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219 Cards in this Set
- Front
- Back
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Question
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Answer
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includes biographical data, nursing health history, chief complaint, present illness, past medical history, health patterns, and Review of systems
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Nursing Interview
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The answer to the question "What is troubling you?" or "Can you tell me the reason you came to the hospital today?". This should be recorded in the client's own words.
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Chief Complaint
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a subjective statement made by a patient describing the most significant or serious symptoms or sings of illness or dysfunction that caused him or her to seek health care
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Chief Complaint
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Would behavioral examination data be considered subjective or objective?
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objective
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physical examination (baseline) as the client enters the health care system
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Initial Exam
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ongoing physical examinations; used to assess an area of concern or evaluate an intervention
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focused
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What 3 things are included in a comprehensive physical examination?
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Nursing Interview
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- Physical Examination"
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a systematic, orderly process by which the nurse collects objective data about the client's body, mind, and spirit. It is a critical investigation and evaluation of the client's present status.
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physical examination
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What are the 6 purposes of the data collected during a physical examination?
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"- evaluate the client's present state of health
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- make clinical judgments about the client's health statu"
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comparing data with another source
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validation
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As a student, we are responsible for knowing _______ _______ for the client's age, sex, and condition in life.
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normal findings
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The student nurse (and professional LVN) is responsible for collecting data in a professional manner using _____ _______.
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proper technique
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The student nurse (and professional LVN) must _____ and _____ data collected. Additionally, you should be able to identify trends and changes.
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validate and analyze
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As a student nurse, you should be able to identify normal findings from what?
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abnormal findings
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What should you do (as a student nurse) as soon as you obtain data that is significantly different or abnormal?
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report these findings to your Clinical Instructor as soon as data is obtained
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What does the abbreviation WNL mean?
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within normal limits
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How should you introduce yourself to the client on the first visit?
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Greet the client professionally, handshake (if culturally acceptable), smile, clearly state your name and title.
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What would you say your title is when you introduce yourself to a client.
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Student Nurse @Summit
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In preparing the client for assessment, you should always offer a time frame and offer the client an opportunity to do what?
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use the restroom
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What are some standard procedures when you are preparing the client for assessment? (5)
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" inform client what will be done (where, when, why)
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, provide privacy (even in a private room)"
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Most examinations are performed in what position?
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Low Fowlers or a sitting position
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What is the normal time frame for an examination?
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15-20 minutes
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What approach will you use in Basics when doing a physical exam?
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"Cephalocaudal (head to toe)
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"
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You should NEVER ask visitors to leave when doing a PE."
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FALSE- Always provide privacy by asking visitors to leave the room **remember to close drapes and the door**
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You should wash your hands before and after performing a PE."
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TRUE
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All information obtained in the PE should be professionally communicated in the ________ ________ and to the appropriate healthcare team members in a timely manner.
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medical information
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What is the ideal position for the nurse when performing a PE?
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on the nurse's dominant hand side of the client
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You do not need to clean your stethoscope between patients because it does not come in contact with body fluids."
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FALSE - you should always clean between patients
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What part of the stethoscope should be used to assess high pitched sounds? low pitched?
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"high pitched = diaphragm
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low pitched = bell"
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What are the techniques of examination in the order which they should be performed?
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"1. Inspection
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4. Auscultation"
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You can alter the order of the PE if the client is experiencing pain/discomfort in a certain region."
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TRUE
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What is the difference between symmetry and equality?
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"Symmetry refers to shape/size
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Equality is a measurement/amount"
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Example: using the sense of touch; to feel, to stroke the surface of an area to detect its characteristics such as temperature, vibration, turgor, texture, masses, etc."
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palpation
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Should the tips or the pads of the fingers be used for palpation? Why?
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pads - high concentration of sensory nerve endings at the pads which are most sensitive to tactile discrimination
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What are the 2 types of Palpation?
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" Light
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, Deep (not practiced in Basics)"
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Describe the technique of light palpation?
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place the hand parallel to the client's skin surface and press gently while moving in a circle
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Example: striking the body to elicit sounds that indicate whether tissue is solid, fluid-filled, or air-filled"
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percussion
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Example: Listening to sounds produced in the body; aided by the use of a stethoscope which focuses and amplifies sound"
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auscultation
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How long should the tubing of your stethoscope be?
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12-14 inches
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The legal implication of all documentation must include evidence that the nurse has followed the _______ ________ and complied with the ________ ___ ________ _______ in that state.
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followed the nursing process and complied with the standard of nursing practice in that state
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What is the first thing you should observe when you walk into the room?
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"the position that the client is in and the client's current activity, consciousness
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(ex. low fowlers, talking with visitor, awake)"
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How do you check a client's level of alertness?
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Check their response to stimuli
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If a client responds to the nurse's entrance to the room, what level of alertness would be documented?
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Spontaneous
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If a nurse has to call the name of a patient to obtain their attention, what level of alertness would be documented?
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verbal/speech
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If a nurse must touch the client to gain their attention, what level of alertness would be documented?
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tactile
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If you cannot gain the attention of a client via verbal or tactile stimulus, what is the next method you can use to gauge alertness?
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painful stimulus
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What is documented if the client does not respond to any method of stimulation?
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Not alert to stimuli
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""State your full name."" and ""What is the name of the city we are in?"" and What month is it?"""
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orientation
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What 3 things to you want to check that a client is oriented to?
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person, place, and time
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If a client is Awake, Alert and Oriented at the top levels in each, how should this be documented? What if there is an abnormality in any of these?
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If all is normal, document as AAO x 3. If any is considered abnormal, it should be documented as noted by the nurse (ex. awake, alert to verbal, oriented)
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A significant change in level of consciousness is not an immediate concern."
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FALSE- one of the most significant signs that a person is in distress is a change in their level of consciousness
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What are the 1st 2 things you should you do if you notice a significant change in a person's level of consciousness not related to sleep?
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quickly assess their neurological system (and related system if you SUSPECT it may be the cause) followed by a quick set of vital signs
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You assess a client's level of consciousness and vital signs and find both significantly worse than previous assessments. What is your next action?
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You activate the emergency response team / call for help
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Signs of distress are often evaluated using the ABCs of distress evaluation. What are they?
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" Airway, Breathing, Circulation
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, Complaint"
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Breathe with a whistling or rattling sound in the chest, as a result of obstruction in the air passages
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wheeze
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A harsh vibrating noise when breathing, caused by obstruction of the windpipe or larynx.
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stridor
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(define) Difficulty breathing
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dyspnea
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(define) Medical term for mucous
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sputum
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(define) bloody sputum
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hemoptysis
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(define) Bluish discoloration of the skin and mucous membranes
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cyanosis
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What causes cyanosis?
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excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule
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(define) passage of a fluid through a specific organ or an area of the body
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perfusion (tissue circulation)
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(define) an inadequate blood supply to an organ or part of the body, esp. the heart muscles.
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ischemia
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A severe change in LOC is acceptable when a client has received a sedative or pain medication."
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FALSE- A minor change is acceptable, however any major change in LOC should be assessed immediately.
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(define) Reddening of the face and neck; may be prolonged as seen with fever or the use of certain drugs
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flush
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(define) patchy areas of blue
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mottled
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(define) skin moist with perspiration; the secretion of sweat, especially profuse secretions associated with an elevated body temperature, physical exertion, exposure to heat, or mental/emotional stress
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diaphoresis
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(define) a statement made by the client regarding any symptom or problem (ex. pain, SOB, nausea, etc.)
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complaint
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What should you do if the client expresses a complaint that is NEW?
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follow the nursing process, started with doing a focused assessment on the region of complaint
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A patient complains of dizziness. What would be the next course of action by the nurse?
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"focused neurological exam, quick set of vitals
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, interpret data to determine if further action is necessary"
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The proper way to assess a client who is complaining of SOB is to do a complete head-to-toe exam."
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FALSE- You will do a focused exam on the area of complaint and vital signs. This is NOT the time for a complete head-to-to exam.
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The use of accessory muscles for breathing could indicate distress."
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TRUE
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Part of the Physical Examination is listing any adjunct equipment in the room. What are some examples of adjunct equipment?
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"oxygen delivery systems
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, anti-embolic hosiery , wound dressings"
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What should you always look for when assessing adjunct equipment?
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make sure that it isn't causing a problem for the client
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Identifying if there are people at the bedside, personal effects, etc. is an example of which part of the PE?
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Environment
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A patient has a history of smoking and regularly using tanning beds. What effect do you think this will have on actual age vs. apparent age?
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Apparent age will likely be older than actual age
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Why is it important to note height and weight upon admission?
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"for medications (many calculated by weight)
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, establish a baseline for future comparisons"
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Rapid weight gain often indicates what?
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fluid gain
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What is the normal range for body shape/size?
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proportionate height and weight, well nourished
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What is considered abnormal for body shape/size?
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" thin
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, emanciated (very thin), obese"
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What type of changes would you expect to see in Body Shape/Size of elderly clients?
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loss of subcutaneous fat, decreased muscle mass
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Describe normal posture.
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"erect, upright
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, relaxed"
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Describe abnormal posture.
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"stooped, slumped
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, tensed"
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What types of changes would you expect to see in the posture of the elderly?
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" forward bending
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, stooped with flexion at the hips, knees, and elbows"
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(define) a gait described as rigid with slow, small steps that progresses to fast and forward-leaning with small steps; difficult to stop moving forward once moving
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propulsive gait
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Describe normal gait.
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" coordinated and steady
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, arms swinging freely at the side"
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Describe abnormal gait.
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"unsteady
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, uses assistive devices"
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What disease is associated with a propulsive gait?
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Parkinson's
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What concern would you have as a nurse for a person with an abnormal gait, such as a propulsive gait?
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client is at risk for falls
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What changes in gait would you expect to see in the elderly?
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"smaller steps and strides
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, cautious"
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What independent order would you write for a client with a propulsive gait?
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assist while walking (ambulating)
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Describe normal movement.
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"smooth, purposeful
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, coordinated"
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Describe abnormal movement.
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" involuntary movements
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, paralysis"
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(define) a localized uncoordinated, uncontrollable twitching of a single muscle group innervated by a single motor nerve or filament that may be palpated and seen under the skin (muscle twitch)
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fasciculation
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What type of body/breath odor would you expect to find normally in a client?
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none
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A fetid, foul odor in the axillae or perineal area may be a result of what?
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poor hygiene (results in bacterial growth in wet, moist regions)
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(define) Offensive breath resulting from poor oral hygiene, dental or oral infections, ingestion of certain foods, use of tobacco, and some systemic diseases
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halitosis
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(define) Tooth disease causes by interaction of food with bacteria that causes plaque; tooth cavities
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dental caries
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What are 5 possible causes of halitosis?
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"poor oral hygiene, dental caries
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, pneumonia"
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A sweet, fruity breath odor may be indicative of what?
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diabetic acidosis with a build-up of ketones
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Breath that smells of alcohol may be caused by what? (2)
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" ingestion of alcohol
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, acid-base imbalance (ketosis)"
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A foul, sickeningly sweet breath odor may indicate what? (2)
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" 'Pseudomonas' pneumonia
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-------- lung infection"
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What 8 things will you look at when assessing the client's physical presence?
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"1. Environment
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8. Body and Breath Odor"
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What 3 things will you assess when examining a client's psychological presence?
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"1. Dress, grooming and personal hygiene
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3. Language and Speech Pattern"
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Describe normal "dress, grooming, and personal hygiene".
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" clean
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, appropriately dressed for climate"
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Describe abnormal "dress, grooming, and personal hygiene".
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"disheveled, unkempt
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, unshaven"
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An abnormal appearance, such as being unshaven or unkempt, may be indicative of what?
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" lack of interest in appearance
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, inability to perform ADLs"
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What change might you expect to see in "dress, grooming, and personal hygiene" in the elderly?
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Older adults have a decrease in SC tissue and may dress warmer than expected for weather (ex. sweaters)
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Describe normal "Mood, Affect, and Manner".
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engaged & smiles appropriately
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Describe abnormal "Mood, Affect, and Manner".
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"sad
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, withdrawn"
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You are assessing a client, and they seem upset and withdrawn. Would you note this information immediately, or is there another action you should take prior to notation?
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You should validate this information first. Ex. "You seem upset?" Simply noting you perception without validating would be a subjective notation.
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Describe normal language and speech patterns.
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"clear
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, respond to questions/commands without hesitation"
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Describe abnormal language and speech patterns.
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"incoherent , slow
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, dysphasia"
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(define) Abnormal neurological condition in which language is not understood
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sensory dysphasia (aphasia)
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(define) Abnormal neurological condition in which words cannot be formed or expressed
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motor dysphasia (aphasia)
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What changes may you see in the elderly regarding language and speech patterns?
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loss of voice quality and range, may be slower to respond
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What is a normal body mass index?
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20-25
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What should you as a nurse do to ensure that height and weight is measured properly when accuracy is essential?
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" use the same scale
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, make sure client is wearing similar kind of clothing and no footwear"
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A client experiences an unexpected and significant weight loss. What 2 things should you note?
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"the time frame the loss occurred
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, the amount of weight loss"
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What is the procedure for assessing the skin?
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Inspect all areas and palpate the non-mucous membrane skin surfaces
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What is considered normal for skin color?
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uniform (light to dark pink) (light to dark brown)
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Caucasian skin is documented as what color? African Americans?
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pink , brown
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What are normal variations in skin color?
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"birthmarks
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, moles (nevi)"
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What are color neutral regions of the body for diagnosing cyanosis?
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"nail beds
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, soles of the feet"
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Pallor, or loss of color, may exhibit how in a dark-skinned individual?
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the person may appear ashen gray
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How should you assess for pallor in a dark-skinned individual?
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assess the conjunctiva, lips, palms
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Give 4 examples of situations that may cause pallor.
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" inadequate circulation
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, general poor health"
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What is preferential perfusion?
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Major organs are perfused first (often due to a drop in blood pressure)
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What change would you expect to see in the skin due to preferential perfusion?
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pallor
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What should you do if you notice a client suddenly go pale?
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take a set of vitals
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How does diaphoresis relate to a drop in blood pressure?
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Often a drop in blood pressure will result in excessive sweating due to vasodilation
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(define) Yellow-orangish skin, sclera, and mucous membranes
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jaundice
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Jaundice is caused by excess _______.
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bilirubin
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What part of the body should be assessed if you suspect jaundice in a dark-skinned individual?
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hard palate
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What is a key symptom in many liver of hemolytic diseases?
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jaundice
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(define) Redness of the skin
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erythema (hyperemia)
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What are some reasons for erythema?
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" increased blood flow
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, excessive alcohol intake"
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Darker pigmentation along the course of a vein may indicate what?
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IV drug use
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Body art and piercing do not need to be documented."
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False- You must document piercings/tattoos. You don't need to describe, simply note what is present and where. (ex. tongue piercing x 1, tattoo on left shoulder)
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(define) brown age spots due to sun exposure
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senile lentigo
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What are some normal changes in skin color you would expect to see in the elderly?
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"senile lentigo (age spots)
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, skin may appear thin and translucent"
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Skin moisture refers to the skin's ________ and _________.
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hydration and oiliness
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(define) A small, bright red, clearly circumscribed vascular tumor on the skin. Occurs most often on the trunk but can be anywhere; common lesion; more than 85% of people over 45 yrs. of age have several
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cherry angioma
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When assessing temperature with your hand, should you use your palm or the back of your hand?
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back of your hand
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Skin should be acceptably dry (no diaphoresis), however some exceptions may occur in what regions of the body?
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"hands
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, skin folds"
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What are some abnormalities in the moisture of the skin?
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"abnormally dry (causes flaking, scaling)
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, abnormally oily"
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What may be some causes of abnormally dry skin?
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"smoking
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, underactive glandular function (such as hypothyroidism)"
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Abnormally oily skin may be caused by what?
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"puberty
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, overactive gland function (ex. hyperthyroidism)"
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How do you assess skin temperature during a PE?
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use the dorsal surface of the hand, comparing upper and lower extremities
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Describe normal skin temperature.
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Warm
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Describe abnormal skin temperature
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cool or cold
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What may be a cause of cool or cold skin to the touch.
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decreased blood circulation (perfusion)
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What are some findings you may expect to see in the skin temperature of older adults?
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"extremities cooler to touch
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, decreased perspiration"
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What is the procedure for assessing the skin's surface texture?
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stroke the skin surface with the pads of the fingers
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Describe normal skin texture.
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smooth, soft, consistent; elbows, palms and soles are rougher/thicker
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Describe abnormal skin texture.
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rough, taut (tight), indurated (hardened), scarred
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(define) Reflection of the skin's elasticity and state of hydration
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turgor
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Describe the procedure for checking skin turgor.
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grasp with fingers and lift skin, then release it. Use the areas of the sternum or clavicle.
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Describe normal skin turgor.
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Supple; when released, the skin quickly snaps back to pre-tested position
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Describe abnormal skin turgor.
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Sluggish; peaked; tented
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What are normal changes that you expect to find in skin turgor of the elderly?
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" sluggish due to decreased elasticity and SC tissue
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, sagging"
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What are we looking for when examining the skin's vascularity?
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"visible superficial blood vessels
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, bleeding"
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Normally, you should not see ecchymosis unless what has occurred?
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trauma or injury
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What is the medical term for "bruise"?
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ecchymosis
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What effect to vascularity is expected with anticoagulants?
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ecchymosis, excessive bleeding
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Describe abnormal vascularity.
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"spider veins, varicose veins
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, petechiae"
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(define) Pinpoint red-purple spots caused by small hemorrhages
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petechiae
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Petechiae may indicate what? (4)
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"bleeding disorder
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, infections"
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What changes would you expect to see in skin vasculartiy of the elderly?
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bruises easily due to loss of subcutaneous tissue and fragile capillary walls
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