 0.5 mL to

A

small children and older infants; small infants

100
Q

normal well develop adult pt tolerates how much medication IM

A

3 mL

101
Q

preferred IM injection site for infants and children less than 12 mo

A

vastus lateralis
1-2mL > 1-12

102
Q

deltoid IM

A

small med volumes
2mL

103
Q

ventrogluteal injection

A
  • position pt in supine or lateral
  • have pt flex knee and hip
  • place palm of hand on greater trochanter of hip with wrist perpendicular to femur
  • move thumb toward pt groin, and index finger toward anterior superior iliac spine
  • extend of open middle finger back along iliac crest toward pt buttock
  • index finger, middle finger, and iliac crest form v shaped triangle with injection site in center
104
Q

z-track method

A
  • using ulnar side of non dominant hand pull overlying skin 1-1/2 in or 2.5-3.5 cm laterally
  • hold skin in place until med has been administered
  • keep needle in for 10 seconds then release skin AFTER withdrawing needle
105
Q

aspiration of injection occurs in

A

IM injections in ventrogluteal muscle

106
Q

vastus lateralis

A

preferred site for admin of biologis to infants toddlers and children
NO aspiration

107
Q

deltoid

A

easily accessible
small med volumes (<2mL)
NO aspiration
used for vaccines

108
Q

intradermal injections

A
  • skin testing or allergy testing
  • inject only SMALL amounts of medication (0.01-0.1mL) intradermally
  • assess for bleb to form, if bleb doesn’t appear or site bleeds after needle withdrawn, med may have entered subcutaneous tissues (testing won’t be valid)
109
Q

ID teaching

A

teach to not squeeze out med
negative skin tests may not rule out allergies
pt instructions that final reading by nurse or HCP is required
pt should wear medical ID listing allergies
caution pt not to wash off markings around injeciton site
explain to pt how to observe for skin rxns

110
Q

smallest needle size =

A

highest guage

111
Q

sub q injection needle size

A

use 1/2 or 5/16-inch (28-31 gauge) needle, perpendicular to pinched skin

112
Q

IM injection needle size

A

1’-1.5’ or 22-25 gauge

113
Q

intradermal injection needle size

A

1mL syringe or TB syringe with a short 3/8-5/8 inch fine gauge (25-27) needle

insert at 5-15 degrees with bevel UP only

114
Q

intradermal injection sites

A

inner aspect of forearm
if forearm not available use upper back
not back not available use subq injection sites

115
Q

urine specimen

A

tests components of urine

116
Q

culture and sensitivity of urine

A

tests for bacterial infection

117
Q

timed urine specimen

A

indicative of renal function

118
Q

urine specimen is contaminated with stool/toilet paper

A

repeat pt instruction and specimen collection
if unable to obtain specimen through clean voiding pt may need catheterization

119
Q

pt unable to void, or urine does not collect in drainage tube

A

offer fluids if permitted to enhance urine production

120
Q

collecting timed urine specimen

A

empty first void of the morning and then monitor everything else until then
must be kept on ice for 2-72 hrs

121
Q

random collection for UA

A
  • use hat cap for toilet collection (first void of day if possible)
  • collect before starting antibiotics
  • nonsterile
  • perineal care first
  • midstream/clean catch if possible
  • collect at least 90-120mLs
  • pour into labeled speciment container
  • pt info sent to lab w/i 20 minutes (note if pt is menstruating)
122
Q

indewlling cathether collection

A
  • explain procedure
  • clamp catheter for 15 minutes below withdrawl part
  • clean part with alcohol for 15 seconds
  • withdraw from port with leurlock system
  • 3mL for sterile sample and 20mL for routine
  • tranfer urine to sterile container for sterile sample
  • label and send to lab within 20 minutes or refrigerate
123
Q

condom cathether

A
  • if uncircumcised male, put foreskin back after cleaning
  • leave 1-2 inches of space at tip to prevent irritation
  • never tape to skin or shave hair - can be clipped if needed
  • connect to drainage bag (keep lower than bladder)
  • after application apply pressure for 10-15 seconds
  • check for kinks
124
Q

bp

A

120/80

125
Q

RR

A

12-20

126
Q

pO2

A

95%+

127
Q

hr

A

60-100

128
Q

donning ppe

A
  1. gown
  2. mask or respirator
  3. googles or face shield
  4. gloves
129
Q

doffing ppe

A
  1. gloves
  2. goggles/shield
  3. gown
  4. mask or respirator
  5. wash hands

OR
1. gown and gloves
2. goggles or face shield
3. mask
4. wash hands

130
Q

general survey includes

A

overall appearance
hygeine and dress
skin color
body structure/development
behavior
facial expressions
level of consciousness
speech
mobility (including posture, gait, ROM)

131
Q

how do you assess why a pt is seeking care

A

OLDCARTS
also explore FIFE

132
Q

inspection MS

A
  • inspection of body posture (“I am inspecting for kyphosis, scoliosis, or lordosis”)
  • inspect gait, balance, and coordination
  • inspect extremities
  • “I am inspecting for deformities, abnormal positioning, asymmetry, or swelling”
133
Q

palpation of MS

A
  • demonstrate correct technique for palpation of each joint and then check active ROM (if client cannot perform active ROM, gently perform passive ROM while supporting joint, do not force joint past resistance)
  • “i am assessing for tenderness and swelling”
134
Q

palpate TMJ

A

while client open and closes their mouth feel for clicks and assess for pain, ask client to move jaw from side to side

134
Q

palpate the cervical spine

A

around c7 and t1
assess ROM (chin to chest, look at ceiling, ear to each shoulder, turn head left and right as far as possible)

134
Q

palpate the shoulder

A
  • assess the clavicle, acromioclavicular joint, scapula,greater tubercle of the humerus, are of the subacromial bursa, and glenoid fossa
  • assess ROM (forward flexion extension, hyperextension, abduction, adduction, internal rotation (hands behind back with back of hand touching scapula) and external rotation (hands behind the head)
  • during abduction put hand over shoulder to feel for crepitus
134
Q

palpate elbow

A
  • including medial and lateral epicondyles and olecranon bursa
  • assess ROM (flexion, extension, supination (palms up), and pronation (palms down)
135
Q

palpate wrist and hands

A
  • assess ROM of wrists (flexion extension, hyperextension, ulnar deviation, radial deviation)
  • assess ROM of metacarpals (flexion, extension)
  • touch thumb to each finger
135
Q

palpate the hip

A

if client had a hip joint repair or replacement, do not flex hip beyond 90 degrees and do not adduct the hip my crossing leg over midline
assess ROM (flexion with knee straight or knee bent; extension (straight), abduction, adduction, internal and external rotation (with knee bent)

136
Q

palpate the knee

A

and tibial margin
palpate quad muscle
assess ROM (flexion, extension)
place hand on knee and feel for crepitus during ROM

137
Q

palpate ankle and foot

A

assess ROM (plantar flexion - foot stepping down on gas pedal, dorsiflexion - toes moving toward head; inversion and eversion)

138
Q

assess the thoracic and lumbar spine

A

maintain safety and preventing falls, have client touch toes
assess for scoliosis
assess spine ROM (flexion extension, hyperextension, lateral bending, rotation to each side)

139
Q

assess gait and balance

A
  • observing client rise from chair without using arms, walk, turn, and sit.
  • observe for staggering, shuffling, foot slapping, or other usual gait appearance
  • assess arm swing
140
Q

general survey of heart assessment

A

“i have assessed temp, pulse, respirations, BP, and O2”
“I am assessing level of consciousness including orientation to time, place, person, and situation”
“i am assessing speech, appearance, signs of distress, posture, movement, color (skin lips, nailbeds)”

141
Q

inspection cardiac

A

with HOB at 30-45 degrees locate and visualize internal (or external) jugular veins
“I am looking for jugular vein distension”
turn head away from clinician and assess using light

142
Q

palpation cardiac

A
  • gentle palpation of right carotid pulse and states amplitude (“right carotid pulse 2+)
  • gentle palpation of left carotid pulse and notes amplitude
  • auscultates carotid pulses with bell of stethescope on right side (ask pt to hold breath to listen for bruit “soft whoosing sound”)
143
Q

inspection - precordium

A

“inspecting skin for lesions, masses and color. i am inspecting masses, lesions, lifts, pulsations, and heaves”

144
Q

palpation precordium

A

“if appropriate i would palpate for lifts, thrills, or heaves, and palpate the PMI which would be found at the 5th intercostal space (5th ICS) near mid clavicular line” (appropriate if lifts or heaves and/or if pt complained of a mass and or auscultation suggests that lifts, heaves, or thrills may be present)

145
Q

auscultation heart sounds

A
  • start from base to apex
  • right 2nd ICS to left 2nd ICS, to left 3rd ICS, then left 5th ICS at left lower sternal border, then 5th ICS at MCL
  • “i am listening for rate and rhythm, s1 and s2, and any extra sounds such as a split s2 or high pitched murmurs
  • repeat using bell of stethescope (“I am listening for rate and rythm, si and s2, any extra sounds such as s3 and 4, or low pitched murmurs
146
Q

inspection - peripheral vascular

A

“i am inspecting upper and lower extremities for hair distribution, color, edema, varicosities, and ulcerations”

147
Q

palpation - peripheral vascular

A
  • assess capillary refill (normal <3 seconds)
  • student palpates each pulse and notes amplitude (radial, brachial, femoral, posterior popliteal, posterior tibial, pedal)
148
Q

palpation - lymphatic system (cardio)

A

palpate the epitrochlear node (between biceps and triceps groove just above medial epicondyle)

149
Q

inspection - abdomen

A

inspect abdomen at patient’s right side and at foot of table/bed
“i am inspecting the abdominal contour for symmetry. i am inspecting skin color and condition and observing for pulsation or movement”

150
Q

auscultation - abdomen

A

use diaphragm of stethoscope, auscultate bowel sounds in all 4 quadrants starting at ileocecal valve (RLQ) then RUQ, LUQ, and LLQ (listen for 5 sec/ Q)
“ if i did not hear bowel sounds, i would listen for another 2 minutes and up to 5 minutes before concluding they were absent”

151
Q

auscultation - abdominal arteries

A

using bell of stethoscope, auscultate aortic, renal (bilateral), and iliac (bilateral) arteries for bruits
“I am listening for a soft, whooshing sound, that may indicate turbulent blood flow. in addition to abdominal bruits, i could also auscultate over femoral arteries to assess for any vascular blockages to lower extremities”

152
Q

percussion of abdomen

A

percuss all 4 areas using zigzag pattern, starting in rlq
“tympany is drum-like and solid organs sound dull. if suspect ascites, i will assess for shifting dullness by percussion with patient supine and lateral”

153
Q

palpation - abdomen

A
  • position pt w/ knees slightly bent to relax abdominal muscles. use light dipping or circular motion with hand, observe pt expressions of grimacing
  • “I am assessing for tenderness, masses, and muscle wall irregularities”
154
Q

palpation - rebound tenderness

A

first palpating on LLQ and releasing (rovsings sign) then palpating in RLQ (not directly over painful area - Blumberg sign)
“I am assessing for rebound tendernesss while palpating first in LLQ and then in RLQ”

155
Q

CVA tenderness

A

place palm of nondominant hand over costal-vertebral angle; thump that hand with ulnar edge of other fist, repeats on other side
“person should feel a thud but no pain”

156
Q

vision testing

A
  • use snellen chart, mark point 20ft away and assess vision by covering one eye at a time, ask pt to read lowest line possible, if pt can read more than half the numbers on the line, record that as vision in that eye
  • with pt seated provide a jaeger card to assess near vision. have pt read about 14 in away, covering one eye at a time
157
Q

hearing test

A

use whispher test standing behind person and saying 2 syllable word

158
Q

demonstrate correct technique for inspection

A
  • inspect head, scalp, and hair
  • inspect facial symmetry, look at eyebrows, lids, eyes, nasolabial folds, and mouth
  • inspect color of sclera/conjunctiva
  • inspect skin color, moisture, lesions rashes, potential skin cancers (inspect behind ears and on top of ears - a common site for skin cancers)
  • inspect neck for any deviations or masses
159
Q

palpation of head and neck

A
  • while gloved, palpate head for massess, depressions, or tenderness, part hair to assess scalp for color and lesions, assess hair pattern, texture, and evidence of infestations
  • palpate temporal arteries
  • palpate temporoandibular joint as pt opens and closes mouth
  • palpate lymph nodes (may not feel them), name each node or chain of nodes, note texture, size, mobility, delimination
  • palpate either side of trachea to assess if trachea is midline, place one finger on either side just above clavicle and medial to the sternocleidomastoid muscle
  • palpate thyroid using first anterior approach, then posterior, give pt sip of water to swallow when palpating, landmark correct spot on either side of trachea by first locating cricoid cartilage and isthmus of thyroid just below it
160
Q
A

nur330L (4 decks)

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