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232 Cards in this Set
- Front
- Back
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Components of health assessment? (4)
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1)nursing interview
2)behavioral examination 3)physical examination 4)comprehensive |
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This part of the health assessment 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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This part of the health assessment is either initial or focused and the complexity is determined by the clients needs
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Physical examination
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This examine is performed when the client enters the health care system
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Initial
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Ongoing, to assess an area of concern or evaluate an intervention
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Focused
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A systemic orderly process by which the nurse collects objective data about the clients body, mind, and spirit. It is critical investigation and evaluation of the clients present status
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Physical exam
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The purpose of data collection is? (6)
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1) evaluate the clients present state of health
2) supplement, confirm, or refute data obtained in the nursing history 3) develope individualized client care 4)evaluate the outcomes of care 5) make clinical judgements about the clients health status 6)identify areas for health promotion and disease prevention. |
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How is the accuracy of data collections and interpretation checked?
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1)validation
2)knowing normal findings for the clients age, sex, condition in life |
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Def- Comparing data with another source
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Validation
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What are the student nurses responsibilities? (4)
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1) collect data in a professional manner using proper techniques
2) validate and analyze the data 3) recognize normal and abnormal findings 4)communicate significant changes and abnormal findings to the clinical instructor as soon as data is obtained, |
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What is the preferred professional greeting?
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A handshake
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What other the other culturally accepted gestures?
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Smile or nod
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During first encounter what should the patient know about you as the student nurse?
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Name and title should be clearly stated
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What 5 preparations of the client are made before a physical exam?
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1) inform the client what you will be doing and why it is important.
2) verify clients identity using agency policy 3) state that all information is kept confidential. 4) position client ( sitting or low fowlers are the most common PE positions) 5) offer client s chance to urinate before starting exam. |
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What is the timeframe of a physical exam.
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15-20 min
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What are the 5 professional behaviors that the nurse ensures during the physical exam?
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1) organization by the following correct steps of a procedure to examine an area or part of the body,
2) organize by using the cephalocaudal or head to toe approach (taught in basics) or Body system approach (highly advanced) 3) remain non-threatening to the client 4) complete by following national guidelines and evidence based practices. 5) professionally communicate in the medical record and to the appropriate healthcare team members in a timely manner |
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What professnal behaviors will ensure a non-threatening environment to the client? (4)
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A) provide privacy by asking the visitors to leave the room and close drapes and door.
B) ensure a warm room with adequate lighting. C) follow standard precautions by washing hands with warm water before and after the PE D) begin with familiar procedures such as providing vital signs, measuring height and weight. |
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Name the (4) techniques of a physical, exam.
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1)Inspection
2)palpation 3)percussion (not in basics) 4)auscultation |
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Visual examination, to observe, to look, to notice, to smell. The nurse notices or observes shape, size, color, position and movement, symmetry, equality
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Inspection
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Using the sense of touch, to feel, to stroke the surface of an area to detect its characteristics such as temp ( use the dorsal surface of the hand ) turgor texture masses
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Palpation
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The pads of the fingers should not be used for palpation. True or false?
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False- pads of fingers not the tips are used since there is a high concentration of sensory nerve endings in the pads which are most sensitive to tactile discrimination
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The effectiveness of palpation is affected by the clients state of____________.
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Relaxation
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During the palpation examine the nurse should observe what for discomfort?
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Verbal and facial expressions for discomfort
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Types of palpation ? Two types
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Light palpation and deep palpation
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Light palpation is performed by?
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Placing the hand parallel to clients skin surface; maintain skin contact while moving in circle
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Def- listening to the 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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High pitched sounds are heard best with the?
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Diaphragm
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The legal implication of all documentation must include evidence that the nurse has followed what two things?
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* The nursing process
* standard of nursing practice |
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Initial observations of the client should include what three things?
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* Position
* client activity or interaction (reading, visiting with family?) * response ( Awake? Alert? Oriented?) |
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What would an example of an awake response be?
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Patients eyes are open
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What would an example of an alert response be?
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The patient responses the stimuli such as the nurse entering the room
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A person would be oriented if they can state what 3 things?
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1) person -State full name
2) place-what is the name of the building (city or state) that we are in? 3) time- what time of the day is it or the month or year. |
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What are the five signs of distress that require immediate actin by the nurse?
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1) Airway
2) Breathing difficulty 3) Circulation 4) change in LOC 5) complaint by client |
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Definition Used of sight or smell to collect data
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Inspection
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Used to inspect with eyes.
Example: compare one leg to other. See if something appears the same |
Symmetry
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Can be used when assessing an amount either by measuring both legs with tape measure or by feeling and assessing volume of pulse
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Equality
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Used to describe match of verbal and non verbal behavior
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Congruence
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Superficial, used to assess if depression illiciates a painfull response, also used to locate superficial lumps and bumps.
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Light palpation
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How deep should pressure be applied to perform light palpation?
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1-2 cm
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Auscultation without the use of an instrument is called?
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Direct auscultation
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Ascultation with the use of an instrument is called?
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Indirect auscultation
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This device increase the sound of pulse,
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Doppler
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When sound Doppler be used?
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If pulse cannot be felt
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Five uses of auscultation
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1) korotkoff sounds (bp)
2) heart sounds 3) lung sounds 4) sounds of peristalsis or bowel sounds 5) turbulent blood flow |
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1)Wheezing (bronchi closing) or strider noise (larynx closing)
2) frothy sputum 3) sudden or violent coughing 4) coughing up blood ( hemoptisis) Are all examples of? |
Possible airway obstructions / sign or distress
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Def - no breathing
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Apnea
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Def - difficulty breathing
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Dyspenea
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< 12 breaths per min
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Bradydyspnea
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Ischemia
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Poor tissue perfussion
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Why is pain produced by poor circulation/ poor perfusion?
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Poor perfusion results in anaerobic respiration which produces lactic acid that causes pain.
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Def- small steps then get faster, pt cannot stop abruptly
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Propulsive gait
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Pt can move individual arm based in commands.
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Active movement
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Patient cannot move limb and nurse has to pick up and move
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Passive movement
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Pallor color can be caused due to
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Sudden drop of temp, decreased blood flow, anemia
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Jaundice is caused by an increase in
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Bilirubin
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Abnormal redness
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Eruthema or hyperemia
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Bells palsy and facial drooping, parkinson's disease and asymmetry is caused due to a deficate in what nerve?
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Cranial nerve VII (7) facial
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Visual acuity is controlled by what cranial nerve?
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Cranial nerve II (2) optic
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If a person can identify a common object at 1-20ft it is said there acuity is?
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Intact
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Nearsidedness
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Myopia
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Farsidedness
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Hyperopia
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Lens is unable to change shape to accommodate close vision; has difficulty reading small print. Starts in middle years of life ~45 yrs
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Presbyopia
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Drooping of the lid over the pupil
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Ptosis
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Deficent to what cranial nerve causes drooping over the pupil or abnormalities to the pupil
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Crainial nerve III (oculomotor)
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PERRLA stands for?
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Pupils equal, round, react to light and accommodation
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Normal size of pupil is what?
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3-7 mm
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What are the two main purposes of vital signs?
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1) Monitor essential physiologic function of vital organs
2) to evalutate health status |
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Observing trends in vital signs allows the nurse to?(4)
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1) do clinical problem solving
2) make decisions about treatments/interventions 3) evaluate effectiveness of medications and treatments 4) evaluate response to illness |
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When are vital signs taken? (5)
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1) on admission
2) per hospital routine or dr orders 3) before and after surgery or diagnostic procedure, medications or nursing interventions affecting vital signs 4) before, during and after blood/blood product transfusion 5) when there is a change in clients condition or a report of physical distress |
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Heat of body determined by the balance of heat produced and heat lost.
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Body temperature (T)
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Two types of temp?
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1) core
2) surface |
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Def- reflects temperature of internal body tissues (muscles or viscer)
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Core temp
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Examples of core temp? 2 t
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Tympanic and rectal
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Def- temperature varies according to site used
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Surface
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Examples of core temps
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Temporal tympanic recal
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Surface temp is greater than core temp. T/F
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False surface temp varies based on location and is lower than core temps
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What two neurovascular aspects control body temperature?
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Hypothalamus and feedback system
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Thermoregulatory center- maintains set point. Receives messages from thermal receptors to produce body heat or increase body loss.
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Hypothalamus
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Def- when nerve cells in the hypothalamus become heated/chilled changing the set point causes compensatory mechanisms to take place. These are characteristics of what system?
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Feedback system
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What is the primary source of heat?
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Metabolism controlled by thyroid and metabolic rate
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BMR
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Heat production at rest
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What 2 actions increases body metabolism
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1)Muscle activity (excerise)
2)Shivering |
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Mechanism of heat transfer
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Heat loss
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Taking a cool bath (transfer through direct contact)
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Conduction
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Using an electric fan to cool off (through air currents)
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Convection
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Sweating and respiration
(conversion of liquid to vapor) |
Evaporation
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Fever, pyrexia
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100.4 F or 38 C
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< 96.8 F or 36 C
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Hypothermia, subnormal
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Over 85 yrs old normal body temp
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95-97 F
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Normal oral temp values
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97.6 to 99.6 F or 36.5 C to 37.5 C
Average 98.6 |
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Rectal temp is how many degrees higher or lower than oral?
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1 F or 0.5 C higher than oral
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Axillary temp is how many degrees higher or lower than oral?
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1 F or 0.5 C lower than oral
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Tempanic temp is how many degrees higher or lower than oral?
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0.5 F higher than oral
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Taking a cool bath (transfer through direct contact)
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Conduction
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Using an electric fan to cool off (through air currents)
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Convection
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Sweating and respiration
(conversion of liquid to vapor) |
Evaporation
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Fever, pyrexia
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100.4 F or 38 C
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Hypothermia: subnormal,
< 96.8 F or 36 C |
Hypothermia, subnormal
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Over 85 yrs old normal body temp
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95-97 F
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Normal oral temp values
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97.6 to 99.6 F or 36.5 C to 37.5 C
Average 98.6 |
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Rectal temp is how many degrees higher or lower than oral?
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1 F or 0.5 C higher than oral
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Axillary temp is how many degrees higher or lower than oral?
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1 F or 0.5 C lower than oral
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Tempanic temp is how many degrees higher or lower than oral?
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0.5 F higher than oral
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Average axillary temp?
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97.6
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Average oral temp?
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98.6
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Average rectal temp?
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99.6
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What type of thermometer contains gallium, indium and tin plastic?
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Mixture
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This thermometer most be shaken down and held at eye level to read
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Mixture
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(a) A digital pen-like probe with cover connected to a microprocessor chip used for oral, axillary, or rectal temperature
(b) infared sensor tip |
Electronic
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Disposable plastic strips change color; use for oral or axillary temp. Also temp sensitive tape applied to forehead or abdomen.
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Chemical
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Changes color according to skin temp
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Temp sensitive tape
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This type of route is more accurate than oral but inconvenient and invasive; gloves must be worn.r
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Rectal
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How far should a thermometer be inserted rectally for an Adult? Child?
Infant? |
-Adult-1.5 inches
-Child 1 inch - Infant 0.5 inches |
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How long should a rectal thermometer be held in place?
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2-4 minutes
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What is the safest most noninvasive temperature route?
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Axillary
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How long should a gallium thermometer be held in place for an axillary temp?
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8-10 minutes
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Which temp route receives heat from the hypothalamus?
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Tympanic
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Fever can result from what three things?
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Infection, inflammatory, or immunologic
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What triggers the fever response and acts on the hypothalamus to raise bodies set point above normal?
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Endogenous pyrogens
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Why is a fever beneficial? (3)
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1) stimulates immune system to produce disease fighting WBCs.
2) decreases iron plasma, which suppresses bacterial growth 3) in viral infections it increases production of interferons |
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Harmful causes of increased temp?
Fever over 41 C may cause? |
1)Increased Basic Metabolic Rate, P, R rates;
2) excessive sweating may lead to dehydration 3) prolonged fever my result in tissue catabolism 4) muscle wasting 5) aching 6) negative nitrogen balance 7) weightloss 8) apathy 9) delirium 10) withdrawal Fever above 41C 1) Seizure 2) neurological complications |
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The febrile episode has what 3 phases?
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-Chill Phase
-Plateau Phase -Fever break |
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During this febrile phase set point rises, client experiences chill and shivering Bc the body is trying to conserve heat
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Chill phase
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When the chill phase subsides, client experiences a warm dry feeling because the new temperature set point is reached
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Plateau phase
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When vasodilation occurs; client experiences sweating (diaphoresis) Bc the setpoint decreases and the body is attempting to lose heat or return to its normal setpoint
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Fever break (heat is lost)
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Nursing care of clients with fever
(4) |
1) assess for causality (dehydration, infection, environment - exposure to extreme heat or cold)
2) monitor VS 3) Assess skin color (flushed face) and temperature (hot,dry skin) 4) Determine phase of febrile episode; assess comfort level |
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Define- During the systolic phase of the cardiac cycle, the left ventricle ejects blood into the aorta in a wave like pulse stroke. Can be felt in the peripheral arteries
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Pulse / Heart rate
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Normal BPM
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60-100 bpm
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Volume of blood pumped out during one min
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Cardiac output
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The pulse is regulated by
the ___________ via the________. |
Autonomic nervous system (ANS)
Via the parasympathetic VAGUS nerve |
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The _____ nerve slows the heart rate.
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VAGUS
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To increase the pulse rate the __________ releases _________ and __________.
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Sympathetic nervous system,
Epinephrine, Norepinephrine |
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What are the 10 factors that affect heart rate or pulse?
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1) age
2) sex 3) activity 4) fever 5) medications 6) hemorrhage 7) stress 8) position changes 9) vagal stimulation 10) pain |
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If a pulse deficit is present what physiological deficiency may be present
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A pulse deficit occurs when the apical pulse is greater than the peripheral pulse and this could indicate a Left Ventricle contraction problem.
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A pulse deficit indicates ?
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poor peripheral perfusion
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def- pattern or spacing between beats
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rhythm
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def- strength or force; quality
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amplitude
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name and describe all pulse amplitudes
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0 = absent,
+1= difficult to feel; obliterates easily +2= normal, easy to feel; obliterates with stronger force +3= strong, bounding; difficult to obliterate |
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number of heartbeats per minute,
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pulse
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def- reflects expansibility or compliance of arteries.
-normal is soft, pliable. -abnormal is hard, twisted, tourted |
elasticity
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def- always compare peripheral pulses on right to the left.
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Equality
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What five characteristics related to pulse should be reported immediately?
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1) absent, weak, thready pulse;
pulse deficit 2) significant change in resting pulse 3) change in volume or rhythm 4) cool, pale skin |
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how should pulse be documented?
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location, rate, rhythm, volume, elasticity
Ex: radial 88/m regular, +2 smooth or apical 54/m, irregular |
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what is stroke volume?
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total volume of blood into aorta with each contraction
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what is cardiac output?
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volume of blood pumped out of the heart during one min.
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cardiac output = ____+____
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Heart rate + Stroke volume = Cardiac output
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act of breathing for one minute
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respiration
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cycle of inspiration and expiration counts as ?
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one breath
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Three main muscles of respiration
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A. Diaphragm
B. Intercostal C. Accessory |
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intercostals are named for what?
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rib above it
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What are the three processes of respiration?
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A. Ventilation
B. Diffusion C. Perfusion |
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def- moving air in and out
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ventilation
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getting through aveoli
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Diffusion
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what is stroke volume?
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total volume of blood into aorta with each contraction
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what is cardiac output?
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volume of blood pumped out of the heart during one min.
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cardiac output = ____+____
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Heart rate + Stroke volume = Cardiac output
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act of breathing for one minute, the mechanism the body uses to exchange gases between the atmosphere, the blood, and the cells.
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respiration
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mechanical movement of gases into and out of the lungs
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ventilation
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Three main muscles of respiration
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A. Diaphragm
B. Intercostal C. Accessory |
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intercostals are named for what?
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rib above it
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What are the three processes of respiration?
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A. Ventilation
B. Diffusion C. Perfusion |
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def- moving air in and out
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ventilation
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the movement of CO2 and O2 between the alveoli and the RBC
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Diffusion
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what is stroke volume?
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total volume of blood into aorta with each contraction
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what is cardiac output?
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volume of blood pumped out of the heart during one min.
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cardiac output = ____ times ____
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Heart rate times Stroke volume = Cardiac output
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act of breathing for one minute, the mechanism the body uses to exchange gases between the atmosphere, the blood, and the cells.
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respiration
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mechanical movement of gases into and out of the lungs
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ventilation
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Three main muscles of respiration
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A. Diaphragm
B. Intercostal C. Accessory |
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intercostals are named for what?
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rib above it
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What are the three processes of respiration?
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A. Ventilation
B. Diffusion C. Perfusion |
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def- moving air in and out
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ventilation
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the movement of CO2 and O2 between the alveoli and the RBC
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Diffusion
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the distribution of RBC to and from the pulmonary capillaries
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perfusion
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What are the five Neural and Chemical Regulation aspects control respirations?
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1) Neural Regulation
2) Cerebral Cortex 3) Medulla oblongata 4) Chemical regulation 5) Chemoreceptors |
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What 4 things need to be observed when assessing respiration?
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-rhythm
-rate -effort/ease -depth |
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normal breaths per minute for an adult
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12-20 breaths per minute
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def- normal unlabored breathing
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eupnea
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def- abnormal respiration use of accessary muscles, open mouth breathing
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labored
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def- breathlessness difficulty breathing
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dyspnea
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def- must assume a particular position to breath, nasal flarring
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orthopenea
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< 12 breaths per minute?
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bradypnea
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> 20 breaths per minute
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tachypnea
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def-no breathing
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apnea
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describes normal depth of respiration
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-full
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describes very little movement during respiration
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-hypoventilation
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increase in respiratory rate, results in excess amounts of CO2 elimination
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-hyperventilation
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expands small airways
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sigh
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def- abnormal very deep, very rapid breath pattern, ketoacidosis and metabolic disfunction are associated
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Kussmaul
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def- happens to the critical ill, very repititous breathing, characterized by slow breathing, then deep breathing, slow breathing, then no breathing
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Cheyne-Stokes
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breathing characterized by totally erratic, happens during death
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Agonal
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Factors that influence the character of respiration (8)
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- exercise
- acute pain - anxiety - smoking - body position - medications - neurological injury - hemoglobin function |
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normal respiration limits for an elderly patient?
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22-24 breaths per minute
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device that measures O2 saturation
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pulse ox
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normal pulse ox?
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95-100%
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life threatening pulse ox level?
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< 70%
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measures the arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle.
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Arterial Blood Pressure
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high value, as the left ventricle ejects blood, more pressue
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systolic BP
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lower value, when the heart relaxes
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diastolic pressure
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pulse pressure equals?
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difference in systolic and diastolic BP.
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normal pulse pressure?
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30-50 mm Hg
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what could be indicative of low pulse pressure?
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may indicate neurological or cardiac dysfunction
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what would have to be present to treat hypotension?
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symptoms
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name the different stages and ranges of hypertension
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stage 1= 140/90 - 159/99
stage 2= 160/100-or above |
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what are normotensive bp values?
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90/60 - 119/79
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name pre-hypertension bp values
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120/80 - 139/89
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resistance to blood flow determined by the tone of vascular musculature and the diameter of the blood vessel
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peripheral resistance
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volume of blood circulating within the vascular system
(don't over think : ) |
blood volume
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thickness of blood
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viscosity
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normal pcv?
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37-52%
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ability of the arteries to stretch
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elasticity ( increased elasticity results in lower blood pressure)
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decreased blood volume
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hypovolemia
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increased blood volume
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hypervolemia
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factors affecting blood pressure (8)
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1) Age
2) Stress 3) Gender 4) Race 5) Diurnal Variations 6) Medications 7) Activity 8) Disease Process |
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As a person ages elasticity in arteries decreases resulting in?
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increased blood pressure
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What act on sympathetic response causes vasoconstriction and increases peripheral blood pressure?
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Stress
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True/False
Males have higher blood pressure than women until menopause then blood pressures between genders level out? |
True
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What ethnicity is more prone to elevated blood pressure?
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African American
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Blood pressure is lower or higher in the morning?
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Blood pressure decrease at night time and is lower in the morning that it is as the day progresses
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A diet low in ____ and high in ___ can lower blood pressure.
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Sodium, Potassium
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Describe each Korotkoff sound 1.
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K1- clear, rhythmic tapping series that corresponds to the pulse rate and gradually increases intensity. onset of this sound corresponds to the systolic pressure
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Describe Korotkoff sound 2
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K2- murmur or swishing sound
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Describe Kortokoff sound 3
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K3- Becomes crisper and more intense tapping
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What is significant regarding Kortokoff 4?
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K4- The onset of K4 is the diastolic reading in infants and children, pregnant women, and patients with elevated cardiac output or peripheral vasoconstriction
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What is K5?
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disapperance of bp sound; Diastolic value in adolescence and most adults
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present when the systolic blood pressure drops to
90 mmHg or below. |
Hypotension
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What contributors could cause hypotension? (2)
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-hemorrhage
-myocardial infarction |
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occurs when arteries dilate, the peripheral vascular resistance decreases, the circulating blood volume decreases, or the heart fails to provide cardiac output
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hypotension
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signs and symptoms associated with hypotension.(8)
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- pallor
- skin mottling - clamminess - confusion - dizziness - chest pain - increased heart rate - decrease urine output |
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referred to as postural _______, is a reduction of systolic blood pressure of at least 20mm Hg or reduction of diastolic blood pressure of at least 10mm Hg within 3 minutes of quiet standing
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orthostatic hypotension
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two methods to assess BP.
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Direct- Arterial line
Indirect a. palpatory (systolic reading only) b. auscultatory |
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disappearance of sound when obtaining a blood pressure; typically occurs between the first and second korotkoff sounds.
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ausculatory gap
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