Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence Flashcards Preview

HAP FINAL - CK > Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence > Flashcards

Flashcards in Weeks 3 & 4: Physical Exam, Vitals, Pain, Skin/hair/nails, violence Deck (98)
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1

what is the typical order of physical assessment (except if doing abdominal)

inspect (always first!)
palpation
percussion
auscultation

2

Indirect percussion technique is used to determine

what is happening in the underlying structures – evaluated by auscultating the sounds.

3

where do you expect to hear "resonant" sound

normal lung tissue (clear and hollow sound)

4

hyperresonant

in an abnormal adult lung (but a NORMAL child's lung)

5

tympany

air-filled viscus (stomach, intestine)

6

dull

dense organ (liver, spleen)

7

flat

large muscles (thigh), bone, tumor

8

when does the general survey begin

with the first moment of encounter!

9

Hyper pituitary dwarfism

lack of growth hormones-disproportionate body parts

10

Gigantism

excessive growth hormones in body

11

Cushing's disease

excess of cortisol

12

addison's disease

too little cortisol

13

Marfan syndrome

genetic disorder affects body's connective tissue

14

Syndactyly

the condition of having some or all of the fingers or toes wholly or partly united, either naturally (as in web-footed animals) or as a malformation

15

normal temperature ranges

“NORMAL”
oral temp is 35.8C-37.3 C (96.4F-99.1F)
Rectal temp is 0.5C (1.0F) HIGHER
Axillary temp is 0.5C (1.0F) LOWER

16

pulse

normal pulse of adult is 60-100 bpm (never use thumb!)

17

vital signs

pulse/HR
BP
O2 sat
RR
temp

18

korotkoff sounds

we listen for these when taking blood pressure.
5 sounds (1st sounds we hear is the systolic. Last sound is diastolic)

19

OXYGEN SATURATION

should be >90%. BUT, if pt is diagnosed with COPD, we do NOT want their O2 to be >90%. So, if they are at 87% we do NOT give them O2.

20

what pain scale do we use with demented PTs

PAINAD

21

Neonate responses to pain

global, evidenced by increased heart rate, hypertension, pallor, sweating, and decreased oxygenation saturation.

22

What intervention is most important to prevent nosocomial infections?

hand hygiene!

23

The patient is complaining of abdominal pain. What technique is used to form an overall impression

light palpation

24

Tympany is a percussion sound commonly located in the

abdomen

Percussion sounds are hyperresonant (diseased lungs), resonant (normal lungs), tympanic (abdomen), dull (over organs), and flat (over bone).

25

Which organs or body areas does the nurse auscultate as part of the admitting assessment

Heart, lungs, and abdomen

26

the diaphragm of the stethescope is used for ____ sounds

high frequency sounds (e.g. bowel sounds)

27

the bell of the stethescope is used for _____ sounds

low-frequency sounds (carotid arteries, bruit)

28

When assessing the child, the nurse makes the following adaptation to the usual techniques:

A pediatric stethoscope is used for better contact

29

The general survey includes

overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.

30

The nurse assesses the pulse for

rate, rhythm, amplitude, and elasticity