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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
Q

Oxygen Saturation Norms

A

95-100%

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26
Q

5th Vital sign?

A

Pain

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27
Q

10-16 year old heart rate

A

50-90

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28
Q

Febrile

A

Fever

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29
Q

Afebrile

A

No fever

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30
Q

Tachycardia

A

High heart rate

31
Q

Bradycardia

A

Low heart rate

32
Q

Absent pulse in limb

A

Considered an emergency, patient could lose limb

33
Q

Costal Breathing

A

Produced by movement of the ribs

34
Q

Diaphragmatic

A

Produced by movement of the diaphragm, taught to patients to improve aeration of the lungs

35
Q

What controls breathing?

A

Medulla Oblongata & Pons

36
Q

Apnea

A

Lack of respirations

37
Q

Tachypnea

A

High respirations

38
Q

Bradypnea

A

Low respirations

39
Q

Polypnea

A

Increased depth of breathing

40
Q

Eupnea

A

Normal respirations

41
Q

Systolic

A

Pressure during heart contractions

42
Q

Diastolic

A

Pressure when ventricles are at rest

43
Q

Elevated Blood Pressure

A

120-129 Systolic and less than 80 Diastolic

44
Q

Stage I Hypetension

A

130-139 Systolic and 80-89 Diastolic

45
Q

Stage II Hypertension

A

Systolic over 140 Diastolic over 90

46
Q

Hypertensive Crisis

A

Systolic over 180 Diastolic over 120

47
Q

Hypotension

A

Below 90/50, Dizziness, light headed or fainting

48
Q

Interventions for low o2 saturation

A

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
Q

Acute Pain

A

Now to 6 months

50
Q

Chronic Pain

A

6 months or older

51
Q

Numeric Pain Scale

A

0-10, great for patients that can understand and respond

52
Q

Wong Baker

A

0-10, even numbers. Great for children that can understand and respond

53
Q

FLACC

A

Face, Legs, Activity, Cry, Consolability. 0-10. Best used on patients who aren’t physically or mentally capable to respond

54
Q

Normal lung sounds

A

Vesicular and Bronchovesicular, and bronchial

55
Q

Fine Crackles (Rales)

A

“Hair between fingers” Collapsed Alveoli and bronchioles snap open

56
Q

Coarse Crackles (Rales)

A

long duration rumbling snoring sound. caused by airway being intermittently occluded by mucus

57
Q

Rhonchi

A

Rumbling, snoring noise. More prominent on expiration. Caused by obstruction or blockage of airways by secretions.

58
Q

Pleural friction rub

A

grating sound. Caused by inflamed pleural surfaces

59
Q

Stridor

A

continuous musical pitch. Caused by blockage or obstruction of larynx or trachea

60
Q

Cheyne-Stokes

A

Deep and rapid breathing followed by periods of apnea, common in those dying

61
Q

Ecchymosis

A

Bruising appearance

62
Q

Cyanosis

63
Q

Jaundice

A

Yellow tone

64
Q

Pallor

65
Q

Erythema

A

Reddened tone

66
Q

Turgor

A

Elasticity of the skin, Tenting test

67
Q

Capillary refill test

A

Blanching the fingertips >2-3 seconds

68
Q

Braden Scale

A

measures risk of pressure injuries

69
Q

PERRLA

A

Way to test the eyes (light test, movement, size and symmetry of pupils

70
Q

Apical Pulse

A

Mid clavicular, Left 5th ICS

71
Q

Pulse Deficit

A

Difference between distal pulses and apical pulse

72
Q

Auscultating Bowel Sounds

A

RL-RU-LU-LL

73
Q

Levels of LOC

A

ALert-Lethargic-Obtunded-Stupor-Coma

74
Q

Glasgow test

A

Tests LOC with eye response, motor and verbal response

Nursing 102 (2 decks)

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