222 Exam 1 Flash Cards

Front 1

What order do you perform your skills in?

Back 1

1.inspection

2. palpation

3. Percussion

4. Auscultation

Front 2

What does palpation assess?

Back 2

Texture

Temp

Moisture

Organ location and size

Swelling,vibration, or pulsation

Rigidity or spasticity

Crepitation

Presence of lumps or masses

Presence of tenderness or pain

Front 3

What are your fingers best for assessing during palpation?

Back 3

Fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps

Front 4

what are the fingers and thumb good to assess during palpation?

Back 4

detection of postion, shape and consistency of an organ or mass

Front 5

What is the Dorsa of hands and fingers good to assess durning palpation?

Back 5

best for determining temp because skin ere is tinner than on palms

Front 6

What is the base of finges or ulnnar surface of hand good for assessing during palpation?

Back 6

vibrations

Front 7

Palpation Sequence

Back 7

start wiht light palpation to detect surface characteristics and and accustion person t being touched. then perform deeper palpation when needed.

Front 8

Bimanual palpation

Back 8

requires both hands to palpate certain ogans or body parts that needed to enveloped to examine

Front 9

Percussion

Back 9

short sharp strokes to assess underlying structures when examining a patient

Front 10

Uses of Percussion

Back 10

mapping locatio and size of organs

signaling density of a structure by a characteristic note

detecting a superficia abnormal mass

eliciting pain if underlying structure is inflamed

eliciting deep tendo reflex using percussion hammer

Front 11

What is the single most importand step to decrease microorganism transmission?

Back 11

Washing your hands

Front 12

When do you wash your hands?

Back 12

Before and after physical contact with each patient

after inadvertent contact with blood, body fluids, secretions, and excertions

after contact with any equipment contaminated with body fluids

after removing gloves

Front 13

When do you wear gloves?

Back 13

when potentail exists for contact with any body fluids

Front 14

When examining a person with shortness of breath or ear pain how do you position them when examining them?

Back 14

sit up

Front 15

When examining a person who is faint or overwhelming fatigue how do you position them?

Back 15

supine

Front 16

When do you start your general survey?

Back 16

the moment they walk in

Front 17

Auscultation

Back 17

Listening to sounds produced by body

Front 18

What can influence your temp?

Back 18

Diurnal cycle (time of day)

Menstruatio cycle

Excercise

age

Front 19

Oral temp

Back 19

-accurate and convient

- quick response to changes in interal temp

- Norm 37c or 98.6f

Front 20

Rectal temp

Back 20

- Norm 37.4c-36.5c

Front 21

How long do you wait to take a person's tem if the have drank someting? Smoked?

Back 21

15 min. ; 2 min

Front 22

Whats the best way to take an infant or young childs temp?

Back 22

Axillary (across the head)

Front 23

Heart stroke volume?

Back 23

Strenght of heart's stroke volume

Front 24

3 point scale used to record pulse force

Back 24

3- full,boundin

2- Normal

1- weak

Front 25

what is the average BP?

Back 25

120/80

Front 26

What factors vary your BP?

Back 26

Age

gender

race

Front 27

why are older adults shorter in there 80's and 90's than they were in there 70's?

Back 27

spinal column shortens, vertebrae shorten, kyphosis (posture changes)

Front 28

Temp. in Aging Adults

Back 28

less likely to have a fever

greater risk for hypothermia

not a reliable indicator of overall health

no sweat glands

Front 29

Whats adnormal about African Americans BP?

Back 29

Higher

the chance of being hypertensive is twice as high

Front 30

pulse in aging adults

Back 30

normal 60 to 100

could be slightlly irregular

radial may be stiff ridgid and tortuous

Front 31

Adnormal findings in hieght and proportion

Back 31

hypopituitary dwarfism

gigantism

Acromegaly

Achondroplastic dwarfism

anorexia nervosa

marfan syndrome

endogenous obesity (crushing syndrome)

Front 32

Adnormal blood pressure

Back 32

hypotension( low bp)

hypertension (high bp)

Front 33

Internal factors of communication

Back 33

liking others, empathy, ability to listen

Front 34

External factors of communication

Back 34

privacy

interruptions

environment

dress

notee-taking

tape and video recording

Front 35

Techniques of communication

Back 35

introducing the interview

working phase

Front 36

working phase of communication

Back 36

gatering data

questinos

Front 37

2 types of questions

Back 37

open-ended ( let them run with it)

closed( specific answer0

Front 38

assisting the narrative

Back 38

encourage patient to say more

silent attentiveness

reflction -echo

Front 39

types of verbal responses

Back 39

1. empathy

2. clariication

3. confrontation

4. intrpretation

5. explanation

6. summary

Front 40

Empathy

Back 40

recognizes a feeling and puts it into words

Front 41

clarification

Back 41

asking for patient to confirm or deny your understanding

Front 42

Confrontation

Back 42

frame of reference shifts from patient to you

Front 43

interpretation

Back 43

corrections

Front 44

explanation

Back 44

informing the patient

Front 45

Summary

Back 45

riiew of what the paitient has said

Front 46

Objective data

Back 46

what you find out through assessment

Front 47

Subjective data

Back 47

what patient says about himself or hersel during history taking

Front 48

Database

Back 48

Subjective data + Objective data

Front 49

Steps of Nursing Process

Back 49

assessment

diagnosis

outcome identification

Planning

Implementation

Evaluation

Front 50

Assessment

Back 50

collection of data from mulitple sources

Front 51

Sources you get data from for your assessment

Back 51

Review of clinical record

Interview

health history

physical examination

functional assessment

cultural and spirtual assessment

consultion

review of the literature

Front 52

Diagnosis

Back 52

interpretation of data by identifying clusters of cues so as to make inferences

Front 53

Outcome identification

Back 53

indentify expected outcome related to patient individualization

Front 54

Planning

Back 54

Establish priorities based on meeting identified patient care goals

Front 55

Implementation

Back 55

Determine patient readiness and involve patients in health care process

Front 56

Evaluation

Back 56

refer to established outcomes

evaluate individuals condition and compare actual outcomes with expected outcoes

modify plaan of care according to findings

Front 57

Sequential Steps

Back 57

incorporation of experience provides foundation for development of clinical practice

Front 58

first priority level

Back 58

emergent, life threating, immediate

Front 59

multidimensional thinking

Back 59

use an organized systematic assessment format

Front 60

Second level prioriy

Back 60

next in order

Front 61

collaborative problems

Back 61

approach to treatment involves multiple decisions

Front 62

Problems and outcomes

Back 62

indentify patient outcoms and elineate measurable goals

included evaluation methods that will allow for validation o results or adjustments t care planning

Continuously evaluate the plan of care

Front 63

Third level priotrity

Back 63

important to patients health but can wait til more urgent problems are addressed

Front 64

Collecting 4 types of data

Back 64

1. complete total health database

2. episodic or problem-centered database

3. followup database

4. emergency database

Front 65

Holistic Model of health

Back 65

mind body spirt are interdepent and funtion as a whole

Front 66

Health promotion and disease prevention

Back 66

form the core of nursing

Front 67

Thyroid gland

Back 67

-an important endocrine glad straddles trachea in middle of neck

- synthesizes and secreates thyroxine and triidodothroine

Front 68

Head of a baby

Back 68

32-38com ; 2 cm larger than chest

Front 69

2 year head

Back 69

head and chest same

Front 70

lymphatic system

Back 70

an extensive vessel system is major part f immune system, which detects ad eliminates foreign substances from body

Front 71

>2 year head

Back 71

chest bigger than head

Front 72

how much of the head is grown by age 6

Back 72

90%

Front 73

Pregant females thyroid gland

Back 73

enlarges slighty during pregancy as a result of hyperplasia of tissue and increased vascularity

Front 74

Why do aging adults look boney?

Back 74

decreased elasticity

decreased subcutaneous fat

decreased moisture in skin

Front 75

inspection and palpation of the skull

Back 75

- note general size and shape

- assess shape; place fingers in person's hair and palpate scalp

- skull nomally feels symmetric and smooth

-there is no tenderness to palpation

-palpate temoral artery above zygomatc bone between eye and top of ear

- palpate TMJ as th person opens the mouth, and ntoe normally smooth movement with no limitations or tenderness

Front 76

Inspection of face

Back 76

- note facial expression

- facial structures should be symetrical

- note any adnomal facial structures

-note any involuntary movmet in facial muscles

Front 77

Trachea

Back 77

- midline

Front 78

Enlarged Thyroid

Back 78

hyperthyroidism

Front 79

Lymph nodes

Back 79

- movable, discrete, soft and nontender

- palpate; note location, size shape, delimitation

- followup (enlarged lymph nodes could mean cancer

Front 80

2 common variations in a babies skull

Back 80

1. Caput succedaneum

2. Cephalhematoma

Front 81

Caput succedaneum

Back 81

edematous selling and ecchymosis of presenting part of head caused by birth trauma, gradually resolves during first few days of life and needs no treatment

Front 82

Cephalhematoma

Back 82

subperiosteal hemorrhage, a result of birth trauma, appears several hours after birth and gradually increases in size; will be reabsorbed during first few weeks of life without treatment

Front 83

Infants and childrens head exam

Back 83

- every visit up age of 2 then yearly til age 6

-note infants head posture and control

-side to side by 2 weeks

- onic neck reflex when had is turned toone side ( disappears after 3 to 4 months )

- holds head up by 4 months

Front 84

Infants and children neck exam

Back 84

-short lengthens during first 3 to 4 years

- can't palpate lympnode during infacny

Front 85

Pregnant females exam

Back 85

-second trimester chloasma may show on face

- thyroid glands palpatable

Front 86

Aging Adults Exam

Back 86

- neck may have concave curve to compensate fr kyphosis of spine

Front 87

pupillary light relfex

Back 87

normal cnstrictio of pupils when brigt light shines on retina

Front 88

accommodation

Back 88

adaptation of eye for near vision

Front 89

Infants and children development eyes

Back 89

- peripheral vision is intact in newborn infant

- macula absent at birth but developed by 8 mon.

- 3-4 months binocularity is developed and they can focus on a single object with both eyes

- lens spherical at birth and grows flatter

Front 90

Aging adults development eyes

Back 90

- pupil size decreases

- lens loses elasticity

- 70 transpartent fibers begin to grow thinker and yellow starting cataracts

-visual acuity starts slowly deminishing at 50

Front 91

most common reasons visual function decreases in aging adults

Back 91

1. cataract formation - clumping of proteins in lens

2. Glaucoma- increased intraocular pressure;

3. macular degeneration - breakdown of cells in macula of retina

Front 92

african american eyes

Back 92

primary open-angle glaucoma is more common

Front 93

How do we test vision?

Back 93

snellen alphabet chart

Front 94

P.E.R.R.L.A

Back 94

Pupils

equal

round

react to light

accomodation

Front 95

Behavior to note when introducing objects to infants vision

Back 95

1. birth to 2 weeks - refusal to reopen eyes after a light has been shined in them, increase alertness to object, fixate on it

2. 2 to 4 weeks - infant can fixate on an oject

3. 1 mon. - infant can fixate and follow light or bright toy

4. 3 to 4 mon. - infant can fixate, follow and reach for toy

5. 6to 10 mon. - infant can fixate and follow toy in all directions