Unit 2 Flashcards
Cephalocaudal
from head to toe
Directive interview
highly structured
closed questions elicit specific information
Subjective Data
- Obtained from client (primary source)
- recorded in “OWN WORDS”
- verified only by client
- symptoms/ covert data
Objective Data
- detected by an observer
- measured/ tested against acceptable standards
- signs/ overt data
Components of the Nursing Health History
Being Complete Makes For Proper Assessment
- Biographic Data
- Chief Complaint & HPI (hx of present illness)
- PMH
- Family Health Hx
- Pscyhosocial- Lifestyle & Health Practice Profile
- Assessment - ADL’s
Discoloration of the skin (subject or objective)
objective
Four Types Of Assessment
- Initial
- Problem-Focused
- Emergency
- Time-lapsed Reassessment
Time-lapsed Reassessment
- several months after initial assessment
- compare to baseline data previously obtained
Inspection
- visual examination; also uses senses (hearing & smell)
- deliberate, purposeful, systematic
Pallor
- result inadequate circulating blood/ hemoglobin & subsequent reduction in tissue oxygenation
Database
subject and objective data that provides baseline for comparing clients responses to medical/ nursing interventions
Initial Assessment
performed within a specific time after admission
Percussion
- tapping/ striking body surface to –> sound/ vibrations
- reveals location, size, and density of underlying structures (air/ fluid - filled, solid)
Direct Percussion
directly on skin
Indirect Percussion
non-dominate hand between subject and striking
Blunt
Ulnar surface of fist against skin surface
Tympany
- gas/ bowels (air-filled stomach)
- musical
- high-pitched, drum-like
- least dense tissues
Dullness
– thudlike; organs→ liver, heart, spleen
Hyper-resonance
- booming → emphysematous lung
- not anticipated
Resonance
– hallow; lungs filled with air
Stethoscope
- Diaphragm - S1/S2; high pitched
- Bell - S3/S4; Bruits, mummurs, low pitched
PERRLA
Pupils Equal Round Respond to Light Accommodation
Normal Pupil Size
3-5mm
Normal Breath Sounds
- heard over Entire Lung
- inspiratory and expiration
- PRIMARY source is turbulent flow of air in larger airways
Tracheal
- pause between I & E
- tubular quality
Bronchial
- 1:2 ratio
- anteriorly over trachea
- Short Inspiratory, Loud Expiratory
Bronchovesicular
- 1:1 ration
- Between scapulae posterior 1&2 ICS Anteriorly
5-P’s
Pain, Pulse, Pallor, Paresthesia, Paralysis
5th Vital Sign (Pain Assessment)
P,Q,R,S,T
- Provocative
- Quality/ Quantity
- Region/ Radiation
- Severity
- Timing
Celsius
(F-32)*(5/9)
F=
(C*9/5)+32
Normal SaO2
95-100
