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Flashcards in Phys Assessment Deck (290):
1

What does subjective mean?

What someone tells you (history)

2

What does objective mean?

measurment/reading (phys exam)

3

What are the 2 components of clinical reasoning?

Diagnostic & Critical Thinking

4

What is the diagnostics composed of

cues, info, signs, symptoms, lab data

5

what is the difference between a sign and symptom

sign= you can see it, symptoms= experiences

6

What are the 6 nursing processes

ADOPIE= Assess, diagnostic, outcome, planning, implementation, evaluation

7

Medicine Treats...

disease

8

Nursing...

how patient reacts

9

Diagnosis

Valid influences, compare "clusters", identify related factors

10

Outcome

realistic, something that can be measured, TIME FRAME, unique to PT

11

Planning

establish priorities, refer back to outcomes, plan of care, interventions

12

Implementation

readiness, review interventions, collaborate team members, counseling, refer continuing care

13

Evaluation

meet or did not meet final outcome

14

What are the first priorties that are essential?

ABCs= Airway, breathing, circulation (brain)

15

What are some components of Critical Thinking

identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate

16

4 Types of Data

1) Complete Health Data 2) Episodic/Problem Centered/Focus data 3) Follow-up data 4) Emergency data base (ABCs)

17

Expanding Concepts of Health...x5

1) Biomedical Model 2) Holistic Health (whole body, culture) 3) Health promotion/prevention 4) culture 5) genetics

18

High level assessmen

holism, life cycle, culture must not detract from importance, hands on expertise

19

Interview means

factors that may affect communication

20

3 Phases of Interview

1) Process of Communication 2) Internal 3) External Factors

21

Process of Communication means.

sending/receiving internal/external facotrs

22

Internal Factors composed of...

empathy, ability to LISTEN

23

External Factors composed of

privacy, refuse interruptions, phys envt, dress, note taking, recording, electronic health record

24

Techniques of Communication

open vs closed ended questions (case by case), nonverbal skills, eye contact, voice, touch, dress

25

What do adolescents prefer being around?

peer groups

26

What are you viewing in infants?

nonverbals

27

At what ages are parents involved in the interviewing?

Infant-school age

28

What should you watch for in communication with older people

slang words

29

What are some special need situations

acute illness, under the influence, anxious, crying, sexually aggressive, hearing impaired

30

What type of questions should you ask for special need situations

closed questions

31

What is the first thing you should do in cross cultural situations

identify your own biases

32

What does cross cultural communication entail?

etiquette, space & distance, cultural considerations on gender, sexual orientation

33

What are ways we overcome communication barriers

interpreters, vocal cues, action cues, object cues, space/touch

34

Are mental status assessments objective or subjective

always subjective

35

What does etiology mean

cause

36

What are 2 types of measuring mental disorders

organic & psychiatric

37

What is an example of an organic mental disorder

alzheimers, dementia, bc they are known causes

38

Alert & Oriented x 4 (behavior orientation)

1) person 2) place 3) time 4)situation (what brought you here)

39

What is recent memory?

short term

40

What is remote memory

long term

41

What does perception mean?

awareness of 5 senses

42

What are 4 components of mental health assessment

1) appearance 2) behavior 3) cognition 4) thought processes

43

What does aphasia mean

language impairment

44

QPR stands for

question, persuade, refer

45

Broca refers to

physical incapability to speak

46

Wernicke

not being able to speak correctly

47

presbycusis means

age related hearing loss

48

Define health

balance of person with one's physical, mental, and environment

49

Illness

loss of balance with physical, mental and environment

50

What is ethnicity

a group having similar traits: common language, common heritage and cultural similarities

51

Race

relates more towards the appearance of a person. Biologically with inherited genetic traits.

52

Nationality

place where the person was born

53

Heritage

ancestors of a person

54

Culture

more of a microcosm; one trait or characteristic

55

What is a database?

Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed

56

What is a nursing "diagnosis"

actual/potential health problems or of wellness strengths

57

Frequencies of visits...

varies depending on person's illness and wellness needs

58

define cultural diversity

transcultural phenomenon. At least 2 people having diff cultural orientations

59

what does evidence based mean?

combining clinical expertise with the use of nursing research, while considered values of the PT

60

What is clustered data

patterns and relationships among the data

61

A good rule of an interviewer is to..

spend more time listening than talking

62

When a patient denies something but acts in the opposite

bring verbal and nonverbal behavior to PT attention

63

When should touch be used

if interviewer knows pt well

64

at what age should interviewer question child him/herself

age 7

65

What interviewing techniques should be avoided for an adolescent

silence and reflection

66

What is the proper distance for personal space

1.5-4 ft

67

Religion is defined as

belief in a divine or superhuman spirit to be obeyed or worshiped

68

Why is there a need for cultural care

demographic change

69

The imbalance of hot and cold is considered "illness" among...

Hispanic-American heritage

70

What is an amulet

the evil eye

71

What does empacho mean?

a culture-bound syndrome that ha no equivalent from a biomedical perspective

72

What does "review of systems" mean?

the evaluation of the past and present health state of each body system

73

What does PQRSTU Stand for

1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding

74

What 2 section of child's health history become important to current health status

developmental and nutritional history

75

What is one way to detect dementia

mini-cog

76

A Major characteristic of dementia is

impairment of short & long term memory

77

Dysarthria

difficult or unclear articulation of speech that is otherwise linguistically normal.

78

What is echolalia

meaningless repetition of another person's spoken words as a symptom of psychiatric disorder.

79

The part of the hand used for assessment of vibration are

ulnar surface of the hand

80

Performing indirect percussion, the stationary finger is struck where..?

at the middle joint

81

How would you describe the pitch of a sound wave obtained by a percussion

number of vibrations per second

82

The bell of the stethoscope is used for..

soft, low pitched sounds

83

Which aperture is used for a patient with undilated pupils

small

84

If an infant is asleep, where can you start with the examination

heart, lung, and abdomen

85

When does examination of a child change to head to toe

school age

86

When inspecting ear canal, which speculum is used for the otoscope

the largest that will fit

87

During gen survey what are the 4 areas of interest

1)Appearance 2)Body structure 3)Mobility 4)Behavior

88

What is gait

a person's manner of walking

89

Measuring gait, the base is usually...

as wide as the shoulder width

90

What changes in head circumference measurements in relation to the chest will occur from infancy to early childhood

head will be 2 cm larger than the chest circumference. Between 6 months & 2 years they will be the same.

91

From 80 - 90 what happens to height and weight

both decrease

92

To accurately assess patients pulse what is the range?

start with zero to 30

93

A normal pulse for a patient is..

2+

94

How do you accurately assess a patient's respiration?

count for 20 seconds

95

What is pulse pressure

the difference between systolic and diastolic pressure

96

What is coarctation?

narrowing of the aorta

97

If PT has coarctation the thigh pressure would be..

lower than in the arm

98

What is the mean arterial pressure

diastolic pressure plus one third pulse pressure

99

Why is sizing of a bp cuff important

too narrow will give false reading that is HIGH

100

Diastolic

when the heart refills with blood

101

systolic

when heart is contracting

102

what is nociception

pain receptors

103

neuropathic pain

burning painful sensation that moves around toes and bottoms of feet.

104

Diaphoretic means

inducing perspirations

105

visceral pain

sweating, pale, pain in abdomen

106

What is a pre-term baby more sensitive too

painful stimuli

107

What is the wong baker scale

visual facial expressions to define pain scale (ex broken arm)

108

analgesics

pain reliever

109

Complex Regional Pain I

chronic pain that usually affects an arm or a leg.

110

This is a pain problem expected with impaired older adult

peripheral vascular disease

111

What is a common physiologic change that occurs with pain

tachycardia

112

Assessing Pain Mnemonic

P- OLDCARTS

113

P-OLDCARTS

previous hx, onset, location, duration, character, aggravating, radiation, timing, severity

114

What are the 4 steps in a regular physical exam

1) inspection 2)Palpation 3)Percussion 4)Auscultation

115

What are the steps when examing the abdomen

1) Inspection 2)Auscultation 3) Palpation 4) Percussion

116

Gen Survey Application

1)Appearance 2)Body Structure (lordosis/kyphosis) 3)Gait (how they walk) 4)Behavior 5)Weight

117

What is the diurnal cycle

difference in temp in the morning vs afternoon (cooler in the morn)

118

Ways to take temp

oral, electronic, axillary, rectal, tympanic membrane, temporal

119

What is normal temperature in the mouth

98.6F or 37C

120

What is normal temp in axillary

97.6F or 38.4C

121

What is normal temp in rectum

99.6F or 37.6C

122

What is normal temp in tympanic membrane?

98.6F

123

What is the conversion Celsius to Fahrenheit

C= 5/9 (f-32)

124

What is the conversion for Fahrenheit to Celsius

(9/5 x C) +32

125

What is the formula for Cardiac Output

CO= SV x HR

126

What is a normal amount of blood that gets pumped every heart beat?

2 ox or 70 mm

127

Where do you place the stethoscope to listen to heart sounds

4-5 Intercostal

128

What is normal for adults heart rate

50-100 beats/min (100+ is tachy)

129

What i normal for infant heart rate

80-160

130

What numeric is used for Force?

0-3+

131

What is normal force

2+

132

What is bounding or after a run

4+

133

What is force is considered "weak"

1+

134

What is respiration?

amount someone breaths in 1 iminute

135

What is the ratio for pulse

4: 1

136

When you see the ration for BP

Systolic is the higher # (top) Diastolic is lower #

137

If the diastolic is high on the bottom is that concerning

yes

138

Pulse Pressure =

Systolic - Diastolic

139

Mean Arterial pressure

force that pushes blood into the tissues

140

To hear Kortkoff sounds and you cant use the arm, what should you do?

use thigh

141

What does the pulse oximeter do?

measure how much hemoglobin carries oxygen (95% or higher)

142

What does a doppler do?

picks up changes in sound frequency as blood flows

143

What is the best indicator of Pain

what they tell you

144

What condition is hard to treat in terms of pain

Neuropathic pain, abnormal procession of pains messages

145

Visceral means

organs

146

Cutaneous means

skin

147

What are signs of acute pain behavior

guarding, grimacing, moaning, restless, stillnes diaphoresis, vital signs change

148

What type of palpation do you use for mobility and turgor?

 

Tenting

149

When is mobility decreased

with edema

150

When does tenting or turgor occur

 

severe dehydration or weight loss

151

What does striae mean?

 

stretch marks

152

What does sterile mean?

 

  • no life
  • using special gases
  • high heat

153

For surgical apses how long do you wash your hands?

 

3 minutes

154

When is surgical apses necessary?

 

  • intentional perforation of the skin
  • body cavity, not exposed to outside

155

What are the golden rules of surgical apses

 

  • an object below the waist is contaminated, because it is out of range of vision
  • never turn your back on a sterile field
  • keep trashcan close by, or drop on ground
  • Both patient and provider wear mask
  • If you break sterile technique- START OVER
  • 1" border

156

What makes a surface/ area contaminated

 

  • prolonged exposure to air
  • wet surfaces
  • 1" border is contaminated

157

Are wrappers of sterile objects sterile?

 

NO

158

Define a sterile field

 

room/space for handling sterile objects

159

Name 5 types where patient needs surgical asepsis technique

  1. Open Body Cavity
  2. Catheter
  3. Burns
  4. Central Line

160

Clean technique

 

  • removes majority of microorganisms, not everything
  • no autoclaving

161

What is lipping

 

  • if you are using a solution more than once
    • pour some out before use

162

When do you use sterile gloves for surgical asepsis?

 

once you've added everything to the sterile field

163

What are the 4 things we asses for skin, hair , nails

 

  1. Structure/Function
  2. Subjective
  3. Objective
  4. Abnormal findings

164

What is the largest organ and our bodies' first line of defense?

 

the skin

165

  • horny layer- shedding
  • basal layer on the bottom

166

What is apocrine

 

  • sweat glands during puberty
  • smells bad

167

What are eccrine glands

 

  • major sweat glands in all humans. Most dense in palms and soles
  • appears as dilute saline solution

168

What are 4 major functions of the skin?

  1. keep fluid in/protect
  2. nonverbal communication
  3. wound repair
  4. vitamin D absorption

169

In infants/children when does hair follicles start developing

 

3 months

170

What is common in skin of pregnant women

 

  • stria grandorum
  • increase pigment

171

What is xerosis

 

dry skin, mostly in older adults

172

What happens to older adults nails?

 

thicken- due to fungus

173

pruritus means?

 

itching

174

Culture and genetics and skin

 

body odors vary by race

175

Jaundice means

 

yellow

176

Cyanosis means

 

blue

177

What causes poor circulation in older adults

 

diabetes

peripheral vascular disease

178

What are examples of subjective data for skin hair nails

 

  • mole inspection/palpation
  • rash/lesions
  • birth marks
  • hair loss
  • env't hazards
  • self-care, wear sunscreen?
  • bruising
  • itching

179

Objective Data examples for skin hair nails

 

  • skin color
  • use pen light
  • ruler

180

Pallor means

 

pail

181

What part of your hand do you use to palpate for temperature

dorsa (back)

182

What are 6 maor things you want to palpate for in skin hair nails

 

  1. Temperature
  2. texture- use finger tips
  3. moisture
  4. diaphoresis (sweating)
  5. thickness
  6. Edema

183

How is edema measured?

 

  • 4 point scale
  • 1+ = 2mm
  • 2+ = 4mm......

 

184

What is pitting edema?

 

  • think memory foam, leaves a thumb print

185

What is non pitting edema

 

The lack of indentation when fingertip pressure is applied to the skin, which classically occurs in hypothyroidism

186

What does vascularity mean?

 

bruising

187

3 Common types of birthmarks

 

  1. freckles
  2. junctional nevus
  3. compound nevus

188

junctional nevus

189

Compound Nevus

190

What are the abnormal signs for pigmented lesions

 

ABCDE

191

ABCDE stands for

  • Asymmetry
  • Border
  • Color variation
  • Diameter grater than 6mm
  • Elevation or Enlargement

192

Hypothermia

 

  • high fever
  • localized coolness

193

Hyperthermia

 

  • fever
  • area feels warn
  • trauma
  • infection/sunburn

194

Uremia

 

renal failure

195

Brown-tan coloration

 

example Addisons disease- increase melanin production

196

  • Annular Lesion
  • circular (ringworm)

197

  • Confluent Lesion
  • ex hives//uriticaria

198

  • Discrete lesion
  • Skin tags//acne

199

Gyrate Lesion

200

grouped lesions

201

linear lesion

202

Target Lesion

203

  • zosteriform
  • linear around unilateral nerve
  • ex: herpes

204

  • Polycyclic
  • i.e. psoriasis
  • anular lesions grow together

205

What are primary skin lesions x6

 

  • Macular/Patch
  • Papule/Plaque
  • Nodule/Tumor
  • Vesicle/bulla
  • Cyst
  • Postule

206

  • Macule
    • Patch larger than 1 cm
  • flat not raised

207

  • Papule
    • Plaque larger than 1 cm
  • can feel, slightly elevated
  • mole wart

208

  • Nodule
    • tumor larger than 3 cm

209

  • Wheal
    • Urticaria-hives
  • raised irregular shape due to edema
  • mosquito bites, allergies

210

  • Vesicle
    • Bulla- larger than 1cm
  • a blister, herpes chicken pox, shingles

211

  • Cyst
  • encapsulated fluid filled cavity
  • subcutaneous layer.

212

  • Pustule
  • pus filled cavity

213

What are some secondary Skin lesions?

  • Crust
  • Scale
  • fissure
  • erosion
  • ulcer
  • Excoriation
  • scar
  • atrophic scar
  • lichenfication
  • Keloid

214

  • Crust
  • dried out when blisters burst

215

  • Scale
  • compact flakes of skin

216

  • Fissure
  • ex cracks at corner of mouth

217

  • Erosion
  • shallow depression
  • moist but no bleeding

218

  • Ulcer
  • irregular shape, may bleed
  • leaves scar

219

  • Scar
  • replaced with connective tissue (collagen)

220

  • Atrophic Scar
  • thinning of the epidermis
  • decreased visibility of normal skin markings
  • shiny

221

  • Lichenification
    • when someone scratches an area excessively

222

  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue

223

  • Pressure Ulcer Stage I
  • red but ubroken
  • will not blanch

224

  • Stage 2 Ulcer
  • loss of epidermis
  • like open blister

225

  • Stage 3 ulcer
  • extending into subcutaneous tissue
  • resembling a crater

226

  • Stage IV Ulcer
  • breaks through all skin layers
  • visible bone or tendons

227

What are some vascular lesions

 

  • petechiae
  • purpura
  • hematoma
  • contusion

228

What is petechiae/purpura

 

  • small purple color

229

What is hematoma

 

  • a bruise you can feel

230

What is a contusion

 

another word for bruise

231

What are the phase/coloration of bruises

 

  1. red
  2. blue-purple
  3. blue-green
  4. yellow
  5. brown-vanishing

232

what is a "pattern" injury

 

  • a bruise or wound whose shape suggests instrument or weapon that caused it
    • belt buckle, broomstick, burning cig, pinch, bite, scalding hot liquid

233

nevus is the medical term for...

 

mole

234

where should you assess for early jaundice?

  • sclera and hard palate

235

Normal angle between the nail base and the nail is...

 

160 degrees

236

How long should it take the capillary beds to refil?

 

1-2 seconds

237

What does flat brown macules on the hands mean?

Sun exposure, do not require treatment

238

Flattening of the angle between the nail and its base...

 

clubbing

239

Lyme disease is more prevalent during

 

May thru September

240

What causes milia?

 

sebum occludes skin follicles

241

Epidermis layer

  • basal layer,
  • thin,
  • stratum corneum

242

Dermis Layer

 

  • collagen
  • elastic tissue

243

Subcutaneous layer

  • adipose tissue

244

This is when lower half of the body turns red, upper half blanches..

 

Harlequin

245

This term is used when you notice mottling on trunk and extremities

 

Cutis Marmorata

246

large round or oval patch of light brown usually present at birth

 

cafe au lait

247

When irrigating a wound, how would the nurse know the right amount of pressure to apply?

 

between 5 and 15psi

248

Which device is used for wound irrigation?

 

19 gauge needle attached to 35 mL syringe

249

Elsevier:

 

What is the nursing action to set up suction for a hemovac drainage system?

 

the nurse should compress it firmly and replace the plug.

250

Elsevier:

 

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?

Culture & sensitivity

251

Elsevier:

 

What's wrong with using a microwave for irrigating a wound?

can create hotspots

252

Elsevier:

 

What is the proper method for cleansing the evacuation port of a wound drainage system?

 

Wipe it with an alcohol sponge.

253

Braden Scale

Risk for skin breakdown/Pressure ulcer

254

ABD

Abdominal

255

What disease is a neurotic disorder?

MS, associating with neuro pain

256

What is the goal of wound care?

 

  • to heal the wound
  • prevent infection

257

What type of patient is at highest risk for suicide?

 

one that devises a plan

258

This is when a wound ruptures along a surgical suture

 

dehiscence

259

What is the primary intention for wound healing?

 

  • tissue surfaces have been approximated
  • low tissue loss
  • remove dressings after drainage

260

What are 4 ways for debriefing a wound?

 

  1. Mechanical
  2. Chemical
  3. Auto
  4. Surgical

261

What is autolytic debriefing?

 

takes advantage of the body's own ability to dissolve dead tissue

262

What is secondary intention for wound healing?

 

  • considerable tissue loss
  • edges cannot be drawn together
  • longer to heal
  • scarring is greater
  • infection risk
    • Pressure ulcers
  • continue dressings for moisture
  • assist debridement

263

What is tertiary intention for wound healing?

 

  • "delayed"
  • require more connective tissue than wounds that heal by secondary intention
    • abdominal wound that is initially left open to allow for drainage but is later closed.

264

What are the phases for a full thickness wound repair?

  1. Hemostasis (fibrin)
  2. Inflammatory phase
  3. Proliferative phase- epithelial
  4. Remodeling- can take years

265

What are some complications for wound healing?

  • hemorrage
  • infection
  • dehiscence
  • avisceration
  • fistula

266

What organ is 15% of our total body weight

Skin

267

Black or brown tissue that must be removed

 

necrotic

268

Yellow tissue in a wound that must be removed

slough

269

 What is evisceration?

 

A surgical wound that opens up (dihiscence) but is a medical emergency

270

What are symptoms of wound Infections?

 

  • puss
  • odor
  • wolume
  • redness
  • fever
  • pain

271

What could be the psychosocial component of wound healing?

  • body image
  • scars
  • odors
  • drains
  • temp prostetic

272

What is a penrose drain?

soft rubber tube placed in a wound area, to prevent the build up of fluid.

273

What is a Hydrocolloid dressing?

  • gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer.
  • protects from surface contaminants

274

What is hydrogel dressing

  • provides moisture to a dry wound
  • dry or dehydrated wounds

  • partial or full-thickness lesions

  • abrasions or severe scrapes

  • minor burns

  • wounds with granulated tissue development

  • radiation skin damage

275

What is a transparent film dressing used for?

  • to protect skin in pressure spots. 
  • cover wounds with little or no drainage

276

What are montgomery ties?

  • used for frequent dressing changes w/o having to remove and reapply tape.
  • Breathable, strong, and comfortable
  • help prevent skin trauma associated with frequent taping.

277

How many grams of protein can a patient lose per day with an open wound?

50 grams

278

Heat Therapy risks

  • vaso-constriction
  • damage epithelial cells
  • blistering
  • no longer than 1 hour

279

Cold Therapy Risks

  • vaso dialation
  • risk is tissue ischemia (frost bite)

280

What happens with negative pressure wound thearpy

  • granulation lines the surface
  • removes fluid and exudates to prevent infection

281

What is required in the delivery of culturally congruent care?

  • knowledge
  • skills
  • attitudes

282

What is an example of a nurse stereotyping a patient?

do you bathe and use deodorant more than one time a week?

283

homelessness is an example of caring for a patient from a different..

culture

284

What are appropriate questions to ask a native american?

  1. do you use folk remedies
  2. do you have a family physician
  3. do you use a shaman

285

What is an example of data validation

  • comparing values with previous values
  • report to charge nurse

286

What are the steps for a nursing diagnosis?

  1. review assessment data
  2. cluster
  3. diagnostic label
  4. contet of pt's health probl and select related factor

287

What could be indicated when a reddened area blances on fingertip touch?

blanching hyperemia. Body overcoming ischemic episode

288

To determine wound infection, where should the specimen be taken?

wound, after it has been cleaned with normal saline

289

After surgery a patient coughs and opens up a wound. What is the nurse's first intervention?

cover with saline-soaked towels and notify surgical team.

Evisceration

290

When do you use a warm compress?

 

  • to relieve edema
  • improve blood flow