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45 Cards in this Set

  • Front
  • Back
Name the four types of assessment
Initial comprehensive
ongoing/partial
focused/problem-oriented
emergency
What is the most common type of assessment performed?
ongoing/partial
Which type of assessment does of Review of Systems?
Initial comprehensive
Name the four steps in the assessment phase
collect subjective data
collece objective data
validate data
document data
What are the four cardinal techniques for physical examination?
inspection
percussion
palpation
auscultation
Define: Interviewing
communication process that focuses on clients response
State the three phases of the interview
introducctory
working
summary and closure
What do open-emded questions usually begin with?
how or what
what do closed-ended questions usually begin with
when or did
What is the process of validating data for?
-verifying that the subjective and objective data is accurate
-preventing errors based on faulty information
When should data be validated
-discrepancies between sub and ob data
-discrepancies in history from one time to another
-inconcistent findings
How do you validate data?
-check own data and repeat assessment
-clarify data with client with more questions
-verify data with another professional
-comapre ob with sub findings
State the three types of documentation
initial
frequent or ongoing
focused
Name the types of initial docyumentation
-open ended
-cued checklist
-integrated cued checklist
-minimum nursing data set
State frequent or ongoing assessment form benefits
flow charts - vs
progress notes for unusual even ts
quick and allow for comparison
streamlines documentation
What are key points to cover in hair, skin and nail assessment?
-skin color, temp, moisture, texture
-skin integrity
-skin lesions
-hair loss/unusual growth
-nail bed color and capillary refill
What do dark skinned people have on the sclera/nailbeds
freckle-like or dark streaks of pigmentation
What are mongolian spots?
bluish, bruise-like marks on back, buttocks, arms, thighs, abdomen
What race do mongolian spots appear most in?
blacks, asians, native americans.
What is used to palpate texture of the skin
palmar surface of three middle fingers
What is used to palpate thickness of skin?
thumb and one finger
What is used to palpate moisture of the skin?
dorsal surface of the hands
What is used to palpate temper ature of the skin?
dorsal/palmar surface of the hands
Which part of the body is used to check for turgor?
skin on sterrnum or under clavicle
How fast should skin return when checking for turgor?
3 seconds
What does vellus hair cover?
entire body except for soles, plams, lips, nipples
What finding signifies malnutrition in AA children?
copper-red hair
What are Beau's Lines?
horizontal ridges on the nails.
What are Beau's Lines a sign of?
acute illness
What causes nail clubbing?
oxygen deficiency
What stage ulcer shows superficial skin locc involving epidermis alone or also the dermis?
state II
Describe State 3 ulcer
-pressure area involved epidermis, dermis and into SQ tissue
-resembles crater
-may have tunneling
-extends thru all layers of skin and beyond SQ
Describe State 4 lesion
-involves epidermis, dermis, SQ, bone and other support tissue
-large crater with hidden areas of damage in adjacent tissue
Describe a macule
-<1 cm
-circumscribed border
-flat, nonpalpable
-brown, red, white, tan, purple
EX. - flat moles, freckles
What is the same as a macule except is > 1 cm?
patch
Describe a papule
-< 0.5 cm
- elevated, palpable, solid mass
-circumscribed border
-EX. moles, warts
What is similar to a papule but greater than 0.5 cm
plaque
Describe a nodule
0.5 - 2 cm
-elevated, palpable, solid mass
-extends deeper into dermis than papule
-circumscribed
-EX. lipoma, poorly absorbed injection
What is the same as a nodule but >1-2 cm
Tumor
Describe a vesicle
-<0.5 cm
-circumscribed, elevated palpable
-serous fluid
-EX. chicken pox,, poison ivy
What is similar to a vesicle but >0.5 cm
Bulla
-EX large blister
Describe a Wheal
elevated with transient borders
often irregular
size, color varies
serous fluid movement into dermis
Describe a Pustule
pus filled vesicle or bulla
superficial
Ex acne
Describe a cyst
encapsulated fluid filled or semisolid mass
located in SQ tissue or dermis
circumscribed
EX sebaceous cyst
Describe Lichenification
-thickening and roughening of skin
accuentated skin markings
may be secondary to repeated rubbing, irritation, scratching
EX contact dermatitis