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NSG 316 TOPIC 1-5 > TOPIC 3 > Flashcards

TOPIC 3 Flashcards

1
Q

the health history provides

A

Subjective data for health assessment

Objective data (the signs perceived by examiner through physical examination)

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2
Q

what physical assessment tools are performed on a patient? (in order)

A

inspection
palpation
percussion
auscultation

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3
Q

inspection begins at…

A

general survey

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4
Q

what is included general survey

A

physical appearance
body structure
mobility
behavior

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5
Q

inspection

A

Concentrated/ close watching/ careful scrutiny
-first the individual as a whole, then each system of the body

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6
Q

inspection requires…

A

good lighting
adequate exposure
occasional use of instruments

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7
Q

palpation

A

applies your sense of touch to assess temperature, texture, moisture, organ size, location, swelling, lumps, tenderness, pain

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8
Q

fingertips

A

best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps

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9
Q

fingers and thumbs

A

detection of position, shape, and consistency of an organ or mass (grasping action)

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10
Q

Dorsa (backs) of hands and fingers

A

best for determining temperature because skin here is thinner than on palms

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11
Q

base of fingers or ulnar surface of hand

A

best for vibration

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12
Q

bimanual palpation

A

the use of both hands to envelop or capture certain body parts or organs, such as the kidneys.

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13
Q

percussion

A

tapping the person’s skin with short, sharp strokes to assess underlying structures

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14
Q

direct percussion

A

striking hand directly contacts body wall

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15
Q

indirect percussion

A

using both hands, the striking hand contacts stationary hand fixed on person’s skin (use middle finger on dominant hand as “striking finger”)

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16
Q

areas with more air produce what sound?

A

louder, deeper, longer sound (lungs)

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17
Q

auscultation

A

listening to sounds within the body such as heart, blood vessels and lungs (must be channeled through a stethoscope)

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18
Q

Stethoscope does not magnify sound, but

A

blocks out extraneous sounds

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19
Q

The diaphragm is best for

A

high pitched sounds (breath, bowel, normal heart sounds)

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20
Q

bell is best for

A

low pitched sounds (extra heart sounds or murmurs)

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21
Q

hold the diaphragm

A

firm

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22
Q

hold the bell

A

lightly to form a seal

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23
Q

what is the single most important step to decrease microorganism transmission

A

washing your hands

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24
Q

when do you want to wear gloves

A

before and after physical contact with each patient
risk of contact with any body fluids (blood, mucous membranes, body fluid, drainage, open skin lesions)

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25
clinical anxiety and reduction of anxiety
anxiety by anticipation of being examined by a stranger help client feel more comfortable
26
following sequence- build your database
1. general survey (measurement and VS) 2. begin with persons hands 3. concentrate on one step at a time 4. examination sequence 5. brief health teaching 6. when findings are complicated 7. summarize findings for person
27
examination of a person who is sick
collect a mini database (emergency or problem found database) and get full health assessment once distress is resolved
28
pain
highly complex and subjective experience that originated from the CNS, PNS or both
29
Nociceptors
specialized nerve endings that detect painful sensations and carry signal to CNS (from periphery to CNS)
30
A fibers
are myelinated and large so pain signal is sent rapidly to CNS (localized, short term, sharp pain)
31
C fibers
small nerve fibers, poorly myelinated or unmyelinated. slow conduction rate. (aching)
32
what are the four phases of nociception
1. Transduction 2. Transmission 3. Perception 4. Modulation
33
transduction
occurs when a noxious stimulus in form of traumatic injury, burn, incision, or tumor takes place in periphery
34
transmission
the pain impulse moves from the level of the spinal cord to the brain
35
perception
conscious awareness of painful sensation
36
modulation
the pain message is inhibited
37
visceral pain
originates from larger internal organs, such as the stomach, intestines, gallbladder, and pancreas
38
deep somatic pain
comes from sources such as blood vessels, joints, tendons, muscles, and bone
39
somatic pain
Pain that originates from skeletal muscles, ligaments, or joints.
40
cutaneous pain
derived from skin surface and subcutaneous tissues; injury is superficial, with a sharp, burning sensation
41
referred pain
pain that is felt in a location other than where the pain originates
42
pain can be describes by its duration
short duration long duration intermittent duration (can be short or long)
43
acute pain
short-term, self-limiting, often predictable trajectory; stops after injury heals
44
chronic pain
episode of pain that lasts for 6 months or longer
45
chronic pain can be divided into which two categories
malignant (cancer related) nonmalignant
46
Malignant Pain/Cancer Pain
Often parallels the pathology caused by the tumor cells. Is induced by tissue necrosis or stretching of an organ by the growing tumor. Pain fluctuates within the course of the disease
47
nonmalignant pain
chronic, usually associated with musculoskeletal conditions such as arthritis, low back pain, or fibromyalgia
48
neuropathic pain
abnormal processing of pain message; burning, shooting in nature ("pins & needles, stabbing")
49
all pain needs to be addressed no matter the age
pain is not a normal process of aging and should never be considered something to tolerate
50
what are some reasons an older adult that will not report pain
fears of... becoming dependent undergoing invasive procedures taking pain medications financial burden
51
gender differences in pain
- men have been raised to be more stoic about pain - women display more emotion about pain - women are more likely to experience migraines during childbearing, more sensitive to pain during PMP and more more likely to have fibromyalgia (hormones are found to have strong influences on pain sensitivity)
52
pain is always ____?
subjective
53
what is used for pain assessment
PQRST and pain scale
54
PQRST: P
provocation/palliation (what brings it on, what makes it better?)
55
PQRST: Q
quality/quantity (what does you pain feel like?)
56
PQRST: R
region/ radiation (where is it? point to it? does it go anywhere?)
57
PQRST: S
severity/scale (0-10) rate pain
58
PQRST: T
timing (come and go? constant? how long?)
59
Initial Pain Assessment
asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors
60
Brief Pain Inventory
Asks the patient to rate the pain within the past 24 hours using graduated scales (0-10) with respect to its impact on areas such as mood, walking ability, and sleep.
61
numeric rating scale
patient chooses level of pain for each site 0-10
62
Verbal Descriptor Scale
uses words to describe the patient's feelings and the meaning of the pain for the person
63
visual analog scale
a pain rating scale using a straight line; the left end of the line represents no pain, the right end represents the worst pain, and patients mark the place on the line that best represents the severity of their pain
64
older adults may prefer what scale
descriptor scale
65
pain is always subjective, but what objective findings may the nurse find?
swelling inflammation lesion brusing decreased ROM abdominal guarding
66
when the cause of acute pain is uncertain what should be done
establishing a diagnosis is priority but symptomatic treatment of pain should be given while investigating (if the patients is comfortable they are more likely to cooperate with diagnostic procedures)
67
what are acute nonverbal behaviors of pain?
guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, change in VS (increase BP & HR)
68
what are chronic nonverbal behaviors of pain?
bracing rubbing, diminished activity, sighing, change in appetite
69
behavioral cues of pain
changes in ADLSs slowness, riditiy, fatigue sudden onset of acute confusion
70
PAINAD
pain assessment in advanced dementia (scale 0-2) 0=normal breathing independent of vocalization negative vocalization facial expression body language consolability

NSG 316 TOPIC 1-5 (13 decks)

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