Phys Assessment Flashcards
1
Q
What does subjective mean?
A
What someone tells you (history)
2
Q
What does objective mean?
A
measurment/reading (phys exam)
3
Q
What are the 2 components of clinical reasoning?
A
Diagnostic & Critical Thinking
4
Q
What is the diagnostics composed of
A
cues, info, signs, symptoms, lab data
5
Q
what is the difference between a sign and symptom
A
sign= you can see it, symptoms= experiences
6
Q
What are the 6 nursing processes
A
ADOPIE= Assess, diagnostic, outcome, planning, implementation, evaluation
7
Q
Medicine Treats…
A
disease
8
Q
Nursing…
A
how patient reacts
9
Q
Diagnosis
A
Valid influences, compare “clusters”, identify related factors
10
Q
Outcome
A
realistic, something that can be measured, TIME FRAME, unique to PT
11
Q
Planning
A
establish priorities, refer back to outcomes, plan of care, interventions
12
Q
Implementation
A
readiness, review interventions, collaborate team members, counseling, refer continuing care
13
Q
Evaluation
A
meet or did not meet final outcome
14
Q
What are the first priorties that are essential?
A
ABCs= Airway, breathing, circulation (brain)
15
Q
What are some components of Critical Thinking
A
identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate
16
Q
4 Types of Data
A
1) Complete Health Data 2) Episodic/Problem Centered/Focus data 3) Follow-up data 4) Emergency data base (ABCs)
17
Q
Expanding Concepts of Health…x5
A
1) Biomedical Model 2) Holistic Health (whole body, culture) 3) Health promotion/prevention 4) culture 5) genetics
18
Q
High level assessmen
A
holism, life cycle, culture must not detract from importance, hands on expertise
19
Q
Interview means
A
factors that may affect communication
20
Q
3 Phases of Interview
A
1) Process of Communication 2) Internal 3) External Factors
21
Q
Process of Communication means.
A
sending/receiving internal/external facotrs
22
Q
Internal Factors composed of…
A
empathy, ability to LISTEN
23
Q
External Factors composed of
A
privacy, refuse interruptions, phys envt, dress, note taking, recording, electronic health record
24
Q
Techniques of Communication
A
open vs closed ended questions (case by case), nonverbal skills, eye contact, voice, touch, dress
25
What do adolescents prefer being around?
peer groups
26
What are you viewing in infants?
nonverbals
27
At what ages are parents involved in the interviewing?
Infant-school age
28
What should you watch for in communication with older people
slang words
29
What are some special need situations
acute illness, under the influence, anxious, crying, sexually aggressive, hearing impaired
30
What type of questions should you ask for special need situations
closed questions
31
What is the first thing you should do in cross cultural situations
identify your own biases
32
What does cross cultural communication entail?
etiquette, space & distance, cultural considerations on gender, sexual orientation
33
What are ways we overcome communication barriers
interpreters, vocal cues, action cues, object cues, space/touch
34
Are mental status assessments objective or subjective
always subjective
35
What does etiology mean
cause
36
What are 2 types of measuring mental disorders
organic & psychiatric
37
What is an example of an organic mental disorder
alzheimers, dementia, bc they are known causes
38
Alert & Oriented x 4 (behavior orientation)
1) person 2) place 3) time 4)situation (what brought you here)
39
What is recent memory?
short term
40
What is remote memory
long term
41
What does perception mean?
awareness of 5 senses
42
What are 4 components of mental health assessment
1) appearance 2) behavior 3) cognition 4) thought processes
43
What does aphasia mean
language impairment
44
QPR stands for
question, persuade, refer
45
Broca refers to
physical incapability to speak
46
Wernicke
not being able to speak correctly
47
presbycusis means
age related hearing loss
48
Define health
balance of person with one's physical, mental, and environment
49
Illness
loss of balance with physical, mental and environment
50
What is ethnicity
a group having similar traits: common language, common heritage and cultural similarities
51
Race
relates more towards the appearance of a person. Biologically with inherited genetic traits.
52
Nationality
place where the person was born
53
Heritage
ancestors of a person
54
Culture
more of a microcosm; one trait or characteristic
55
What is a database?
Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed
56
What is a nursing "diagnosis"
actual/potential health problems or of wellness strengths
57
Frequencies of visits...
varies depending on person's illness and wellness needs
58
define cultural diversity
transcultural phenomenon. At least 2 people having diff cultural orientations
59
what does evidence based mean?
combining clinical expertise with the use of nursing research, while considered values of the PT
60
What is clustered data
patterns and relationships among the data
61
A good rule of an interviewer is to..
spend more time listening than talking
62
When a patient denies something but acts in the opposite
bring verbal and nonverbal behavior to PT attention
63
When should touch be used
if interviewer knows pt well
64
at what age should interviewer question child him/herself
age 7
65
What interviewing techniques should be avoided for an adolescent
silence and reflection
66
What is the proper distance for personal space
1.5-4 ft
67
Religion is defined as
belief in a divine or superhuman spirit to be obeyed or worshiped
68
Why is there a need for cultural care
demographic change
69
The imbalance of hot and cold is considered "illness" among...
Hispanic-American heritage
70
What is an amulet
the evil eye
71
What does empacho mean?
a culture-bound syndrome that ha no equivalent from a biomedical perspective
72
What does "review of systems" mean?
the evaluation of the past and present health state of each body system
73
What does PQRSTU Stand for
1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding
74
What 2 section of child's health history become important to current health status
developmental and nutritional history
75
What is one way to detect dementia
mini-cog
76
A Major characteristic of dementia is
impairment of short & long term memory
77
Dysarthria
difficult or unclear articulation of speech that is otherwise linguistically normal.
78
What is echolalia
meaningless repetition of another person's spoken words as a symptom of psychiatric disorder.
79
The part of the hand used for assessment of vibration are
ulnar surface of the hand
80
Performing indirect percussion, the stationary finger is struck where..?
at the middle joint
81
How would you describe the pitch of a sound wave obtained by a percussion
number of vibrations per second
82
The bell of the stethoscope is used for..
soft, low pitched sounds
83
Which aperture is used for a patient with undilated pupils
small
84
If an infant is asleep, where can you start with the examination
heart, lung, and abdomen
85
When does examination of a child change to head to toe
school age
86
When inspecting ear canal, which speculum is used for the otoscope
the largest that will fit
87
During gen survey what are the 4 areas of interest
1)Appearance 2)Body structure 3)Mobility 4)Behavior
88
What is gait
a person's manner of walking
89
Measuring gait, the base is usually...
as wide as the shoulder width
90
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.
91
From 80 - 90 what happens to height and weight
both decrease
92
To accurately assess patients pulse what is the range?
start with zero to 30
93
A normal pulse for a patient is..
2+
94
How do you accurately assess a patient's respiration?
count for 20 seconds
95
What is pulse pressure
the difference between systolic and diastolic pressure
96
What is coarctation?
narrowing of the aorta
97
If PT has coarctation the thigh pressure would be..
lower than in the arm
98
What is the mean arterial pressure
diastolic pressure plus one third pulse pressure
99
Why is sizing of a bp cuff important
too narrow will give false reading that is HIGH
100
Diastolic
when the heart refills with blood
101
systolic
when heart is contracting
102
what is nociception
pain receptors
103
neuropathic pain
burning painful sensation that moves around toes and bottoms of feet.
104
Diaphoretic means
inducing perspirations
105
visceral pain
sweating, pale, pain in abdomen
106
What is a pre-term baby more sensitive too
painful stimuli
107
What is the wong baker scale
visual facial expressions to define pain scale (ex broken arm)
108
analgesics
pain reliever
109
Complex Regional Pain I
chronic pain that usually affects an arm or a leg.
110
This is a pain problem expected with impaired older adult
peripheral vascular disease
111
What is a common physiologic change that occurs with pain
tachycardia
112
Assessing Pain Mnemonic
P- OLDCARTS
113
P-OLDCARTS
previous hx, onset, location, duration, character, aggravating, radiation, timing, severity
114
What are the 4 steps in a regular physical exam
1) inspection 2)Palpation 3)Percussion 4)Auscultation
115
What are the steps when examing the abdomen
1) Inspection 2)Auscultation 3) Palpation 4) Percussion
116
Gen Survey Application
1)Appearance 2)Body Structure (lordosis/kyphosis) 3)Gait (how they walk) 4)Behavior 5)Weight
117
What is the diurnal cycle
difference in temp in the morning vs afternoon (cooler in the morn)
118
Ways to take temp
oral, electronic, axillary, rectal, tympanic membrane, temporal
119
What is normal temperature in the mouth
98.6F or 37C
120
What is normal temp in axillary
97.6F or 38.4C
121
What is normal temp in rectum
99.6F or 37.6C
122
What is normal temp in tympanic membrane?
98.6F
123
What is the conversion Celsius to Fahrenheit
C= 5/9 (f-32)
124
What is the conversion for Fahrenheit to Celsius
(9/5 x C) +32
125
What is the formula for Cardiac Output
CO= SV x HR
126
What is a normal amount of blood that gets pumped every heart beat?
2 ox or 70 mm
127
Where do you place the stethoscope to listen to heart sounds
4-5 Intercostal
128
What is normal for adults heart rate
50-100 beats/min (100+ is tachy)
129
What i normal for infant heart rate
80-160
130
What numeric is used for Force?
0-3+
131
What is normal force
2+
132
What is bounding or after a run
4+
133
What is force is considered "weak"
1+
134
What is respiration?
amount someone breaths in 1 iminute
135
What is the ratio for pulse
4: 1
136
When you see the ration for BP
Systolic is the higher # (top) Diastolic is lower #
137
If the diastolic is high on the bottom is that concerning
yes
138
Pulse Pressure =
Systolic - Diastolic
139
Mean Arterial pressure
force that pushes blood into the tissues
140
To hear Kortkoff sounds and you cant use the arm, what should you do?
use thigh
141
What does the pulse oximeter do?
measure how much hemoglobin carries oxygen (95% or higher)
142
What does a doppler do?
picks up changes in sound frequency as blood flows
143
What is the best indicator of Pain
what they tell you
144
What condition is hard to treat in terms of pain
Neuropathic pain, abnormal procession of pains messages
145
Visceral means
organs
146
Cutaneous means
skin
147
What are signs of acute pain behavior
guarding, grimacing, moaning, restless, stillnes diaphoresis, vital signs change
148
What type of palpation do you use for mobility and turgor?
Tenting
149
When is mobility decreased
with edema
150
When does tenting or turgor occur
severe dehydration or weight loss
151
What does striae mean?
stretch marks
152
What does sterile mean?
* no life
* using special gases
* high heat
153
For surgical apses how long do you wash your hands?
3 minutes
154
When is surgical apses necessary?
* intentional perforation of the skin
* body cavity, not exposed to outside
155
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
156
What makes a surface/ area contaminated
* prolonged exposure to air
* wet surfaces
* 1" border is contaminated
157
Are wrappers of sterile objects sterile?
NO
158
# Define a sterile field
room/space for handling sterile objects
159
Name 5 types where patient needs surgical asepsis technique
1. Open Body Cavity
2. Catheter
3. Burns
4. Central Line
160
Clean technique
* removes majority of microorganisms, not everything
* no autoclaving
161
What is lipping
* if you are using a solution more than once
* pour some out before use
162
When do you use sterile gloves for surgical asepsis?
once you've added everything to the sterile field
163
What are the 4 things we asses for skin, hair , nails
1. Structure/Function
2. Subjective
3. Objective
4. Abnormal findings
164
What is the largest organ and our bodies' first line of defense?
the skin
165
* horny layer- shedding
* basal layer on the bottom
166
What is apocrine
* sweat glands during puberty
* smells bad
167
What are eccrine glands
* major sweat glands in all humans. Most dense in palms and soles
* appears as dilute saline solution
168
What are 4 major functions of the skin?
1. keep fluid in/protect
2. nonverbal communication
3. wound repair
4. vitamin D absorption
169
In infants/children when does hair follicles start developing
3 months
170
What is common in skin of pregnant women
* stria grandorum
* increase pigment
171
What is xerosis
dry skin, mostly in older adults
172
What happens to older adults nails?
thicken- due to fungus
173
pruritus means?
itching
174
Culture and genetics and skin
body odors vary by race
175
Jaundice means
yellow
176
Cyanosis means
blue
177
What causes poor circulation in older adults
diabetes
peripheral vascular disease
178
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
179
Objective Data examples for skin hair nails
* skin color
* use pen light
* ruler
180
Pallor means
pail
181
What part of your hand do you use to palpate for temperature
dorsa (back)
182
What are 6 maor things you want to palpate for in skin hair nails
1. Temperature
2. texture- use finger tips
3. moisture
4. diaphoresis (sweating)
5. thickness
6. Edema
183
How is edema measured?
* 4 point scale
* 1+ = 2mm
* 2+ = 4mm......
184
What is pitting edema?
* think memory foam, leaves a thumb print
185
What is non pitting edema
The lack of indentation when fingertip pressure is applied to the skin, which classically occurs in hypothyroidism
186
What does vascularity mean?
bruising
187
3 Common types of birthmarks
1. freckles
2. junctional nevus
3. compound nevus
188
junctional nevus
189
Compound Nevus
190
What are the abnormal signs for pigmented lesions
ABCDE
191
ABCDE stands for
* **A**symmetry
* **B**order
* **C**olor variation
* **D**iameter grater than 6mm
* **E**levation or Enlargement
192
Hypothermia
* high fever
* localized coolness
193
Hyperthermia
* fever
* area feels warn
* trauma
* infection/sunburn
194
Uremia
renal failure
195
Brown-tan coloration
example Addisons disease- increase melanin production
196
* Annular Lesion
* circular (ringworm)
197
* Confluent Lesion
* ex hives//uriticaria
198
* Discrete lesion
* Skin tags//acne
199
Gyrate Lesion
200
grouped lesions
201
linear lesion
202
Target Lesion
203
* zosteriform
* linear around unilateral nerve
* ex: herpes
204
* Polycyclic
* i.e. psoriasis
* anular lesions grow together
205
What are primary skin lesions x6
* Macular/Patch
* Papule/Plaque
* Nodule/Tumor
* Vesicle/bulla
* Cyst
* Postule
206
* Macule
* Patch larger than 1 cm
* flat not raised
207
* **Papule**
* Plaque larger than 1 cm
* can feel, slightly elevated
* mole wart
208
* Nodule
* tumor larger than 3 cm
209
* **Wheal**
* Urticaria-hives
* raised irregular shape due to edema
* mosquito bites, allergies
210
* **Vesicle**
* Bulla- larger than 1cm
* a blister, herpes chicken pox, shingles
211
* **Cyst**
* encapsulated fluid filled cavity
* subcutaneous layer.
212
* **Pustule**
* pus filled cavity
213
What are some secondary Skin lesions?
* Crust
* Scale
* fissure
* erosion
* ulcer
* Excoriation
* scar
* atrophic scar
* lichenfication
* Keloid
214
* **Crust**
* dried out when blisters burst
215
* **Scale**
* compact flakes of skin
216
* Fissure
* ex cracks at corner of mouth
217
* **Erosion**
* shallow depression
* moist but no bleeding
218
* Ulcer
* irregular shape, may bleed
* leaves scar
219
* **Scar**
* replaced with connective tissue (collagen)
220
* **Atrophic Scar**
* thinning of the epidermis
* decreased visibility of normal skin markings
* shiny
221
* Lichenification
* when someone scratches an area excessively
222
* Keloid
* hypertrophic scar
* elevetated skin by excess scar tisue
223
* **Pressure Ulcer Stage I**
* red but ubroken
* will not blanch
224
* Stage 2 Ulcer
* loss of epidermis
* like open blister
225
* Stage 3 ulcer
* extending into subcutaneous tissue
* resembling a crater
226
* Stage IV Ulcer
* breaks through all skin layers
* visible bone or tendons
227
What are some vascular lesions
* petechiae
* purpura
* hematoma
* contusion
228
What is petechiae/purpura
* small purple color
229
What is hematoma
* a bruise you can feel
230
What is a contusion
another word for bruise
231
What are the phase/coloration of bruises
1. red
2. blue-purple
3. blue-green
4. yellow
5. brown-vanishing
232
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
233
nevus is the medical term for...
mole
234
where should you assess for *early* jaundice?
* sclera and hard palate
235
Normal angle between the nail base and the nail is...
160 degrees
236
How long should it take the capillary beds to refil?
1-2 seconds
237
What does flat brown macules on the hands mean?
Sun exposure, do not require treatment
238
Flattening of the angle between the nail and its base...
clubbing
239
Lyme disease is more prevalent during
May thru September
240
What causes milia?
sebum occludes skin follicles
241
Epidermis layer
* basal layer,
* thin,
* stratum corneum
242
Dermis Layer
* collagen
* elastic tissue
243
Subcutaneous layer
* adipose tissue
244
This is when lower half of the body turns red, upper half blanches..
Harlequin
245
This term is used when you notice mottling on trunk and extremities
Cutis Marmorata
246
large round or oval patch of light brown usually present at birth
cafe au lait
247
When irrigating a wound, how would the nurse know the right amount of pressure to apply?
between 5 and 15psi
248
Which device is used for wound irrigation?
19 gauge needle attached to 35 mL syringe
249
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.
250
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
251
Elsevier:
What's wrong with using a microwave for irrigating a wound?
can create hotspots
252
Elsevier:
What is the proper method for cleansing the evacuation port of a wound drainage system?
Wipe it with an alcohol sponge.
253
Braden Scale
Risk for skin breakdown/Pressure ulcer
254
ABD
Abdominal
255
What disease is a neurotic disorder?
MS, associating with neuro pain
256
What is the goal of wound care?
* to heal the wound
* prevent infection
257
What type of patient is at highest risk for suicide?
one that devises a plan
258
This is when a wound ruptures along a surgical suture
dehiscence
259
What is the *primary intention* for wound healing?
* tissue surfaces have been approximated
* low tissue loss
* remove dressings after drainage
260
What are 4 ways for debriefing a wound?
1. Mechanical
2. Chemical
3. Auto
4. Surgical
261
What is autolytic debriefing?
takes advantage of the body's own ability to dissolve dead tissue
262
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
263
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.
264
What are the phases for a full thickness wound repair?
1. Hemostasis (fibrin)
2. Inflammatory phase
3. Proliferative phase- *epithelial*
4. Remodeling- can take years
265
What are some complications for wound healing?
* hemorrage
* infection
* dehiscence
* avisceration
* fistula
266
What organ is 15% of our total body weight
Skin
267
Black or brown tissue that must be removed
necrotic
268
Yellow tissue in a wound that must be removed
slough
269
What is evisceration?
A surgical wound that opens up (dihiscence) but is a medical emergency
270
What are symptoms of wound Infections?
* puss
* odor
* wolume
* redness
* fever
* pain
271
What could be the psychosocial component of wound healing?
* body image
* scars
* odors
* drains
* temp prostetic
272
What is a penrose drain?
soft rubber tube placed in a wound area, to prevent the build up of fluid.
273
What is a Hydrocolloid dressing?
* gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer.
* protects from surface contaminants
274
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
275
What is a transparent film dressing used for?
* to protect skin in pressure spots.
* cover wounds with little or no drainage
276
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.
277
How many grams of protein can a patient lose per day with an open wound?
50 grams
278
Heat Therapy risks
* vaso-constriction
* damage epithelial cells
* blistering
* no longer than 1 hour
279
Cold Therapy Risks
* vaso dialation
* risk is tissue ischemia (frost bite)
280
What happens with negative pressure wound thearpy
* granulation lines the surface
* removes fluid and exudates to prevent infection
281
What is required in the delivery of culturally congruent care?
* knowledge
* skills
* attitudes
282
What is an example of a nurse stereotyping a patient?
do you bathe and use deodorant more than one time a week?
283
homelessness is an example of caring for a patient from a different..
culture
284
What are appropriate questions to ask a native american?
1. do you use folk remedies
2. do you have a family physician
3. do you use a shaman
285
What is an example of data validation
* comparing values with previous values
* report to charge nurse
286
What are the steps for a nursing diagnosis?
1. review assessment data
2. cluster
3. diagnostic label
4. contet of pt's health probl and select related factor
287
What could be indicated when a reddened area blances on fingertip touch?
blanching hyperemia. Body overcoming ischemic episode
288
To determine wound infection, where should the specimen be taken?
wound, after it has been cleaned with normal saline
289
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.
## Footnote
**Evisceration**
290
When do you use a warm compress?
* to relieve edema
* improve blood flow
