Unit Two Test Flashcards
sources of data in Interview
primary and secondary
primary is
patient
secondary is
from family or chart
what are the phases of the interview
orientation
working
termination
begins at the introduction, knock on door and introduce self
orientation phase
collecting data, actually doing your physical care and planning nursing care
working phase
documented and saved data at end of assessment with patient
termination phase
physical examination is when you
gather by observation, look, listen, and feel
what are the types of physical assessment
comprehensive
focused and systemic specific
ongoing and head to toe are not assessments that are separate, they are part of the
comprehensive, focused and system specific
in depth assessment where you are manipulating the body to get a medical diagnosis from it (PA or NP usually do this)
comprehensive
obtain specific info based on pt admitting dx or potential problem (ex. shortness of breath- assess lungs and respiration, oxygenation, color of skin)
focused
focusing on only one system (we will do every system assessment)
system specific
how often do you have to come into the room is
ongoing
all assessments we do this in a systematic way to help us not leave anything out)
head to toe
what is the nursing process of physical assessment
assessment
nursing diagnosis
planning
evaluation
what are the 5 techniques for assessment
inspection palpation percussion auscultation olfaction
observing is
inspection
touching is
palpation
listening by THUMPING is
percussion
listen with stethoscope is
auscultation
smelling is
olfaction
in assessment we use all senses except
taste!
when inspecting what should you do with body parts not being inspected
drape or cover body parts
what parts are needing additional lighting
eyes, ears, throat
what are you observing for
color, shape/symmetry, movement, position
what is considered light palpation
1cm or 1/2 in depth
what is considered deep palpation
4cm or 2in depth
what are the techniques of palpation
bimanual/ manual
dorsum of hand
palm or ulnar surface of hand
plamar surface of finger/finger pads
you palpate to assess
texture, resistance, resilience, mobility, temperature, thickness, shape and moisture
what is another word used for moist
diaphoric
where should you assess turgor
at clavicle
what are the 2 ways to percuss
direct and indirect
applied directly to body is
direct
applied through another or surface is
indirect
where do you typically percuss
over the stomach and the intestines
what are the characteristics of auscultation
frequency
loudness
quality
duration
of oscillations per second generated by a vibrating object
frequency
amplitude of a sound wave
loudness
descriptive is
quality
length of time that sound lasts is
duration
when using the stethoscope it is always best to
directly place it on skin
best for LOW pitched sounds
bell
best for HIGH pitch sounds
diaphragm
olfaction is used to detect
abnormal and normal symptoms
what should you clean between clients
stethoscope head and blood pressure cuffs
what are the special considerations when assessing for the aged
may need to adjust position
may need to allow more time
may need to allow more space
when is the health history taken
before physical exam
what is the exception for taking height and weight
only need to take it upon admitted and not usually taken continuously unless patient has fluid filling
when measuring circumference what is measured
head, chest, stomach, legs
when should vital signs be taken
evry 4 hours unless noted otherwise
what do lasix (diuretic) meds do to a patient
tend to make patient urinate more and expect weight to drop
when a pt has swollen legs what should be done
elevation and TED hose
blue skin=
not enough oxygenation
yellow skin=
jaundice
turgor is checked for
hydration status
bright red bleeding of a wound should be
reported
in integument what are you assessing
oxygenation, circulation, nutrition, tissue damage, hydration (skin nails and hair)
if pt has been on bedrest pay extra attention to
skin over bony prominences such as elbows, coccyx, hips and heels
if there is redness on skin what should you do
check for blanching
fluid building (pooling in certain areas(
pitting edema
how would you document pitting edema status
press until you feel bone and depending on how far deep finger goes is what you document
terminal hair is
scalp, axillae, pubic, and beard
vellus hair is
soft tiny hairs covering the body except palms and soles
hair loss
alopecia
excessive hair
hirsutism
when the nail has long term oxygen deprivation (finger enlarges because it hasn’t been the normal growth
clubbing
a pupil dilated in
the dark
a pupil constricts in the
light
when is the only time pupils will not react
if pt has cataracts, trauma, injury to head
what is the pupillary reflex
Pupils Equal Round Reactive Light (Accommodation) PERRLA
abscess teeth can cause
heart disease
clear liquid in ears is
cerebrospinal fluid (indicated head injury)
low set ears=
downsyndrome
red ears=
fever, ear infection, picking at ear
extreme palor=
paleness (not getting enough oxygen, or cold)
jugular vein distention usually indicates
high blood pressure
COPD people cannot
recoil and have difficulty breathing (their level of carbon dioxide makes them take a breath)
funnel chest=
indention (nothing wrong unless doing CPR)
pigeon chest
structure of sternum the way it grows outward
check for scoliosis by
bending over and touching toes
kyphosis
hunchback
type of breathing pattern where pt is going through a hard time of breathing (panting)
kussmauls
why should you ask pt for history of smoking
history can cause lung damage and affect what we are hearing
when assessing cardiovascular what is the PMI (point of maximum impulse)
5th intercostal space just medially to the left mid clavicular line)
when should you listen to apical
if radius is abnormal or pt is taking digoxin (for qt intervals)
sound associated with closing of mitral/tricuspid valves
lub or S1
sound associated with the closing of the aortic/pulmonic valves
Dub or S2
pulse points 0 1+ 2+ 3+ 4+
0= absent non palpable 1+= diminished, palpable 2+= strong, normal 3+= full, inceased 4+= bounding
typically around feet and ankles; older adults and those who stand a lot
dependent edema
venous insufficiency or R heart failure, fluid accumulates in tissue
pitting edema
when assessing gastrointestinal what should you ask the patient to do
go to the bathroom before assessment
in gastrointestinal assessment no deep palpation more interested in
the bowel sounds
why do you palpate the abdomen last
palpation causes unneeded sounds
what hinders abdomen exam
tense muscles
what order should the assessment go
inspection, auscultation, percussion, palpation
bowel sounds normal=
5-35 times per minute
bowel sounds of hyperactive=
greater than 35 times per minute
bowel sounds of hypoactive=
less than 5 times per minute
bowel sounds of absense=
5 minutes
areas of air are
stomach
areas of solid masses
liver, intestines
when should you use light palpation (1/2 in depth)
using palm of hand with fingers extended check
- distended bladder
- superficial masses
- tenderness
IV sites are NOT considered a wound it is a
access site
