Adv. Fundamentals Final Review Flashcards
(25 cards)
What is subjective data in physical assessment?
Data collected as reported by the patient, such as pain levels and feelings.
Subjective data reflects the patient’s personal experience and cannot be measured directly.
What is objective data in physical assessment?
Data that can be quantified and verified by diagnostics, such as vital signs and lab results.
Objective data is observable and measurable, providing a factual basis for assessment.
What is the proper order of assessment techniques?
- Inspection 2. Auscultation 3. Palpitation 4. Percussion
This order changes for abdominal assessments, where auscultation precedes palpitation.
What does the term ‘palpitation’ refer to in physical assessment?
Using hands and sense of touch to assess a patient’s condition.
Palpation can reveal temperature, turgor, moisture, and texture of the skin.
How do you assess skin temperature?
Use the back of your hands to assess skin temperature.
Cool skin may suggest poor perfusion, while warm skin may indicate vasodilation or fever.
What is the significance of skin turgor in assessment?
It indicates hydration status; tenting suggests dehydration.
Turgor is assessed by pinching the clavicle.
What are the four main tools used in auscultation?
- Stethoscope 2. Diaphragm 3. Bell 4. Observation of sound characteristics.
The diaphragm is used for high-pitched sounds, while the bell is for low-pitched sounds.
What is eupnea?
Normal breathing pattern.
Eupnea indicates a healthy respiratory rate and rhythm.
Define dyspnea.
Difficult and labored breathing, also called shortness of breath (SOB).
Dyspnea can indicate underlying respiratory or cardiac conditions.
What are Kussmaul respirations?
Increased rate and depth of breathing with panting and long, grunting exhalation, often associated with diabetic acidosis.
This type of respiration reflects a compensatory mechanism for metabolic acidosis.
What are adventitious breath sounds?
Abnormal breath sounds that can indicate respiratory issues.
Examples include crackles, wheezing, and stridor.
What does a respiratory acidosis lab value indicate?
pH < 7.35, PaCO₂ > 45 mm Hg.
Respiratory acidosis is often caused by hypoventilation.
What is the normal range for pulse oximetry?
95%-100%.
Pulse oximetry measures oxygen saturation in the blood.
How many lobes does each lung have?
Right lung has three lobes; left lung has two lobes.
The left lung has fewer lobes due to space occupied by the heart.
What are the main symptoms of left-sided heart failure?
Trouble breathing, coughing, tiredness, crackles in lungs.
Left-sided heart failure leads to pulmonary congestion.
What do complete proteins contain?
All nine essential amino acids.
Complete proteins are typically found in animal sources.
What is the function of vitamin A?
Needed for immune response and night vision.
Sources include leafy greens and deep orange vegetables.
What is the normal urine specific gravity range?
1.005 to 1.030.
This test measures the concentration of solutes in urine.
What are the stages of pressure injuries?
- Stage 1: Non-blanchable erythema. 2. Stage 2: Partial-thickness skin loss. 3. Stage 3: Full-thickness skin loss. 4. Stage 4: Exposed muscle/tendon/bone. 5. Unstageable: Wound bed not visible. 6. Deep Tissue: Deep red/maroon discoloration.
Each stage reflects the severity of skin breakdown.
What is the PIE model in charting?
Problem, Intervention, Evaluation.
This model organizes nursing documentation effectively.
What does the acronym FACT stand for in documentation?
Factual, Accurate, Complete, Timely.
These principles ensure high-quality documentation.
What is the main purpose of therapeutic communication?
To establish a trusting relationship with the patient.
Effective communication enhances patient care and outcomes.
What are some complications of immobility?
Pressure ulcers, muscle atrophy, deep vein thrombosis.
Prolonged immobility can lead to serious health issues.
What does RACE stand for in fire safety?
R: Rescue, A: Alarm, C: Contain, E: Extinguish.
This acronym provides a systematic approach to fire emergencies.
