Assessment 2 Flashcards
(150 cards)
1
Q
Normal range for oral temp
A
98-98.6
2
Q
Hypertensive Crisis
A
> 180 systolic and/or >120 diastolic
3
Q
When are vital signs performed?
A
on admission, every shift, before, during and after procedures, to monitor medication effects, changes in pt condition
4
Q
Assessment order
A
inspection
palpation
percussion
auscultation
5
Q
Thermoregulation
A
constant body temp = balance between heat production and loss
6
Q
Core temp range
A
97-100.8
7
Q
How does your body decrease temp?
A
Sensors in hypothalamus are stimulated and send impulses which causes vasodilation
8
Q
How does your body increase temp?
A
Sensors in hypothalamus are stimulated and send impulses which causes vasoconstriction
9
Q
How heat is exchanged between body and environment?
A
Radiation
Convection (transfer of heat to water)
Evaporation (perspirations/breathing)
Conduction (from warm to cool surface by touch)
10
Q
Do infants shiver?
A
No, use brown fat metabolism. Non-shivering thermogenesis.
11
Q
Pyrexia oral
A
> 100
12
Q
Pyrexia rectal
A
> 101
13
Q
Normal range for rectal temp
A
99-99.6
14
Q
Normal range for respirations
A
12-20
15
Q
Normal BP
A
> 120/>80
16
Q
Hypertension stage 1
A
130-139 systolic/ 80-89 diastolic
17
Q
Hypertension stage 2
A
> 140 systolic and/or >90 diastolic
18
Q
Febrile
A
fever
19
Q
Afebrile
A
without fever
20
Q
Hyperthermia
A
> 105.8
21
Q
Normal urine output per hr
A
30 mL
22
Q
Hypothermia
A
<90
23
Q
Systole S1
A
lub sound, heart contracts
closing/shutting of tricuspid and mitral valves
24
Q
Diastole S2
A
dub sound, heart relaxes
aortic and pulmonic valves closing
25
PMI
point of maximal impulse
5th intercostal space mid clavicular line
26
Radial pulse
laterally on anterior wrist
27
Brachial pulse
medially in antecubital space
28
Carotid pulse
between midline and side of neck
29
Temporal pulse
side of forehead
30
Dorsalis pedis pulse
top of foot
31
Femoral pulse
in groin fold
32
Popliteal pulse
behind knee
33
Apical pulse
apex of heart
34
Bradycardia
<60 bpm
35
Tachycardia
>100 bpm
36
Pulse quality
absent, weak/thready, normal, bounding, bilaterally equal
37
When the diaphragm goes up
you exhale
38
When the diaphragm goes down
you inhale
39
Kussmals respirations
regular but abnormally deep and high rate
40
Biot's respirations
irregular, variable depth altering w/ periods or apnea
41
Cheyne stokes
gradual high depth, followed by gradual low depth and a period of apnea
42
Wheezing
high pitched, continuous musical sounds, usually on expiration
43
Rhonchi
low pitched continuous sounds caused by secretions in large airways
44
Crackles
sounds like pop rocks
45
Stridor
piercing, high-pitched usually on inspiration
46
Stertor
labored breathing that produces a snoring sound
47
3 phases of a fever
febrile episode; onset
course; flushed/warm to touch
temp drops to normal, pt sweats to lose heat "fever is breaking"
48
Oxygenation
how well the cells, tissues and organs of the body are supplied with oxygen
49
Perfusion
the continuous supply of oxygenated blood through the blood vessels to the vital organs
50
Vital signs
means of assessing vital or critical physiological functions TPR BP
51
Nonexertional
prolonged exposure to an environmental temperature (classic heat stroke)
52
Cardiac output
stroke volume x HR
53
Dyspnea
difficulty/labored breathing
54
Orthopnea
difficulty breathing when laying down
55
Hypoxia
Low oxygen saturation of the body, not enough oxygen in the blood
56
What is the purpose of a health assessment?
establish baseline data, identify nursing diagnoses, collaborative problems or wellness diagnoses, monitor the status of an identified problem and screen for health problems
57
What does a nurse need for a health assessment?
theoretical knowledge, self-knowledge, knowledge about client situation and plan of care review (initial and ongoing)
58
Preparing the client for a health assessment
promote comfort, develop rapport, explain the procedure, and be respectful about cultural differences, always introduce yourself, identify the patient and ask if they would like to use the bathroom before you start
59
Preparing the environment for a health assessment
provide privacy, noise control, use adequate lighting, adjust room temp to make the pt comfortable, and make sure you have the proper equipment
60
Comprehensive physical exam
start with health history and then complete a full head to toe assessment
61
Focused exam
focus on a specific problem
62
System specific exam
focusing on a specific body system
63
Ongoing exam
performed as needed to assess status, evaluates client outcomes
64
Age modifications for young/middle adults for physical assessment
modify in presence of acute or chronic illness
65
Age modifications for older adults for physical assessment
special positioning if needed, adapt for vision and hearing, assess for change in physical ability and support system, assess for ability for perform ADL's, provide rest periods if needed
66
Acronym SPICES is used for who?
older adults
67
What does SPICES mean?
sleep disorders
problems w/ eating or feeding
incontinence
confusion
evidence of falls
skin breakdown
68
Contusion
bruise
69
Petechiae
small, pinpoint hemorrhages
70
Mottling
usually on a pt who is at EOL, purplish web-like and starts at the toes
71
Hyperhydrosis
excessive sweating
72
LOC
level of consciousness
73
Arterial impairment
not getting blood to the extremities and usually have none/little hair on the extremities
74
Venous issues
a lot of blood to extremities, rough leather like skin
75
Nevi
moles
76
Striae
stretch marks
77
Hirsutism
excessive hair growth
78
Finger clubbing cause
usually respiratory issues
79
ABCDE for moles
asymmetry
boarders
color
diameter
evolving (changes size, shape or color)
80
HEENT
head
eyes
ears
nose
throat
81
Periorbital layer
outer layer of eye
82
PERRLA
pupils
equal
round
reactive to
light
accommodation
83
Anisocoria
unequal pupil size
84
What syndromes make ears unaligned?
fetal alcohol and down syndrome
85
How many lobes are in the right lung?
3
86
How many lobes are in the left lung?
2
87
How many spots are there to auscultate the lungs?
10 on front and 10 on back
88
Varicosities
abnormally enlarged, twisted veins
89
Romberg test
eyes closed and maintain a standing position; balance
90
Order for assessing the abdomen
LL
UL
UR
LR
91
What are the dietary guidelines for the general population?
low fat diet with plenty of fruits and vegetables
92
What are the dietary guidelines for the older population?
low sodium options, choose herbs and spices, focus on fluid selection of water, fat free milk and soup, incorporate healthy oil into the diet and incorporate physical activity into the diet
93
Nutrition
science of food and it's relationship to health
94
Why is water an essential nutrient?
makes up half of total body weight
95
What are the functions of water in the human body?
solvent
transport
body structure and form
temperature
lubricant
catalyst
96
BMR
basal metabolic rate
97
What is a BMR?
measure of energy used while at rest in a neutral environment
98
Potassium rich
peaches, molasses, meats, avocados, milk, shellfish, dates, figs, and potatoes
99
Sodium rich
eggs, celery, spinach, beets, baking soda and baking powder
100
Phosphorus rich
dairy products, beef, pork, sardines, eggs, chicken, wheat bran and chocolate
101
Calcium rich
egg yolks, nuts, sardines, dairy products, broccoli and legumes
102
Body composition
water
protein
fat/lipids
ash (mineral content in bone)
carbohydrates
103
Carbohydrates
primary energy source for the body - sugars
104
Lipids
fats; back up energy source for the body- serve as organ insulation and protection
105
Minerals
elements found in nature (calcium, iron, sodium etc)
106
Proteins
complex molecules made up of amino acids, the structural material of every cell in the body
107
Water
aids in essential body functions
108
Vitamins
needed for metabolism and preventing a deficiency, fat soluble and water soluble
109
Fat soluble vitamins
ADEK
110
Water soluble vitamins
C and B complex
111
Digestion
takes place in the alimentary canal with the help of accessory organs
112
Mechanical digestion
physical breaking down of food into smaller pieces
113
Chemical digestion
occurs through hydrolysis- when water and digestive enzymes are used to break down complex molecules
114
Where does absorption occur?
small intestine
115
What does the large intestine do?
reabsorbs water and forms stool
116
What is considered elimination?
stool
urine
gaseous waste
sweat
117
Steatorrhea
fat in stools (makes stool float)
118
Enteral tube
GI tract
119
Parenteral tube
directly in the bloodstream
120
NG tube placement
nose
121
G tube placement
stomach
122
J tube placement
jejunum
123
What must be done immediately after a NG tube placement?
chest x-ray
124
Hyponatremia
low sodium (135-145)
125
Frail elderly syndrome
weight loss, lessened activity and interaction and increasing frailty
126
What is a sign of dehydration in the elderly?
confusion
127
Osteoporosis
weak and brittle bones
128
Nutritional assessment steps
assessment
analysis/diagnosis
planning/intervention
evaluation and documentation
129
Campylobacter
caused by undercooked poultry
130
Listeria
caused by soft cheeses and deli meats (can grow at refrigerated temp)
131
What does r/t mean?
related to
132
Nursing care plan assessment for nutrition
mini assessment which screens elderly for a detection of malnutrition
133
ADPIE
assessment
diagnosis
planing
implementation
evaluation
134
A in ADPIE
assessment
systemic gathering of information
135
Purpose of assessment
to obtain data to allow you to help the patient by creating a plan of care
136
Objective data
what professionals observe
137
Subjective data
what the patient says
137
D in ADPIE
diagnosis
when critical thinking skills are used to analyze assessment data
138
Before giving a patient a diagnosis what must you do?
verify the problem w/pt
139
Writing a diagnostic statement
PES
140
What does PES stand for?
problem
etiology
s/s
141
Constipation r/t inadequate intake of fluids and fiber rich foods AEB(as evidence by) painful, hard stool, and bowel movement every 3 or 4 days
PES example
142
P of ADPIE?
planning
develop a holistic plan of care (mind, body and spirit) that addresses the patient's unique concerns and health goals
make sure the pt understands when you are explaining to them
143
Maslow's Hierarchy of Human Needs
can be used for prioritizing problems, basic needs must be met before a person can focus on higher needs, most nursing diagnosis fall at the cognitive and lower levels
144
Types of planning
initial
ongoing
discharge
145
Initial planning
begins with first patient contact and is the stat of the initial care plan
146
On-going planning
changes made to the plan as you elevate the patient's responses to care, obtain new data and diagnosis
147
Discharge planning
process of planning for the patient to care for themselves and stay active with their plan of care once leaving the facility
148
SMART goals
specific to client problems
measurable'
attainable
realistic
timely
149
Delegation
The assignment of new or additional responsibilities to a subordinate
