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70 Cards in this Set

  • Front
  • Back
def
Visual examination: to observe, to look, to smell. The nurse observes shape, size, color, shape, position, movement, symmetry, equality, etc.
Inspection
def
using the sense of touch; to feel, to stroke the surface of an area to detect its characteristics such as temp (use dorsal surface of the hand), vibration (use the palmar surface of the hand); turgor, texture, masses, etc.
palpation
def
listening to sounds produced in the body; aided by the use of a stethoscope which focuses and amplifies sound.
auscultation
def
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 client's present status.
physical examination
What is the student nurse responsibility?
-collecting data in a professional manner using proper techniques
-validating and analyzing the data
-recognizing normal findings from abnormal ones
-communicating significant changes and abnormal findings to the clinical instructor as soon as data obtained.
how would you introduce yourself to a client in a professional manner?
greet the client w/ a handshake, and if this is the first encounter, clearly state your name and your title.
How would you prepare the client for a physical exam?
-inform the client of what will be done, when, where and why it is important.
-State the info is confidential (HIPPA)
-move pt into low Fowlers or a sitting position.
-timeframe is approx 15-20 min
-give the pt the opportunity to void (urinate) before the exam, for it may need to be collected.
What type of palpation do we use in basics?
light (superficial) palpation by placing the hand parallel to the client's skin surface and press gently while moving in a circle.
def
shortness of breath
dyspnea
def
blue; blue-gray
cyanotic
def
patchy areas of blue
mottled
def
pale, white
pallor
def
reddish hue
flushed
def
skin moist with perspiration, (sweating)
diaphoretic
def
which is the client's awareness of his surroundings
level of consciousness (LOC)
what would be documented as adjunct equipment?
includes any medical equipment or devices in use. May document these at any time. Includes this as oxygen delivery systems, nasogastric tubes, tubes, anti-embolic hosiery,SCDs (sequential compression devices), wound dressing, etc.
What is important to identify if adjunct equipment is ________ __ ______?
creating a probelm. ex break in the skin, pressure marks on the skin, redness, etc.
def
armpits
axillae
def
mouth odor
halitosis
def
cavities
dental caries
def
sweet, fruity smell, nuild-up of ketones
diabetic acidosis
def
difficulty with speech (expressive) or difficulty understanding the spoken word (receptive)
dysphasia
Normal Body Mass Index?
BMI 20-25
def
bluish color,most evident in the nail beds, lips, mouth, buccal mucosa or mucous membranes (mm); in dark-skinned clients, close inspection of the palpebral conjunctiva (the linning of the eyelids), palms, and soles of feet.
cyanotic
def
loss of color due to inadequate circulating blood or hemoglobin; or decreased oxygenation of the hemoglobin. assess for this in the conjunctiva, lips, palms, and mucous membranes (mm).
pallor
def
yellowish-orange skin, sclera, mm; in dark-skinned: assess hard palate; excess bilirubin; liver or hemolytic deseases.
jaundice
def
red; increased blood flow; inflammation; rashes
erythema
def
brown age spots due to sun exposure in the elderly.
senile lentigo
def
skin's elasticity and state of hydration
turgor
def
when released, the skin quickly snaps back to pre-tested position.
supple
def
visible superficial blood vessels
vascularity
def
bruising, extravasion of blood under the skin.
ecchymosis
def
pinpoint red-purple spots caused by small hemorrhages
petechiae
def
the abnormal presence of fluid in the body
edema
def
fluid formed around the eyes
periorbital
def
prescense of fluid in the abdominal cavity
ascites
def
generalized edema (all over) the body
anasarca
def
if a indentation remains, the nurse should measure depth of the indention.
pitting edema
what are some causes of edema?
Trauma and the inflammatory response; kidneys overloaded/damaged; cannot "clear out" fluid/wastes (ex renal or cardiac failure; excess Na intake, nephrotoxins); impairment of venous return which override the capacity of the veins (ex pregnancy); decreased serum protein levels allow fluid to shift out of the blood vessels (liver diseases; malnutrition)
def
any abnormal (pathological) area of the skin; (ex wound, cyst, rash, boil, pustule, tumor, etc).
lesions
def
small, raised red papules
cherry angiomas
def
a normal head size is referred to as
normocephalic
def
enlargement of the head
hydrocephalus
def
nearsightedness
myopia
def
farsightedness
hyperopia
def
difficulty reading small print (elderly)
presbyopia
def
drooping of the eyelid
ptosis
def
benign (not serious), bilateral gray ring around the iris; lipis deposits, occurs in the elderly
arcus senilis
def
opacity or cloudiness of the lens
cataracts
What controls the opening and closing of the pupils?
CN III Oculomotor
What does PERRLA stand for?
P-upils E-qual, R-ound, R-eact to L-ight and A-ccommodation
What is the normal size of the pupil?
3-7 mm
def
dilation for distant
mydriasis
def
pinpoint constriction for close
miosis
def
the glands secrete earwax which lubricates and protects the canal of the ear. What do the glands create?
cerumen
def
hearing deficit (hard of hearing)
presbycusis
def
no teeth, or number of teeth missing
edentulous
The size of the airway determines the characteristice of the lung sounds. The ________ the airway diameter, the harsher and louder the sound should be.
larger
def
when listening to the lungs unequal sounds, or if the incorrect sound is heard in a location, they are referred to as?
adventitious sounds
def
atelectasis or fluid in the alveoli sacs. Pneumonia, PE, CHF
crackles
def
narrowed bronchial airways. Asthma, bronchitis
wheezes
def
snoring sound, sputum in bronchi; various causes.
rhonchi
def
crowing; obstruction of trachea or larynx; FBAO, anaphylactic or allergic reaction, croup, tumor etc.
stridor
def
is produced by the closure of the (atrioventricular valve) AV valves (mitral, tricuspid). This represents systole or the ejection phase and creates the peripheral pulses.
S1
is produced by the closure of the semi-lunar valves (aortic, pulmonic). Represent diastole or filling phase. no pulse is produced
S2
def
a period in which the ventricles contract.
systole
def
a period in which the ventricles relax.
diastole
Normal apical pulse (AP-rate) rate is?
60-100/min
How many quadrants do you divide the abdomen in and what are they?
4 quadrants
RLQ right lower quadrant
RUQ right upper quadrant
LUQ left upper quadrant
LLQ left lower quadrant
Bowel sounds occur within ?
5-20 seconds