Fundamentals Of Nursing Care Ch 21

Front 1

Comprehensive Health assessment

Back 1

An in-depth assessment of the whole person including physical mental emotional cultural and spiritual aspects of patience health.

Front 2

Focused assessment

Back 2

Involves an examination and an interview regarding a specific body system. Such as examining solely the integumentary system or the respiratory system

Front 3

Initial head to toe shift assessment

Back 3

Provides you with a quick overall assessment of the patient's condition to establish a baseline against which you can compare later assessments. Neurological, cardiovascular, respiratory, integumentary, gastrointestinal, genitourinary, muscular, skeletal.

Vital Signs, appearance, speech, safety risk factors, tubes and Equipment, Comfort or complains, needs

Front 4

Subjective data

Back 4

The info the patient or his family and friends tell you

Front 5

5 techniques to collect objective data

Back 5

Inspection, observation, palpation, percussion, auscultation, and olfaction

Front 6

Order of abdominal assessment

Back 6

Inspection or observation, auscultation, palpation, percussion, and olfaction

Front 7

Signs vs. symptoms

Back 7

Signs of disease are those that can be detected by the nurse, while symptoms of disease are apparent only to the patient so they must be verbally communicated to the nurse

Front 8

Inspection

Back 8

Visible observation of anything about the body that you can see with the naked eye or with the assistance of other equipment

Front 9

Otoscope

Back 9

Lighted instrument used to inspect the lining of the nose, tympanic membranes and ear canals

Front 10

Ophthalmoscope

Back 10

Lighted instrument used to assess or examine the internal structures of the eyes

Front 11

Palpation

Back 11

The application of your hands to the external surfaces of the body to detect abnormalities of the skin or tissues line below the skin, that is, to examine by touch or feel

Front 12

Light palpation

Back 12

Depresses the tissue between 1 and 2 centimeters

Front 13

Moderate compression palpation

Back 13

Depresses the tissue between 2 and 3 cm

Front 14

Deep palpation

Back 14

Depresses the tissue between 4 and 5 cm

Front 15

Rebound tenderness

Back 15

Reflexive tensing of abdominal muscles or verbalization of increased pain with the release of pressure. Common in appendicitis

Front 16

Percussion

Back 16

Striking body parts with the tips of fingers to:

Elicit sounds that can help locate and determine the size of structures beneath the surface

Tell if structure is hollow or solid

Detect areas containing air or fluid

Front 17

How to do percussion

Back 17

Fingers of non-dominant hand placed flat on Surface to be percussed. Use dominant hand, middle fingertips to tap light and quick on the middle finger of non-dominant hand two to three times

Front 18

Blunt percussion

Back 18

Use his fists and not finger to tap or percuss, useful in detecting tenderness of the kidneys

Front 19

ASCITES

Back 19

Fluid in the peritoneal cavity

Front 20

Fluid wave test

Back 20

Patient places hand vertically in the middle of abdomen with fingers pointing toward feet. Place hands on each side of abdomen use your fingers to tap on the sides of the abdomen while the other hand palpates the opposite side, tapping will cause a fluid wave felt by the palpating hand if ascites is present

Front 21

Auscultation

Back 21

Listening to sounds produced by the body

Front 22

Eructation

Back 22

Belching, passing of flatus or rectal gas, loud wheezing or gurgling and Loud bowel sounds

Front 23

Bruit

Back 23

Rushing of blood through a vessel such as the Carotid artery

Front 24

Olfaction

Back 24

Sense of smell, used to detect odor characteristic of different health problems

Front 25

Halitosis

Back 25

Bad breath possibly caused from poor oral hygiene, a sinus infection, or gastric upset

Front 26

Sour smelling breath

Back 26

Individuals with high stress levels often have

Front 27

Ammonia or urine smelling breath

Back 27

Patients with kidney failure may have this

Front 28

Musty or sweet odor breath

Back 28

Patient with liver disease may have

Front 29

Acetone, or fruity smelling breath

Back 29

Maybe indicator of diabetes

Front 30

Neurological assessment

Back 30

Front 31

Cardiovascular assessment

Back 31

Front 32

Respiratory assessment

Back 32

Front 33

Integumentary assessment

Back 33

Skin color, texture, moisture, and temp

Turgor

Skin Integrity, including pressure points and lesions

Surgical incisions

Front 34

Gastrointestinal assessment

Back 34

Front 35

Genitourinary system assessment

Back 35

Front 36

Musculoskeletal system assessment

Back 36

Front 37

Aphasia

Back 37

Patient knows what he wants to say but cannot say it

Front 38

Accommodation response

Back 38

Pupils constrict when focusing on close objects and dilate when focusing on a fire object

Front 39

Orthopenia

Back 39

Difficulty breathing while lying flat

Front 40

Excursion

Back 40

Equal chest expansion during inspiration

Front 41

Dysphasia

Back 41

Difficulty coordinating and organizing the words correctly

Front 42

ptosis

Back 42

Drooping of the eyelid

Front 43

Retractions

Back 43

Chest walls appears sunken in between ribs and under the xiphoid process as the patient inhales

Front 44

Sordes

Back 44

Dried mucus or food caked on the lips and teeth

Front 45

Rhonchi

Back 45

Sort of rattling, however they cleared when patient coughs

Front 46

What part of brain controls the respiratory rate portion of oxygen

Back 46

Medulla and pons

Front 47

Part of brain that controls body temperature and autonomic nervous system

Back 47

Hypothalamus

Front 48

Part of brain that extends some control over blood pressure and pulse

Back 48

The medulla oblongata

Front 49

Skin color

Back 49

Pallor indicates poor circulation or anemia while cyanosis indicates hypoxia

Front 50

Lethargy

Back 50

Drowsiness or mental sluggishness

Front 51

Four spheres of a patient's orientation level

Back 51

Person place time and situation

Front 52

Erythema

Back 52

Tissue redness

Front 53

Flexor posturing

Back 53

Arms flexed to chest, hands clenched into fists and rotated internally, feet extended, indicates problem is at or above the brain stem

Front 54

Extension posturing

Back 54

Arms extended, hands clenched into fists, wrist flexed, and forearm severely pronated or internally rotated, indicates the problem is at the level of the midbrain or pons and is more ominous of the two postures

Front 55

Arcus senilis

Back 55

An opaque White Ring around the outer edge of the cornea, common in older adults

Front 56

Anisocoria

Back 56

Pupils of different sizes

Front 57

Consensual reflex or consensual response

Back 57

Shining Light in either eye should cause both pupils to rapidly constrict simultaneously and equally

Front 58

Candida albicans

Back 58

Fungal infection, yeast

Front 59

Painless ulcerations in mouth

Back 59

Could be sign of syphilis

Front 60

White lesions and erythema of the tonsils

Back 60

Due to infection

Front 61

Severe ulcerations or growths on the oral mucosa

Back 61

Maybe cancer

Front 62

An ulceration that has perforated the hard palate or roof of the mouth

Back 62

May be indicative of cocaine use

Front 63

Reddish purple or hemorrhagic appearing gums

Back 63

Could be sign of leukemia

Front 64

Black hairy appearance of the tongue

Back 64

Indicates fungal infection

Front 65

Red beefy looking tongue

Back 65

Pernicious anemia

Front 66

Smooth, painful tongue

Back 66

Glossitis , due to inflammation or side effect of medication

Front 67

Cheilitis

Back 67

Inflammation of the lips, as well as excessive dryness and cracking

Front 68

Cheilosis

Back 68

Fissures or cracking at the corners of the mouth, usually related to Vitamin B deficiencies

Front 69

Cherry red lips

Back 69

May be a sign of carbon monoxide poisoning and acidosis

Front 70

Pale lips

Back 70

Associated with anemia

Front 71

Pale lips where the pallor is circumoral

Back 71

Maybe indicative of scarlet fever

Front 72

Endentulous

Back 72

Patient without teeth

Front 73

If jugular veins in neck are distended or full enough that you can see them

Back 73

Indicative of fluid overload of the cardiovascular system, as in congestive heart failure.

Front 74

Non productive cough

Back 74

A dry cough

Front 75

Productive cough

Back 75

Cough that produces sputum

Front 76

Rust colored sputum

Back 76

Common in pneumonia patients

Front 77

Blood-tinged sputum

Back 77

Could be due to tuberculosis

Front 78

Yellow, green, white, clear, frothy, or pink tinged sputum

Back 78

Indicative of pulmonary edema as a result of worsening CHF

Front 79

Nocturnal cough

Back 79

Coughing that occurs mostly at night, maybe sign of pulmonary edema and CHF

Front 80

Eupnea

Back 80

Breathing within normal parameters

Front 81

Atelectasis

Back 81

Severe pneumonia or lung collapse

Front 82

Bronchial breath sounds

Back 82

Sounds heard over the bronchi, located under the manubrium, shorter inspiration phase longer expiration phase, will sound louder and slightly harsher than other breath sounds

Front 83

Vesicular breath sounds

Back 83

Heard over the periphery of the lungs, longer inspiratory phase than expiratory phase, softer rustling sounds

Front 84

Decreased breath sounds

Back 84

If there are fewer breath sounds on one side than the other

Front 85

Consolidation

Back 85

When secretions and exudate from pneumonia solidify in lung tissues, may result in absence of breath sounds in that lobe

Front 86

Adventitious breath sounds

Back 86

Abnormal breath sounds including crackles, rhonchi, wheezes, pleural friction rub, and stridor

Front 87

Crackles or rales

Back 87

Discontinuous, usually heard during inspiration, maybe fine or coarse

Cannot be cleared by coughing

Front 88

Wheezes

Back 88

Continuous melodious musical or whistling sounds of the lungs, caused by constriction of the Airways can be inspiratory or expiratory

Front 89

Pleural friction rub

Back 89

Grading, creaking sound due to inflamed edematous pleural surfaces rubbing together during breathing. Sounds often heard during first couple of days of a lung inflammation

Front 90

Pt position for auscultation of breath sounds

Back 90

High Fowler's position, if patient can't sit up try to place patient in at least a semi Fowler's position if tolerated. Otherwise Place patient in supine or lateral position for lung auscultation

Front 91

Placement of stethoscope to auscultate breath sounds anteriorly

Back 91

Front 92

Placement of stethoscope to auscultate breath sounds laterally

Back 92

Front 93

Position of stethoscope to auscultate breath sounds posteriorly

Back 93

Front 94

Patient position to auscultate heart sounds

Back 94

Sitting, but can also be heard using the left lateral or Supine position

Front 95

Site to best hear the mitral valve, and where you will auscultate the apical pulse for rate Rhythm and strength

Back 95

Point of Maximum impulse, because it is located over the Apex of the left ventricle . for most patients, this is the spot just inferior to the left nipple

Front 96

Site to auscultate the aortic valve

Back 96

2nd intercostal space, just to the right of the sternum, known as the right base heart sound

Front 97

Sites to auscultate the pulmonic valve

Back 97

2nd intercostal space just to the left of the sternum, known as the left base heart sound

Front 98

Site to auscultate the tricuspid valve

Back 98

Edge of the sternum at the level of the fourth intercostal space, just left of sternum, also known as left lateral sternal border heart sound LLSB

Front 99

Cardiac auscultation sites

Back 99

Front 100

Heart murmur

Back 100

Hear extra heart sounds, may present as a swishing, rumbling, or blowing sound, or maybe soft, loud, or booming

Front 101

Auscultation of abdomen for bowel sounds

Back 101

Begin listening in right lower quadrant, then right upper quadrant, then left upper quadrant, and lastly left lower quadrant. Pattern tracks the ascending colon up to transverse colon and then to descending colon and sigmoid

Front 102

Peristalsis

Back 102

Wavelike muscular contractions of the intestines that move intestinal contents through the alimentary canal where absorption of nutrients and water takes place, toward the rectum for elimination

Front 103

Bowel sound normal range

Back 103

Should be between five and thirty clicks or gurgles per minute in each of the four quadrants, should be high-pitched, known as active bowel sounds

Front 104

Hypoactive bowel sounds

Back 104

Fewer than five clicks or gurgles per minute in any quadrant of bowel sounds, result of slowed peristalsis

Front 105

Active bowel sounds

Back 105

Between 5 and 30 clicks or gurgles per minute in each of the abdomen 4 quadrants

Front 106

Hyperactive bowel sounds

Back 106

More than thirty clicks are gurgles per minute in four quadrants of abdomen

Front 107

Borborygmus

Back 107

Gargling bowel sounds that are loud enough to hear without stethoscope

Front 108

Guarding

Back 108

Defense mechanism of tightening the abdominal muscles to prevent further compression of tender or inflamed areas

Front 109

Paresthesia

Back 109

Numbness or decreased sensation in skin, commonly seen as a complication of diabetes and a result of stroke

Front 110

Solar lentigines

Back 110

Numerous spots of yellowish Brown discoloration of skin caused by years of sun exposure, common in elderly patients

Front 111

Diaphoretic

Back 111

If patient is perspiring she is considered diaphoretic

Front 112

Pale, skin color descriptor

Back 112

Lighter color, more white than usual. If not the patient's normal Fair coloring, indicates poor circulation, anemia

Front 113

Erythematous, skin color descriptor

Back 113

Redness of designated site. Usually sign of inflammation due to increased circulation to inflamed site

Front 114

Flushed, skin color descriptor

Back 114

Widespread, diffuse red color of face, possibly includes the body. Usually caused by fever, embarrassment, exertion, sunburn.

Front 115

Jaundiced, skin color descriptor

Back 115

Yellow or orange coloring of skin and mucous membranes, Easily detected in the sclera and palm of hands. Jaundice caused by liver impairment.

Front 116

Cyanotic, skin color descriptor

Back 116

Bluish gray color of skin and mucous membranes. Do to hypoxia and extreme vasoconstriction

Front 117

Ecchymotic, skin color descriptor

Back 117

Caused by bruising of skin. Fresh bruises are bluish purple, older bruises turn yellow green as they begin to resolve

Front 118

Bronzing, skin color descriptor

Back 118

Bronze pigmentation of skin, due to disorders of iron metabolism. Iron pigments are deposited in body tissues