NURS 100 Test 1 Flashcards by Lisa Ornelas

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

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Normal BP

Systolic: less than 120
Diastolic: less than 80

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elevated BP

Systolic: 120-129
Diastolic: less than 80

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High BP (hypertension) Stage 1

Systolic: 130-139
Diastolic: 80-89

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High BP (hypertension) Stage 2

Systolic: 140 or higher
Diastolic: 90 or higher

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Hypertensive crisis

Systolic: higher than 180
Diastolic: higher than 120

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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

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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

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subjective data

-apparent only to person affected
-what the client states
-symptoms

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Objective Data

-detectable by the observer/ nurse
-signs
-see, hear, smell, feel

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examination sequence

1) inspection
2) palpation
3) percussion
4) auscultation

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abdomen inspection

1) inspection
2) auscultation
3) percussion
4) palpation

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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%

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Data collection methods

1) Observing
2) Interviewing
3) Examining
4) Collaboration

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physical assessment

1) general survey
2) measurements
3) Head-to-toe assessment

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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)

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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

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PERRL

-Equality
-Shape
-Reactive to light
-Direct/consensual

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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

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