NURS 100 Test 1 Flashcards
A nurse is completing a clients history and physical examination. Which of the following should the nurse consider subjective data?
A) BP
B) Cyanosis
C) Nausea
D) Rash
C) Nausea
Normal BP
Systolic: less than 120
Diastolic: less than 80
elevated BP
Systolic: 120-129
Diastolic: less than 80
High BP (hypertension) Stage 1
Systolic: 130-139
Diastolic: 80-89
High BP (hypertension) Stage 2
Systolic: 140 or higher
Diastolic: 90 or higher
Hypertensive crisis
Systolic: higher than 180
Diastolic: higher than 120
what is the purpose got obtaining a physical assessment
1) identifies patient needs
2) to establish a database about the patients health concerns or illness
3) determine the ability to manage health care needs
Pain assessment (PQRST)
P: palliative/provokes: what makes the pain lessen or worse
Q: Quality: sharp, stabbing, throbbing, aching
R: Region/Radiate: where is the pain and does it spread
S: Severity: scale 0-10
T: timing: when did the pain start
subjective data
-apparent only to person affected
-what the client states
-symptoms
Objective Data
-detectable by the observer/ nurse
-signs
-see, hear, smell, feel
examination sequence
1) inspection
2) palpation
3) percussion
4) auscultation
abdomen inspection
1) inspection
2) auscultation
3) percussion
4) palpation
Normal assessment findings in an adult
-A&O x4
-temp: 36-38C (96.8-100.4F)
-pulse: 60-100 bpm @rest
-respiration: 12-20/min
-oxygenation: 95-100%
Data collection methods
1) Observing
2) Interviewing
3) Examining
4) Collaboration
physical assessment
1) general survey
2) measurements
3) Head-to-toe assessment
systematic approach to physical assessment
1) general survey/ psychosocial
2) integumentary
3) neuro/muscular
4)EENT
5)cardiovascular
6) respiratory
7) gastrointestinal (GI)
8) genitourinary (GI)
9) misc. (dressings, IV, drains)
General patient survey
-general body structure
-facial expression and affect
-are they in distress or pain
-speech
-hygiene, grooming, and dress
-posture and mobility
-equipment
-odors
PERRL
-Equality
-Shape
-Reactive to light
-Direct/consensual
paresis
weakness; slight incomplete paralysis
hemiparesis
weak on one side of the body
plegia
no movement; paralysis
hemiplegia
paralysis on one side of the body
Muscle strength grading
0: no contraction
1: flicker of contraction
2: active movement; can’t resist gravity y
3: active movement against gravity
4: active movement against resistance
5: normal strength
Strength and quality of pulse
0: absent, not palpable
+1: diminished, barely palpable
+2: easily palpable, normal pulse
+3: bounding, cannot be obliterated
Measuring pitting edema
0+: no pitting
1+: mild pitting, 2mm deep and disappears rapidly
2+: moderate pitting, 4mm deep and last 10-15 seconds
3+ moderately severe, 6mm deep, may last more than a min.
4+: severe pitting, 8mm deep can last more than 2 min.
Measuring pitting edema
0+: no pitting
1+: mild pitting, 2mm deep and disappears rapidly
2+: moderate pitting, 4mm deep and last 10-15 seconds
3+ moderately severe, 6mm deep, may last more than a min.
4+: severe pitting, 8mm deep can last more than 2 min.
COCA
Color
Odor
Consistency
Amount
5 steps of nursing process
1) assessment
2) nursing diagnosis/ analysis
3) planning
4) implementation
5) evaluation
how do you get assessment data?
observe, physical assessment, nursing interview
3 part nursing diagnosis
1) diagnosis
2) r/t and secondary to
3) defining characteristics AEB
medical diagnosis
identification of disease condition based on specific evaluation of signs and symptoms
(focus is on a disease process)
nursing diagnosis
a clinical judgement about the patients response to an actual or health problem
(focus on the human response to the health problem)
Nursing Diagnosis errors
1) errors in data collection
2) errors in interpretation of data
3) errors in data clustering
intervention types
1) independent
2) dependent
3) collaborative
independent intervention
-nurse initiated
-does not require direction or an order
-acting independently behalf of the patient
Dependent interventions
-provider initiated
-requires an order from a physician based on response to treat a medical diagnosis
collaborative interventions
-interdependent nursing interventions that require expertise of multiple health care professions
direct care
interventions performed though interactions with patients at the bedside
indirect care
interventions performed away from the patient on behalf of the patient
Cognitive Domain
the thinking domain; client must think through the information presented to them and be able to comprehend the information
affective domain
involves the clients feelings, precisely their values, attitudes, and beliefs
psychomotor domain
learning based on action; involves physical movement skills, coordination and use of senses
crackles
wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration
wheezes
continuous sounds caused by air moving through constricted airways; high-pitch common in asthma or low pitch
rhonchi
low pitched wheeze that may clear with coughing
location of apical pulse
5th IC space, mid-clavicular line
