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Flashcards in unit II Deck (148)
1

When is the healthcare assessment done?

It is a continuous process carried out during all phases of the nursing process

2

What does assessment focus on?

Strengths
Problems
Needs

3

Data base

Collection or store of information

4

Subjective data

Obtained from clients description of the problem

5

Objective data

Detectable by an observer
Can be measured or tested

6

Data collection

Process of gathering information about a clients health status

7

Subjective or Objective??
Itching
Pain
B/P
Anxiety
Wheezing

Subjective
Subjective
Objective
Subjective
Objective

8

What is the purpose of the assessment ?

To enable the nurse to make a judgement or diagnosis about the pt's health state

9

The purpose of assessment is to identify?

-Deviations from normal
-The clients health beliefs & patterns of health and illness
-presence of risk factors for physical &/or behavioral problems
-pt's resources for support & adaptation

10

Name the 5 components of the nursing process?

A Nurse Plans Incase of Emergency

Assessment
Nursing diagnosis
Planning
Implementation
Evaluation

11

Name the types of assessment

Initial
Problem focused
Emergency
Time-lapsed

12

Initial assessment

Performed within a specified time to establish a complete database

13

Problem focused assessment

Ongoing process integrated with nursing care

14

Emergency assessment

Performed during crisis

15

Time lapsed assessment

Several months after initial assessment to compare to baseline

16

Head to tie assessment

A complete health assessment conducted from head & proceeding in a systematic manner to the toes

17

Functional health

Evaluation of mind body and environment

18

What is the purpose of data collection review?

To provide info to identify the pt's needs

19

Primary source of data

Client (pt)
Best source

20

Secondary source of data

Support ppl
Client records
Medical records

21

Interviewing is used to?

Identify problems of mutual concerns, evaluate change, teach, provide support, counseling or therapy

22

The nursing interview is a communication process that has two focuses, they are?

Est. rapport & trust
Gather info on client

23

What are the three phases of the interview ?

Orientation or opening phase
Working or body phase
Closing or termination phase

24

The working or body phase is used to?

Form a database to develop a plan of care

25

What are the components of the nursing health history?

Biographic data
Chief complaint & HPI
Past medical Hx
Family health history
Psychosocial-lifestyles
ADLs

26

The history of present illness is?

A chronological description of the clients chief concern

27

Trendelenburg

Legs elevated

28

Lithotomy

OB exam

29

What is the sequence of the assessment exam?

I-inspect
P-palpate
P-percussion
A-auscultation

30

IPPA is used except in ?

Abdominal assessment
IAPP

31

Inspection

Visual examination

32

Palpation

Using hands to elicit information

33

Percussion

.

34

Tapping body surface to elicit sounds

.

35

Auscultation

The process of listening to sounds produced within the body

36

Skin turger is used for what?

Checking for tenting (dehydration)

37

Pitting checks for?

Edema

38

Assessment of an older adult reveals significant renting of the skin over the forearm, what else besides dehydration could it be?

Loss of adipose tissue and elasticity

39

PERRLA

Pupils
Equal
Round
Reactive to
Light &
Accommodation

40

Normal sign of pupils?

3-5 mm

41

Normal breath sounds are

Are described as soft & breezy

42

Crackles

Bubbling, crackling sounds primarily on inspiration

43

Wheezes

High pitched squeaky
Air moving through narrowed airway

44

Rhonchi

Course gargling
Air passes through narrowed passages upper airway

45

Apex of heart

Bottom of heart

46

Where is the heart located

Lies behind & left of sternum

47

PMI

Point of maximum impulse
5th left intercostal space @ midclavicular line

48

Capillary refill

Less than 3 seconds

49

Where are S1 & S2 located ?

S1- mitral valve (apex)
S2- aorta (right sternal boarder)

50

What are visicular breath sounds?

Normal soft and breezy

51

Best position to listen to heart sounds?

Supine?

52

If we can't hear heart sounds how do we move the pt?

Left side or leaning forward

53

When checking for pulses what do you check for?

Rate
Rhythm
Quality

54

HOMANS sign

DVT, dorsiflex of the foot, is there pain in calf

55

Seizure precautions

Airway, padded side rails, suction

56

Arterial pulses name them & are found where?

Radial
Carotid
Brachial
Pedal
Femoral

57

S 1

Closing of mitral valve & tricuspid valve

58

S 2

Closing of aortic & pulmonic valves
Marks beginning of diastole

59

Bruit

Sign of arterial narrowing
Listen for a blowing or rushing sound

60

When you check for JVD, the pt is positioned how?

Laying at a 45 degree angle

61

Bowel sounds are heard every?

5-15 seconds

62

Borborygmus

Loud intestinal rumbling

63

Dysuria

Painful urination

64

Validating data

Double checking data

65

SLIDE

Single line thru error
Initials
Date
Error (write out)

66


Pack year

# cigarettes x # years smoking =

67

Cage (alcohol) questionnaire

C- ever tried to cut down
A- ever annoyed by criticism
G- ever felt guilty
E- ever have Eye Opener

68

What is the purpose of the physical exam?

Gather baseline data about health

69

Pitting

Sign of edema
+1 2mm
+2 4mm
+3 6mm
+4 8mm

70

Chest landmarks

C. Chest wall symmetry
R. Resp. Rate rhythm depth
A. Accessory muscles
M. Masses or scars
P. paradoxical movement

71

Assessing

Process of collecting organizing and recording data

72

Cephalocaudal

Proceeding in the direction from head to toe

73

Closed question

Restrictive question, only a short answer

74

Covert data

Data apparent only to the person affected

75

Cues

Any piece of info that influences decisions

76

Data

Information

77

Directive interview

Highly structured interview that uses closed questions to elicit specific information

78

Inferences

Interpretations or conclusions made based on cues or observed data

79

Interview

A planned communication
A conversation with a purpose

80

Leading question

A question that influences the client to give a particular answer

81

Neutral question

A question that does not direct or pressure a client to answer in a certain way

82

Non directive interview

An interview using open ended questions and empathetic responses to build rapport and learn client concerns

83

Objective data

Data that is detectable by an observer or can be tested
Can be seen heard felt or smelled

84

Open ended question

Questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic

85

Rapport

A relationship between two or more people of mutual trust and understanding

86

Review of systems (screening examination)

A brief review of essential functioning of various body parts or systems

87

Subjective data

Data that are apparent only to the person affected

88

Validation

The determination that the diagnosis accurately reflects the problem of the client

89

Name the 5 vital signs

B/p
Pulse
Respirations
Temperature
Pain
Pulse ox

90

Why take viral signs

Identify acute medical problems
Reflect changes in the body

91

When do you take vital signs

Baseline
Surgery
Medication
Treatment/therapy
As ordered

92

Blood pressure

Measure of pressure exerted by the blood as it flows through arteries

93

Systolic pressure

Pressure of blood exerted on the arteries when ventricles contract

94

Diastolic pressure

Pressure exerted in the arteries when the ventricles are at rest

95

Normal B/P for adult

120/80

96

Pulse pressure

Difference between systolic and diastolic pressures
Normal is 30-50mmHg

97

T/F
BP is a product of cardiac output and systemic vascular resistance

True

98

Stroke volume

Amy of blood ejected from the heart with each contraction

99

Heart rate

# beats per minute

100

Peripheral/systemic vascular resistance

Resistance of blood flow due to blood vessel size

101

Arteriosclerosis

Elastic & muscular tissue of arteries are replaced with fibrous tissue

102

What causes arteriosclerosis ?

Increased B/P

103

Viscosity

Thickness of blood

104

Doppler BP

Obtains only SBP
Infants, obese, shock

105

Bladder of BP cuff must go around at least

80% of upper arm

106

When is a direct/invasive BP method used

Crital care pt's
Unstable

107

When taking a BP what do you listen for?

Korotkoff sounds

108

Ortho static BP

BP falls after sudden change in position

109

C=

(F-32)x5/9

110

F=

(Cx9/5)+32

111

Normal temperature
orally

98.6

112

Body continually produces hear due to

Metabolism

113

Basal metabolic rate

Rate of energy used to maintain body's essential activities

114

Stress / sympathetic nervous sustem

Fight or flight

115

Your body looses heat through

Radiation, respiration
Conduction, contact
Convection, air
Evaporation, sweat

116

3 main regulators of the body are

Sensors in core
Hypothalamus
Effector system

117

3 physiological processes incense body temperature are

Sweating
Shivering

118

Hypothalamus

Controls core temperature

119

Name the five types of fever

Intermittent-rises above normal
Remittent-wide range of temp
Relapsing-
Constant
Fever spike-rises rapidly then decreases to normal quickly

120

Causes of elevated temperatures

Head injury
Environmental
Pathogens

121

Hypothermia

Core body temp below 95f-35c

122

Induced hypothermia

Deliberate lowering of body temperature

123

Common sites to take temperatures

Oral
Rectal
Auxillary
Tympanic
Temporal

124

Rectal thermometer

99.6F normal
Insert 1.5 inches
PT lies on left side

125

Axillary temperature

97.6 F normal
Non invasive

126

Stroke volume

Amt of blood that enters arteries with each contraction

127

Cardiac out put

Volume blood pumped into body's arteries by the heart every minute

128

Cardiac Output =

Stroke volume X heart rate

129

Hypovelimia

Loss of blood

130

Apical pulse is found?

Left side 5 th intercostal at the midclavicular line

131

Tachycardia

Heart rate over 100

132

Bradycardia

Heart rate less than 60

133

Newborn heart rate

80-180

134

Children 1-10

70-120

135

Pulse deficit

Discrepancy between apical pulse and radial pulse

136

Normal respiratory rate

12-20 per minute

137

Apnea

Absence of breathing

138

Crackes

Fluid in lungs

139

Wheezes

Spasm of airway

140

Diminished

Swelling in airway

141

Rhonchi

Mucus in airway

142

Orthopnea

Only breath sitting upright

143

Kussmaul

Consistent increase of rate and depth

144

Biots

Shallow breathing followed by apnea

145

Dyspnea

Difficulty breathing

146

Normal pulse ox

95-100%

147

Temperature regulation comes from

Hypothalamus & pons

148

Name the 4 major assessment activities

Collection
Organization
Validation
Documentation