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► Med Misc 49 > unit II > Flashcards

unit II Flashcards

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1
Q

When is the healthcare assessment done?

A

It is a continuous process carried out during all phases of the nursing process

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2
Q

What does assessment focus on?

A

Strengths
Problems
Needs

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3
Q

Data base

A

Collection or store of information

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4
Q

Subjective data

A

Obtained from clients description of the problem

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5
Q

Objective data

A

Detectable by an observer

Can be measured or tested

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6
Q

Data collection

A

Process of gathering information about a clients health status

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7
Q 
Subjective or Objective??
Itching
Pain
B/P
Anxiety
Wheezing
A 
Subjective
Subjective
Objective
Subjective 
Objective
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8
Q

What is the purpose of the assessment ?

A

To enable the nurse to make a judgement or diagnosis about the pt’s health state

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9
Q

The purpose of assessment is to identify?

A
  • Deviations from normal
  • The clients health beliefs & patterns of health and illness
  • presence of risk factors for physical &/or behavioral problems
  • pt’s resources for support & adaptation
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10
Q

Name the 5 components of the nursing process?

A

A Nurse Plans Incase of Emergency

Assessment
Nursing diagnosis
Planning
Implementation 
Evaluation
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11
Q

Name the types of assessment

A

Initial
Problem focused
Emergency
Time-lapsed

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12
Q

Initial assessment

A

Performed within a specified time to establish a complete database

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13
Q

Problem focused assessment

A

Ongoing process integrated with nursing care

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14
Q

Emergency assessment

A

Performed during crisis

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15
Q

Time lapsed assessment

A

Several months after initial assessment to compare to baseline

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16
Q

Head to tie assessment

A

A complete health assessment conducted from head & proceeding in a systematic manner to the toes

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17
Q

Functional health

A

Evaluation of mind body and environment

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18
Q

What is the purpose of data collection review?

A

To provide info to identify the pt’s needs

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19
Q

Primary source of data

A

Client (pt)

Best source

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20
Q

Secondary source of data

A

Support ppl
Client records
Medical records

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21
Q

Interviewing is used to?

A

Identify problems of mutual concerns, evaluate change, teach, provide support, counseling or therapy

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22
Q

The nursing interview is a communication process that has two focuses, they are?

A

Est. rapport & trust

Gather info on client

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23
Q

What are the three phases of the interview ?

A

Orientation or opening phase
Working or body phase
Closing or termination phase

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24
Q

The working or body phase is used to?

A

Form a database to develop a plan of care

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25
Q

What are the components of the nursing health history?

A 
Biographic data
Chief complaint & HPI
Past medical Hx
Family health history
Psychosocial-lifestyles
ADLs
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26
Q

The history of present illness is?

A

A chronological description of the clients chief concern

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27
Q

Trendelenburg

A

Legs elevated

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28
Q

Lithotomy

A

OB exam

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29
Q

What is the sequence of the assessment exam?

A

I-inspect
P-palpate
P-percussion
A-auscultation

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30
Q

IPPA is used except in ?

A

Abdominal assessment

IAPP

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31
Q

Inspection

A

Visual examination

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32
Q

Palpation

A

Using hands to elicit information

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33
Q

Percussion

A

.

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34
Q

Tapping body surface to elicit sounds

A

.

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35
Q

Auscultation

A

The process of listening to sounds produced within the body

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36
Q

Skin turger is used for what?

A

Checking for tenting (dehydration)

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37
Q

Pitting checks for?

A

Edema

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38
Q

Assessment of an older adult reveals significant renting of the skin over the forearm, what else besides dehydration could it be?

A

Loss of adipose tissue and elasticity

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39
Q

PERRLA

A 
Pupils
Equal
Round
Reactive to
Light &
Accommodation
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40
Q

Normal sign of pupils?

A

3-5 mm

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41
Q

Normal breath sounds are

A

Are described as soft & breezy

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42
Q

Crackles

A

Bubbling, crackling sounds primarily on inspiration

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43
Q

Wheezes

A

High pitched squeaky

Air moving through narrowed airway

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44
Q

Rhonchi

A

Course gargling

Air passes through narrowed passages upper airway

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45
Q

Apex of heart

A

Bottom of heart

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46
Q

Where is the heart located

A

Lies behind & left of sternum

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47
Q

PMI

A

Point of maximum impulse

5th left intercostal space @ midclavicular line

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48
Q

Capillary refill

A

Less than 3 seconds

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49
Q

Where are S1 & S2 located ?

A

S1- mitral valve (apex)

S2- aorta (right sternal boarder)

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50
Q

What are visicular breath sounds?

A

Normal soft and breezy

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51
Q

Best position to listen to heart sounds?

A

Supine?

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52
Q

If we can’t hear heart sounds how do we move the pt?

A

Left side or leaning forward

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53
Q

When checking for pulses what do you check for?

A

Rate
Rhythm
Quality

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54
Q

HOMANS sign

A

DVT, dorsiflex of the foot, is there pain in calf

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55
Q

Seizure precautions

A

Airway, padded side rails, suction

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56
Q

Arterial pulses name them & are found where?

A 
Radial
Carotid
Brachial
Pedal
Femoral
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57
Q

S 1

A

Closing of mitral valve & tricuspid valve

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58
Q

S 2

A

Closing of aortic & pulmonic valves

Marks beginning of diastole

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59
Q

Bruit

A

Sign of arterial narrowing

Listen for a blowing or rushing sound

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60
Q

When you check for JVD, the pt is positioned how?

A

Laying at a 45 degree angle

61
Q

Bowel sounds are heard every?

A

5-15 seconds

62
Q

Borborygmus

A

Loud intestinal rumbling

63
Q

Dysuria

A

Painful urination

64
Q

Validating data

A

Double checking data

65
Q

SLIDE

A

Single line thru error
Initials
Date
Error (write out)

66
Q

Pack year

A

cigarettes x # years smoking =

67
Q

Cage (alcohol) questionnaire

A

C- ever tried to cut down
A- ever annoyed by criticism
G- ever felt guilty
E- ever have Eye Opener

68
Q

What is the purpose of the physical exam?

A

Gather baseline data about health

69
Q

Pitting

A 
Sign of edema
\+1 2mm
\+2 4mm
\+3 6mm
\+4 8mm
70
Q

Chest landmarks

A 
C. Chest wall symmetry
R. Resp. Rate rhythm depth 
A. Accessory muscles
M. Masses or scars
P. paradoxical movement
71
Q

Assessing

A

Process of collecting organizing and recording data

72
Q

Cephalocaudal

A

Proceeding in the direction from head to toe

73
Q

Closed question

A

Restrictive question, only a short answer

74
Q

Covert data

A

Data apparent only to the person affected

75
Q

Cues

A

Any piece of info that influences decisions

76
Q

Data

A

Information

77
Q

Directive interview

A

Highly structured interview that uses closed questions to elicit specific information

78
Q

Inferences

A

Interpretations or conclusions made based on cues or observed data

79
Q

Interview

A

A planned communication

A conversation with a purpose

80
Q

Leading question

A

A question that influences the client to give a particular answer

81
Q

Neutral question

A

A question that does not direct or pressure a client to answer in a certain way

82
Q

Non directive interview

A

An interview using open ended questions and empathetic responses to build rapport and learn client concerns

83
Q

Objective data

A

Data that is detectable by an observer or can be tested

Can be seen heard felt or smelled

84
Q

Open ended question

A

Questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic

85
Q

Rapport

A

A relationship between two or more people of mutual trust and understanding

86
Q

Review of systems (screening examination)

A

A brief review of essential functioning of various body parts or systems

87
Q

Subjective data

A

Data that are apparent only to the person affected

88
Q

Validation

A

The determination that the diagnosis accurately reflects the problem of the client

89
Q

Name the 5 vital signs

A 
B/p
Pulse
Respirations
Temperature
Pain
Pulse ox
90
Q

Why take viral signs

A

Identify acute medical problems

Reflect changes in the body

91
Q

When do you take vital signs

A 
Baseline
Surgery 
Medication
Treatment/therapy 
As ordered
92
Q

Blood pressure

A

Measure of pressure exerted by the blood as it flows through arteries

93
Q

Systolic pressure

A

Pressure of blood exerted on the arteries when ventricles contract

94
Q

Diastolic pressure

A

Pressure exerted in the arteries when the ventricles are at rest

95
Q

Normal B/P for adult

96
Q

Pulse pressure

A

Difference between systolic and diastolic pressures

Normal is 30-50mmHg

97
Q

T/F

BP is a product of cardiac output and systemic vascular resistance

98
Q

Stroke volume

A

Amy of blood ejected from the heart with each contraction

99
Q

Heart rate

A

beats per minute

100
Q

Peripheral/systemic vascular resistance

A

Resistance of blood flow due to blood vessel size

101
Q

Arteriosclerosis

A

Elastic & muscular tissue of arteries are replaced with fibrous tissue

102
Q

What causes arteriosclerosis ?

A

Increased B/P

103
Q

Viscosity

A

Thickness of blood

104
Q

Doppler BP

A

Obtains only SBP

Infants, obese, shock

105
Q

Bladder of BP cuff must go around at least

A

80% of upper arm

106
Q

When is a direct/invasive BP method used

A

Crital care pt’s

Unstable

107
Q

When taking a BP what do you listen for?

A

Korotkoff sounds

108
Q

Ortho static BP

A

BP falls after sudden change in position

109
Q

C=

A

(F-32)x5/9

110
Q

F=

A

(Cx9/5)+32

111
Q

Normal temperature

orally

112
Q

Body continually produces hear due to

A

Metabolism

113
Q

Basal metabolic rate

A

Rate of energy used to maintain body’s essential activities

114
Q

Stress / sympathetic nervous sustem

A

Fight or flight

115
Q

Your body looses heat through

A

Radiation, respiration
Conduction, contact
Convection, air
Evaporation, sweat

116
Q

3 main regulators of the body are

A

Sensors in core
Hypothalamus
Effector system

117
Q

3 physiological processes incense body temperature are

A

Sweating

Shivering

118
Q

Hypothalamus

A

Controls core temperature

119
Q

Name the five types of fever

A 
Intermittent-rises above normal
Remittent-wide range of temp
Relapsing-
Constant
Fever spike-rises rapidly then decreases to normal quickly
120
Q

Causes of elevated temperatures

A

Head injury
Environmental
Pathogens

121
Q

Hypothermia

A

Core body temp below 95f-35c

122
Q

Induced hypothermia

A

Deliberate lowering of body temperature

123
Q

Common sites to take temperatures

A 
Oral
Rectal
Auxillary
Tympanic
Temporal
124
Q

Rectal thermometer

A

99.6F normal
Insert 1.5 inches
PT lies on left side

125
Q

Axillary temperature

A

97.6 F normal

Non invasive

126
Q

Stroke volume

A

Amt of blood that enters arteries with each contraction

127
Q

Cardiac out put

A

Volume blood pumped into body’s arteries by the heart every minute

128
Q

Cardiac Output =

A

Stroke volume X heart rate

129
Q

Hypovelimia

A

Loss of blood

130
Q

Apical pulse is found?

A

Left side 5 th intercostal at the midclavicular line

131
Q

Tachycardia

A

Heart rate over 100

132
Q

Bradycardia

A

Heart rate less than 60

133
Q

Newborn heart rate

134
Q

Children 1-10

135
Q

Pulse deficit

A

Discrepancy between apical pulse and radial pulse

136
Q

Normal respiratory rate

A

12-20 per minute

137
Q

Apnea

A

Absence of breathing

138
Q

Crackes

A

Fluid in lungs

139
Q

Wheezes

A

Spasm of airway

140
Q

Diminished

A

Swelling in airway

141
Q

Rhonchi

A

Mucus in airway

142
Q

Orthopnea

A

Only breath sitting upright

143
Q

Kussmaul

A

Consistent increase of rate and depth

144
Q

Biots

A

Shallow breathing followed by apnea

145
Q

Dyspnea

A

Difficulty breathing

146
Q

Normal pulse ox

147
Q

Temperature regulation comes from

A

Hypothalamus & pons

148
Q

Name the 4 major assessment activities

A

Collection
Organization
Validation
Documentation

► Med Misc 49 (29 decks)

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