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Nursing 102 > Physical Assessment and Vitals > Flashcards

Physical Assessment and Vitals Flashcards

1
Q

60 Second Survey

A

ABC’s-Tubes and Lines-Respiratory Equipment-Patient Safety Survey-Environmental Survey-Sensory

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2
Q

3 Concepts of a complete assessment

A

Health history, Physical exam, Diagnostic Study

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3
Q

Subjective Data

A

What a patient tells you.

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4
Q

Objective Data

A

Something quantifiable (Lab work, Vitals)

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5
Q

Preparing patient for a physical assessment.

A

Explain procedure-Assist Client into gown-Empty Bladder-Turn off TV, etc-Wash Hands

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6
Q

High Fowler’s

A

90 degrees

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7
Q

Fowler’s

A

45 degrees

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8
Q

Semi-Fowlers

A

30 degrees

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9
Q

Supine

A

Flat on back

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10
Q

Prone

A

Flat on stomach

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11
Q

Sims

A

On side, knee out

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12
Q

Dorsal recumbent

A

“Pregnancy position”

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13
Q

Lithotomy

A

“Pregnancy position in stirrups”

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14
Q

Four methods of assessment

A

Inspection-Palpitation-Percussion-Auscultation

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15
Q

Light palpitation depth

A

Approx. 1/2”

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16
Q

Percussion sounds

A

Flatness, Dullness, Resonance, Hyper Resonance, Tymphany

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17
Q

Bell of stethoscope

A

Smaller side, Low pitched Sounds

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18
Q

Diaphragm of stethoscope

A

Larger side, High pitched sounds

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19
Q

Direct Auscultation

A

Sounds heard by the unaided ear

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20
Q

Indirect Auscultation

A

Using an instrument (Stethoscope)

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21
Q

Temperature Norms

A

36.0-38.5 C or 98.6 F

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22
Q

Pulse Norms Adult

A

60-100

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23
Q

Respiration Norms Adult

A

12-20

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24
Q

Blood Pressure Norms

A

120/80 or less

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25
Oxygen Saturation Norms
95-100%
26
5th Vital sign?
Pain
27
10-16 year old heart rate
50-90
28
Febrile
Fever
29
Afebrile
No fever
30
Tachycardia
High heart rate
31
Bradycardia
Low heart rate
32
Absent pulse in limb
Considered an emergency, patient could lose limb
33
Costal Breathing
Produced by movement of the ribs
34
Diaphragmatic
Produced by movement of the diaphragm, taught to patients to improve aeration of the lungs
35
What controls breathing?
Medulla Oblongata & Pons
36
Apnea
Lack of respirations
37
Tachypnea
High respirations
38
Bradypnea
Low respirations
39
Polypnea
Increased depth of breathing
40
Eupnea
Normal respirations
41
Systolic
Pressure during heart contractions
42
Diastolic
Pressure when ventricles are at rest
43
Elevated Blood Pressure
120-129 Systolic and less than 80 Diastolic
44
Stage I Hypetension
130-139 Systolic and 80-89 Diastolic
45
Stage II Hypertension
Systolic over 140 Diastolic over 90
46
Hypertensive Crisis
Systolic over 180 Diastolic over 120
47
Hypotension
Below 90/50, Dizziness, light headed or fainting
48
Interventions for low o2 saturation
Be sure the patient is pulled up in bed, make sure the head of the bed is atleast 30 degrees. Have patient try a few deep breaths
49
Acute Pain
Now to 6 months
50
Chronic Pain
6 months or older
51
Numeric Pain Scale
0-10, great for patients that can understand and respond
52
Wong Baker
0-10, even numbers. Great for children that can understand and respond
53
FLACC
Face, Legs, Activity, Cry, Consolability. 0-10. Best used on patients who aren't physically or mentally capable to respond
54
Normal lung sounds
Vesicular and Bronchovesicular, and bronchial
55
Fine Crackles (Rales)
"Hair between fingers" Collapsed Alveoli and bronchioles snap open
56
Coarse Crackles (Rales)
long duration rumbling snoring sound. caused by airway being intermittently occluded by mucus
57
Rhonchi
Rumbling, snoring noise. More prominent on expiration. Caused by obstruction or blockage of airways by secretions.
58
Pleural friction rub
grating sound. Caused by inflamed pleural surfaces
59
Stridor
continuous musical pitch. Caused by blockage or obstruction of larynx or trachea
60
Cheyne-Stokes
Deep and rapid breathing followed by periods of apnea, common in those dying
61
Ecchymosis
Bruising appearance
62
Cyanosis
Blue tone
63
Jaundice
Yellow tone
64
Pallor
Pale tone
65
Erythema
Reddened tone
66
Turgor
Elasticity of the skin, Tenting test
67
Capillary refill test
Blanching the fingertips >2-3 seconds
68
Braden Scale
measures risk of pressure injuries
69
PERRLA
Way to test the eyes (light test, movement, size and symmetry of pupils
70
Apical Pulse
Mid clavicular, Left 5th ICS
71
Pulse Deficit
Difference between distal pulses and apical pulse
72
Auscultating Bowel Sounds
RL-RU-LU-LL
73
Levels of LOC
ALert-Lethargic-Obtunded-Stupor-Coma
74
Glasgow test
Tests LOC with eye response, motor and verbal response

Nursing 102 (2 decks)

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