unit II Flashcards
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1
Q
When is the healthcare assessment done?
A
It is a continuous process carried out during all phases of the nursing process
2
Q
What does assessment focus on?
A
Strengths
Problems
Needs
3
Q
Data base
A
Collection or store of information
4
Q
Subjective data
A
Obtained from clients description of the problem
5
Q
Objective data
A
Detectable by an observer
Can be measured or tested
6
Q
Data collection
A
Process of gathering information about a clients health status
7
Q
Subjective or Objective?? Itching Pain B/P Anxiety Wheezing
A
Subjective Subjective Objective Subjective Objective
8
Q
What is the purpose of the assessment ?
A
To enable the nurse to make a judgement or diagnosis about the pt’s health state
9
Q
The purpose of assessment is to identify?
A
- 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
Q
Name the 5 components of the nursing process?
A
A Nurse Plans Incase of Emergency
Assessment Nursing diagnosis Planning Implementation Evaluation
11
Q
Name the types of assessment
A
Initial
Problem focused
Emergency
Time-lapsed
12
Q
Initial assessment
A
Performed within a specified time to establish a complete database
13
Q
Problem focused assessment
A
Ongoing process integrated with nursing care
14
Q
Emergency assessment
A
Performed during crisis
15
Q
Time lapsed assessment
A
Several months after initial assessment to compare to baseline
16
Q
Head to tie assessment
A
A complete health assessment conducted from head & proceeding in a systematic manner to the toes
17
Q
Functional health
A
Evaluation of mind body and environment
18
Q
What is the purpose of data collection review?
A
To provide info to identify the pt’s needs
19
Q
Primary source of data
A
Client (pt)
Best source
20
Q
Secondary source of data
A
Support ppl
Client records
Medical records
21
Q
Interviewing is used to?
A
Identify problems of mutual concerns, evaluate change, teach, provide support, counseling or therapy
22
Q
The nursing interview is a communication process that has two focuses, they are?
A
Est. rapport & trust
Gather info on client
23
Q
What are the three phases of the interview ?
A
Orientation or opening phase
Working or body phase
Closing or termination phase
24
Q
The working or body phase is used to?
A
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
