X Foundations - Chpt 5 - Assessment Flashcards
Order of Priority - ABC
- Airway
- Breathing
- Circulation
The first step in the nursing process
Assessment
Purpose of physical assessment
- evaluate current phys condition
- detect early signs of health prob
- establish BASELINE for future comparison
- evaluate clients response to treatment
The first admission assessment done by
RN
4 assessment technicques
- Inspection (with eyes)
- Percussion (lightly w fingertips, tapping, usually docs)
- Palpation (light touch. Deep palpation usually docs)
- Auscultation (stethoscope)
PERRLA
Pupils, Equal, Round, Reactive to Light, Accommodation
use pen light to assess
COPD
Chronic Obstructive Pulmonary Disease
Sounds of heart indicated by
S1, S2 (lub, dub)
normal bowels sounds
8-30 gurgles p/minute
Borborygmus
abnormal bowel/abdomen sounds
If claiming bowel sounds absent, how do you confirm
listen for 1 minute per quadrant (4 min)
Equipment needed for Physical Assessment
- tongue depressor
- pen light
- pen/paper
- stethoscope
- Spygmonometer
- watch w second hand
- thermometer
- scale
- Snellen chart (eye )
- Wong-Baker chart (faces, objectify pain)
Approaches for collecting data
- head to toe approach
- body systems approach
A&O x 3
Alert and Oriented ( 1.Person, 2.Place, 3.Time)
Where do you perform skin turgor test?
under clavicle. look for skin tenting (when skin stays up after you pinch it)
Lung Sounds
- Trachael
- Bronchial (main stem bronchi)
- Bronchovesicular (tubes and alveoli)
- Vesicular (margin of lungs, Alveoli)
Adventitious Lung Sounds
other than clear sounds
- crackles (fluid in alveoli)
- Gurgles (wet, noisy)
- Wheezes
- Rubs (pleura rubbing, leather creaking)
Capillary refill
press on nail bed, blood should return in under 3 sec.
Brawny/Turgid Edema
so swollen, you can’t even push it in
Weeping Edema
when the interstitial fluid seeps out of pores.
Jaeger Chart
EEE symbols testing vision when pt doesn’t know english alphabet or KIDS
A&Ox3
Alert and Oriented to Person, Place, Time
Assess pt in what manner
Head to Toe
Ronchi
Rhonchi are continuous low pitched, rattling lung sounds that often resemble snoring. Obstruction or secretions in larger airways are frequent causes of rhonchi. They can be heard in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis. Rhonchi usually clear after coughing.
Rales
Listen for fine crackles, which are discontinuous, popping sounds similar to velcro being pulled apart
Percussion used to determine….
density (fluid, hollow etc)
Ischemia
restriction in blood supply to tissues,[3] causing a shortage of oxygen and glucose needed for cellular metabolism (to keep tissue alive).[4] Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue. It also means local anemia in a given part of a body sometimes resulting from congestion (such as vasoconstriction, thrombosis or embolism).
Pallor
pale
Echinosis
A condition in which the red blood cells have lost their smooth outlines and come to resemble an echinus or sea urchin.
petechiae
Bleeding under the skin can occur from broken blood vessels that form tiny pinpoint red dots
erythema
redness of the skin
ecchymosis
Blood also can collect under the tissue in a very large bruised area
purpura
Purpura occurs when small blood vessels leak blood under the skin.
When purpura spots are less than 3 millimeters in diameter, they are called petechiae. Purpura spots larger than 1 centimeter are called ecchymoses.
diaphoresis
profuse sweating or perspiring.
pruritis
Itchy skin that makes you scratch
Purulent Discharge
Pus
Exudate
Seeping out. (Cyst breaks open)
Order of Assessment
1) Instpection
2) Palpation
3) Auscultation
4) Percussion
Abuse looks like
?
List of Disease Processes
?
Dyspnea
Difficulty breathing
Orthopnea
difficulty breathing while lying down
Positions
?
Signs are ….
Objective
Exudate
Seeping out, cyst breaks open, puss, serum
Sign or symptom Objective
Sign
Sign or symptoms subective
Symptoms
Etiology
Cause of the disease
Pruritis
Itchy skin
Asthenia
Weak and lethargic
