Phys Assessment Flashcards
What does subjective mean?
What someone tells you (history)
What does objective mean?
measurment/reading (phys exam)
What are the 2 components of clinical reasoning?
Diagnostic & Critical Thinking
What is the diagnostics composed of
cues, info, signs, symptoms, lab data
what is the difference between a sign and symptom
sign= you can see it, symptoms= experiences
What are the 6 nursing processes
ADOPIE= Assess, diagnostic, outcome, planning, implementation, evaluation
Medicine Treats…
disease
Nursing…
how patient reacts
Diagnosis
Valid influences, compare “clusters”, identify related factors
Outcome
realistic, something that can be measured, TIME FRAME, unique to PT
Planning
establish priorities, refer back to outcomes, plan of care, interventions
Implementation
readiness, review interventions, collaborate team members, counseling, refer continuing care
Evaluation
meet or did not meet final outcome
What are the first priorties that are essential?
ABCs= Airway, breathing, circulation (brain)
What are some components of Critical Thinking
identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate
4 Types of Data
1) Complete Health Data 2) Episodic/Problem Centered/Focus data 3) Follow-up data 4) Emergency data base (ABCs)
Expanding Concepts of Health…x5
1) Biomedical Model 2) Holistic Health (whole body, culture) 3) Health promotion/prevention 4) culture 5) genetics
High level assessmen
holism, life cycle, culture must not detract from importance, hands on expertise
Interview means
factors that may affect communication
3 Phases of Interview
1) Process of Communication 2) Internal 3) External Factors
Process of Communication means.
sending/receiving internal/external facotrs
Internal Factors composed of…
empathy, ability to LISTEN
External Factors composed of
privacy, refuse interruptions, phys envt, dress, note taking, recording, electronic health record
Techniques of Communication
open vs closed ended questions (case by case), nonverbal skills, eye contact, voice, touch, dress
What do adolescents prefer being around?
peer groups
What are you viewing in infants?
nonverbals
At what ages are parents involved in the interviewing?
Infant-school age
What should you watch for in communication with older people
slang words
What are some special need situations
acute illness, under the influence, anxious, crying, sexually aggressive, hearing impaired
What type of questions should you ask for special need situations
closed questions
What is the first thing you should do in cross cultural situations
identify your own biases
What does cross cultural communication entail?
etiquette, space & distance, cultural considerations on gender, sexual orientation
What are ways we overcome communication barriers
interpreters, vocal cues, action cues, object cues, space/touch
Are mental status assessments objective or subjective
always subjective
What does etiology mean
cause
What are 2 types of measuring mental disorders
organic & psychiatric
What is an example of an organic mental disorder
alzheimers, dementia, bc they are known causes
Alert & Oriented x 4 (behavior orientation)
1) person 2) place 3) time 4)situation (what brought you here)
What is recent memory?
short term
What is remote memory
long term
What does perception mean?
awareness of 5 senses
What are 4 components of mental health assessment
1) appearance 2) behavior 3) cognition 4) thought processes
What does aphasia mean
language impairment
QPR stands for
question, persuade, refer
Broca refers to
physical incapability to speak
Wernicke
not being able to speak correctly
presbycusis means
age related hearing loss
Define health
balance of person with one’s physical, mental, and environment
Illness
loss of balance with physical, mental and environment
What is ethnicity
a group having similar traits: common language, common heritage and cultural similarities
Race
relates more towards the appearance of a person. Biologically with inherited genetic traits.
Nationality
place where the person was born
Heritage
ancestors of a person
Culture
more of a microcosm; one trait or characteristic
What is a database?
Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed
What is a nursing “diagnosis”
actual/potential health problems or of wellness strengths
Frequencies of visits…
varies depending on person’s illness and wellness needs
define cultural diversity
transcultural phenomenon. At least 2 people having diff cultural orientations
what does evidence based mean?
combining clinical expertise with the use of nursing research, while considered values of the PT
What is clustered data
patterns and relationships among the data
A good rule of an interviewer is to..
spend more time listening than talking
When a patient denies something but acts in the opposite
bring verbal and nonverbal behavior to PT attention
When should touch be used
if interviewer knows pt well
at what age should interviewer question child him/herself
age 7
What interviewing techniques should be avoided for an adolescent
silence and reflection
What is the proper distance for personal space
1.5-4 ft
Religion is defined as
belief in a divine or superhuman spirit to be obeyed or worshiped
Why is there a need for cultural care
demographic change
The imbalance of hot and cold is considered “illness” among…
Hispanic-American heritage
What is an amulet
the evil eye
What does empacho mean?
a culture-bound syndrome that ha no equivalent from a biomedical perspective
What does “review of systems” mean?
the evaluation of the past and present health state of each body system
What does PQRSTU Stand for
1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding
What 2 section of child’s health history become important to current health status
developmental and nutritional history
What is one way to detect dementia
mini-cog
A Major characteristic of dementia is
impairment of short & long term memory
Dysarthria
difficult or unclear articulation of speech that is otherwise linguistically normal.
What is echolalia
meaningless repetition of another person’s spoken words as a symptom of psychiatric disorder.
The part of the hand used for assessment of vibration are
ulnar surface of the hand
Performing indirect percussion, the stationary finger is struck where..?
at the middle joint
How would you describe the pitch of a sound wave obtained by a percussion
number of vibrations per second
The bell of the stethoscope is used for..
soft, low pitched sounds
Which aperture is used for a patient with undilated pupils
small
If an infant is asleep, where can you start with the examination
heart, lung, and abdomen
When does examination of a child change to head to toe
school age
When inspecting ear canal, which speculum is used for the otoscope
the largest that will fit
During gen survey what are the 4 areas of interest
1)Appearance 2)Body structure 3)Mobility 4)Behavior
What is gait
a person’s manner of walking
Measuring gait, the base is usually…
as wide as the shoulder width
What changes in head circumference measurements in relation to the chest will occur from infancy to early childhood
head will be 2 cm larger than the chest circumference. Between 6 months & 2 years they will be the same.
From 80 - 90 what happens to height and weight
both decrease
To accurately assess patients pulse what is the range?
start with zero to 30
A normal pulse for a patient is..
2+
How do you accurately assess a patient’s respiration?
count for 20 seconds
What is pulse pressure
the difference between systolic and diastolic pressure
What is coarctation?
narrowing of the aorta
If PT has coarctation the thigh pressure would be..
lower than in the arm
What is the mean arterial pressure
diastolic pressure plus one third pulse pressure
Why is sizing of a bp cuff important
too narrow will give false reading that is HIGH
Diastolic
when the heart refills with blood
systolic
when heart is contracting
what is nociception
pain receptors
neuropathic pain
burning painful sensation that moves around toes and bottoms of feet.
Diaphoretic means
inducing perspirations
visceral pain
sweating, pale, pain in abdomen
What is a pre-term baby more sensitive too
painful stimuli
What is the wong baker scale
visual facial expressions to define pain scale (ex broken arm)
analgesics
pain reliever
Complex Regional Pain I
chronic pain that usually affects an arm or a leg.
This is a pain problem expected with impaired older adult
peripheral vascular disease
What is a common physiologic change that occurs with pain
tachycardia
Assessing Pain Mnemonic
P- OLDCARTS
P-OLDCARTS
previous hx, onset, location, duration, character, aggravating, radiation, timing, severity
What are the 4 steps in a regular physical exam
1) inspection 2)Palpation 3)Percussion 4)Auscultation
What are the steps when examing the abdomen
1) Inspection 2)Auscultation 3) Palpation 4) Percussion
Gen Survey Application
1)Appearance 2)Body Structure (lordosis/kyphosis) 3)Gait (how they walk) 4)Behavior 5)Weight
What is the diurnal cycle
difference in temp in the morning vs afternoon (cooler in the morn)
Ways to take temp
oral, electronic, axillary, rectal, tympanic membrane, temporal
What is normal temperature in the mouth
98.6F or 37C
What is normal temp in axillary
97.6F or 38.4C
What is normal temp in rectum
99.6F or 37.6C
What is normal temp in tympanic membrane?
98.6F
What is the conversion Celsius to Fahrenheit
C= 5/9 (f-32)
What is the conversion for Fahrenheit to Celsius
(9/5 x C) +32
What is the formula for Cardiac Output
CO= SV x HR
What is a normal amount of blood that gets pumped every heart beat?
2 ox or 70 mm
Where do you place the stethoscope to listen to heart sounds
4-5 Intercostal
What is normal for adults heart rate
50-100 beats/min (100+ is tachy)
What i normal for infant heart rate
80-160
What numeric is used for Force?
0-3+
What is normal force
2+
What is bounding or after a run
4+
What is force is considered “weak”
1+
What is respiration?
amount someone breaths in 1 iminute
What is the ratio for pulse
4: 1
When you see the ration for BP
Systolic is the higher # (top) Diastolic is lower #
If the diastolic is high on the bottom is that concerning
yes
Pulse Pressure =
Systolic - Diastolic
Mean Arterial pressure
force that pushes blood into the tissues
To hear Kortkoff sounds and you cant use the arm, what should you do?
use thigh
What does the pulse oximeter do?
measure how much hemoglobin carries oxygen (95% or higher)
What does a doppler do?
picks up changes in sound frequency as blood flows
What is the best indicator of Pain
what they tell you
What condition is hard to treat in terms of pain
Neuropathic pain, abnormal procession of pains messages
Visceral means
organs
Cutaneous means
skin
What are signs of acute pain behavior
guarding, grimacing, moaning, restless, stillnes diaphoresis, vital signs change
What type of palpation do you use for mobility and turgor?
Tenting
When is mobility decreased
with edema
When does tenting or turgor occur
severe dehydration or weight loss
What does striae mean?
stretch marks
What does sterile mean?
- no life
- using special gases
- high heat
For surgical apses how long do you wash your hands?
3 minutes
When is surgical apses necessary?
- intentional perforation of the skin
- body cavity, not exposed to outside
What are the golden rules of surgical apses
- an object below the waist is contaminated, because it is out of range of vision
- never turn your back on a sterile field
- keep trashcan close by, or drop on ground
- Both patient and provider wear mask
- If you break sterile technique- START OVER
- 1” border
What makes a surface/ area contaminated
- prolonged exposure to air
- wet surfaces
- 1” border is contaminated
Are wrappers of sterile objects sterile?
NO
Define a sterile field
room/space for handling sterile objects
Name 5 types where patient needs surgical asepsis technique
- Open Body Cavity
- Catheter
- Burns
- Central Line
Clean technique
- removes majority of microorganisms, not everything
- no autoclaving
What is lipping
- if you are using a solution more than once
- pour some out before use
When do you use sterile gloves for surgical asepsis?
once you’ve added everything to the sterile field
What are the 4 things we asses for skin, hair , nails
- Structure/Function
- Subjective
- Objective
- Abnormal findings
What is the largest organ and our bodies’ first line of defense?
the skin
- horny layer- shedding
- basal layer on the bottom
What is apocrine
- sweat glands during puberty
- smells bad
What are eccrine glands
- major sweat glands in all humans. Most dense in palms and soles
- appears as dilute saline solution
What are 4 major functions of the skin?
- keep fluid in/protect
- nonverbal communication
- wound repair
- vitamin D absorption
In infants/children when does hair follicles start developing
3 months
What is common in skin of pregnant women
- stria grandorum
- increase pigment
What is xerosis
dry skin, mostly in older adults
What happens to older adults nails?
thicken- due to fungus
pruritus means?
itching
Culture and genetics and skin
body odors vary by race
Jaundice means
yellow
Cyanosis means
blue
What causes poor circulation in older adults
diabetes
peripheral vascular disease
What are examples of subjective data for skin hair nails
- mole inspection/palpation
- rash/lesions
- birth marks
- hair loss
- env’t hazards
- self-care, wear sunscreen?
- bruising
- itching
Objective Data examples for skin hair nails
- skin color
- use pen light
- ruler
Pallor means
pail
What part of your hand do you use to palpate for temperature
dorsa (back)
What are 6 maor things you want to palpate for in skin hair nails
- Temperature
- texture- use finger tips
- moisture
- diaphoresis (sweating)
- thickness
- Edema
How is edema measured?
- 4 point scale
- 1+ = 2mm
- 2+ = 4mm……
What is pitting edema?
- think memory foam, leaves a thumb print
What is non pitting edema
The lack of indentation when fingertip pressure is applied to the skin, which classically occurs in hypothyroidism
What does vascularity mean?
bruising
3 Common types of birthmarks
- freckles
- junctional nevus
- compound nevus
junctional nevus
Compound Nevus
What are the abnormal signs for pigmented lesions
ABCDE
ABCDE stands for
- Asymmetry
- Border
- Color variation
- Diameter grater than 6mm
- Elevation or Enlargement
Hypothermia
- high fever
- localized coolness
Hyperthermia
- fever
- area feels warn
- trauma
- infection/sunburn
Uremia
renal failure
Brown-tan coloration
example Addisons disease- increase melanin production
- Annular Lesion
- circular (ringworm)
- Confluent Lesion
- ex hives//uriticaria
- Discrete lesion
- Skin tags//acne
Gyrate Lesion
grouped lesions
linear lesion
Target Lesion
- zosteriform
- linear around unilateral nerve
- ex: herpes
- Polycyclic
- i.e. psoriasis
- anular lesions grow together
What are primary skin lesions x6
- Macular/Patch
- Papule/Plaque
- Nodule/Tumor
- Vesicle/bulla
- Cyst
- Postule
- Macule
- Patch larger than 1 cm
- flat not raised
-
Papule
- Plaque larger than 1 cm
- can feel, slightly elevated
- mole wart
- Nodule
- tumor larger than 3 cm
-
Wheal
- Urticaria-hives
- raised irregular shape due to edema
- mosquito bites, allergies
-
Vesicle
- Bulla- larger than 1cm
- a blister, herpes chicken pox, shingles
- Cyst
- encapsulated fluid filled cavity
- subcutaneous layer.
- Pustule
- pus filled cavity
What are some secondary Skin lesions?
- Crust
- Scale
- fissure
- erosion
- ulcer
- Excoriation
- scar
- atrophic scar
- lichenfication
- Keloid
- Crust
- dried out when blisters burst
- Scale
- compact flakes of skin
- Fissure
- ex cracks at corner of mouth
- Erosion
- shallow depression
- moist but no bleeding
- Ulcer
- irregular shape, may bleed
- leaves scar
- Scar
- replaced with connective tissue (collagen)
- Atrophic Scar
- thinning of the epidermis
- decreased visibility of normal skin markings
- shiny
- Lichenification
- when someone scratches an area excessively
- Keloid
- hypertrophic scar
- elevetated skin by excess scar tisue
- Pressure Ulcer Stage I
- red but ubroken
- will not blanch
- Stage 2 Ulcer
- loss of epidermis
- like open blister
- Stage 3 ulcer
- extending into subcutaneous tissue
- resembling a crater
- Stage IV Ulcer
- breaks through all skin layers
- visible bone or tendons
What are some vascular lesions
- petechiae
- purpura
- hematoma
- contusion
What is petechiae/purpura
- small purple color
What is hematoma
- a bruise you can feel
What is a contusion
another word for bruise
What are the phase/coloration of bruises
- red
- blue-purple
- blue-green
- yellow
- brown-vanishing
what is a “pattern” injury
- a bruise or wound whose shape suggests instrument or weapon that caused it
- belt buckle, broomstick, burning cig, pinch, bite, scalding hot liquid
nevus is the medical term for…
mole
where should you assess for early jaundice?
- sclera and hard palate
Normal angle between the nail base and the nail is…
160 degrees
How long should it take the capillary beds to refil?
1-2 seconds
What does flat brown macules on the hands mean?
Sun exposure, do not require treatment
Flattening of the angle between the nail and its base…
clubbing
Lyme disease is more prevalent during
May thru September
What causes milia?
sebum occludes skin follicles
Epidermis layer
- basal layer,
- thin,
- stratum corneum
Dermis Layer
- collagen
- elastic tissue
Subcutaneous layer
- adipose tissue
This is when lower half of the body turns red, upper half blanches..
Harlequin
This term is used when you notice mottling on trunk and extremities
Cutis Marmorata
large round or oval patch of light brown usually present at birth
cafe au lait
When irrigating a wound, how would the nurse know the right amount of pressure to apply?
between 5 and 15psi
Which device is used for wound irrigation?
19 gauge needle attached to 35 mL syringe
Elsevier:
What is the nursing action to set up suction for a hemovac drainage system?
the nurse should compress it firmly and replace the plug.
Elsevier:
Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?
Culture & sensitivity
Elsevier:
What’s wrong with using a microwave for irrigating a wound?
can create hotspots
Elsevier:
What is the proper method for cleansing the evacuation port of a wound drainage system?
Wipe it with an alcohol sponge.
Braden Scale
Risk for skin breakdown/Pressure ulcer
ABD
Abdominal
What disease is a neurotic disorder?
MS, associating with neuro pain
What is the goal of wound care?
- to heal the wound
- prevent infection
What type of patient is at highest risk for suicide?
one that devises a plan
This is when a wound ruptures along a surgical suture
dehiscence
What is the primary intention for wound healing?
- tissue surfaces have been approximated
- low tissue loss
- remove dressings after drainage
What are 4 ways for debriefing a wound?
- Mechanical
- Chemical
- Auto
- Surgical
What is autolytic debriefing?
takes advantage of the body’s own ability to dissolve dead tissue
What is secondary intention for wound healing?
- considerable tissue loss
- edges cannot be drawn together
- longer to heal
- scarring is greater
- infection risk
- Pressure ulcers
- continue dressings for moisture
- assist debridement
What is tertiary intention for wound healing?
- “delayed”
- require more connective tissue than wounds that heal by secondary intention
- abdominal wound that is initially left open to allow for drainage but is later closed.
What are the phases for a full thickness wound repair?
- Hemostasis (fibrin)
- Inflammatory phase
- Proliferative phase- epithelial
- Remodeling- can take years
What are some complications for wound healing?
- hemorrage
- infection
- dehiscence
- avisceration
- fistula
What organ is 15% of our total body weight
Skin
Black or brown tissue that must be removed
necrotic
Yellow tissue in a wound that must be removed
slough
What is evisceration?
A surgical wound that opens up (dihiscence) but is a medical emergency
What are symptoms of wound Infections?
- puss
- odor
- wolume
- redness
- fever
- pain
What could be the psychosocial component of wound healing?
- body image
- scars
- odors
- drains
- temp prostetic
What is a penrose drain?
soft rubber tube placed in a wound area, to prevent the build up of fluid.
What is a Hydrocolloid dressing?
- gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer.
- protects from surface contaminants
What is hydrogel dressing
- provides moisture to a dry wound
- dry or dehydrated wounds
- partial or full-thickness lesions
- abrasions or severe scrapes
- minor burns
- wounds with granulated tissue development
- radiation skin damage
What is a transparent film dressing used for?
- to protect skin in pressure spots.
- cover wounds with little or no drainage
What are montgomery ties?
- used for frequent dressing changes w/o having to remove and reapply tape.
- Breathable, strong, and comfortable
- help prevent skin trauma associated with frequent taping.
How many grams of protein can a patient lose per day with an open wound?
50 grams
Heat Therapy risks
- vaso-constriction
- damage epithelial cells
- blistering
- no longer than 1 hour
Cold Therapy Risks
- vaso dialation
- risk is tissue ischemia (frost bite)
What happens with negative pressure wound thearpy
- granulation lines the surface
- removes fluid and exudates to prevent infection
What is required in the delivery of culturally congruent care?
- knowledge
- skills
- attitudes
What is an example of a nurse stereotyping a patient?
do you bathe and use deodorant more than one time a week?
homelessness is an example of caring for a patient from a different..
culture
What are appropriate questions to ask a native american?
- do you use folk remedies
- do you have a family physician
- do you use a shaman
What is an example of data validation
- comparing values with previous values
- report to charge nurse
What are the steps for a nursing diagnosis?
- review assessment data
- cluster
- diagnostic label
- contet of pt’s health probl and select related factor
What could be indicated when a reddened area blances on fingertip touch?
blanching hyperemia. Body overcoming ischemic episode
To determine wound infection, where should the specimen be taken?
wound, after it has been cleaned with normal saline
After surgery a patient coughs and opens up a wound. What is the nurse’s first intervention?
cover with saline-soaked towels and notify surgical team.
Evisceration
When do you use a warm compress?
- to relieve edema
- improve blood flow
