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Flashcards in Unit 2 Deck (32):
1

Cephalocaudal

from head to toe

2

Directive interview

highly structured
closed questions elicit specific information

3

Subjective Data

- Obtained from client (primary source)
- recorded in "OWN WORDS"
- verified only by client
- symptoms/ covert data

4

Objective Data

- detected by an observer
- measured/ tested against acceptable standards
- signs/ overt data

5

Components of the Nursing Health History

Being Complete Makes For Proper Assessment
- Biographic Data
- Chief Complaint & HPI (hx of present illness)
- PMH
- Family Health Hx
- Pscyhosocial- Lifestyle & Health Practice Profile
- Assessment - ADL's

6

Discoloration of the skin (subject or objective)

objective

7

Four Types Of Assessment

1. Initial
2. Problem-Focused
3. Emergency
4. Time-lapsed Reassessment

8

Time-lapsed Reassessment

- several months after initial assessment
-compare to baseline data previously obtained

9

Inspection

- visual examination; also uses senses (hearing & smell)
- deliberate, purposeful, systematic

10

Pallor

- result inadequate circulating blood/ hemoglobin & subsequent reduction in tissue oxygenation

11

Database

subject and objective data that provides baseline for comparing clients responses to medical/ nursing interventions

12

Initial Assessment

performed within a specific time after admission

13

Percussion

- tapping/ striking body surface to --> sound/ vibrations
- reveals location, size, and density of underlying structures (air/ fluid - filled, solid)

14

Direct Percussion

directly on skin

15

Indirect Percussion

non-dominate hand between subject and striking

16

Blunt

Ulnar surface of fist against skin surface

17

Tympany

- gas/ bowels (air-filled stomach)
- musical
- high-pitched, drum-like
- least dense tissues

18

Dullness

– thudlike; organs→ liver, heart, spleen

19

Hyper-resonance

- booming → emphysematous lung
- not anticipated

20

Resonance

– hallow; lungs filled with air

21

Stethoscope

- Diaphragm - S1/S2; high pitched
- Bell - S3/S4; Bruits, mummurs, low pitched

22

PERRLA

Pupils
Equal
Round
Respond to Light
Accommodation

23

Normal Pupil Size

3-5mm

24

Normal Breath Sounds

- heard over Entire Lung
- inspiratory and expiration
- PRIMARY source is turbulent flow of air in larger airways

25

Tracheal

- pause between I & E
- tubular quality

26

Bronchial

- 1:2 ratio
- anteriorly over trachea
- Short Inspiratory, Loud Expiratory

27

Bronchovesicular

- 1:1 ration
- Between scapulae posterior 1&2 ICS Anteriorly

28

5-P's

Pain, Pulse, Pallor, Paresthesia, Paralysis

29

5th Vital Sign (Pain Assessment)

P,Q,R,S,T
- Provocative
- Quality/ Quantity
- Region/ Radiation
- Severity
- Timing

30

Celsius

(F-32)*(5/9)

31

F=

(C*9/5)+32

32

Normal SaO2

95-100