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45 Cards in this Set
- Front
- Back
What is the importance of a physical assessment
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1) to provide baseline data to allow nurse to monitor changes and patterns in client's status
2) opportunity to determine risks, deficits, strengths of client 3) insight into factors contributing to the health issue/concern |
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Nursing interventions may be related to...
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prevention
advocacy treatment return to the community |
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Things to note when first seeing patient
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1) general survey
2) physical presence 3) psychological presence 4) visible distress |
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4 types of health histories
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1) emergency - most important things
2) complete - upon admission 3) Focus-specific concern 4) follow up |
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Percussion sounds
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flat
dull tympany resonance hyperresonance |
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Components of timing used to describe symptom experience
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onset
frequency duration |
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CAGE screening tool
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alcoholism screening tool
C - have you ever felt you should cut down on your alcohol intake A - have people annoyed you by criticizing your alcohol intake? G - have you ever felt guilty about your alcohol intake? E - have you ever needed alcohol for an eye-opener? |
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4 A's of smoking cessation
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Ask
Advise Assist Arrange |
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HITS screening tool
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H - have you ever been physically hurt?
I - have you been insulted or did someone talk down to you? T - have you been threatened with physical harm? S - has someone screamed at you or cursed you? |
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What are the components of routine practices?
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must be used with each patient for every encounter:
-handwashing -gloves -mask, eye protection, face shield -gowns -accomodation patient care equipment -environmental control |
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What does light palpation reveal?
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skin texture and moisture
overt, large, or superficial masses fluid muscle guarding superficial tenderness |
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What is direct vs. indirect auscultation?
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direct - listening with unaided ear
indirect - listening with stethoscope |
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What sounds do the bell and diaphragm transmit?
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bell - low
diaphragm - high |
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Things to observe in a general survey - physical presence
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stated age vs. apparent age
general appearance body fat stature motor activity body and breath odours |
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Things to observe in a general survey - psychological presence
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dress, grooming, personal hygiene
mood and manner speech facial expressions |
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Things to observe in a general survey - distress
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laboured breathing
painful facial expression, sweating, physical protection of painful area serious or life-threatening occurences sign of emotional distress or anxiety |
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Normal resp rate:
1) newborn 2) 1 year 3) 3 years 4) 6 years 5) 10 years 6) 14 years 7) adult |
1) newborn (30-50)
2) 1 year (20-40) 3) 3 years (20-30) 4) 6 years (16-22) 5) 10 years (16-20) 6) 14 years (14-20) 7) adult (12-20) |
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What is tachypnea?
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>20 breaths/min in adult
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What is bradypnea?
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<12 breaths/minute in adult
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What is apnea?
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absence of spontaneous breathing for 10 or more seconds
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factors affecting pulse rate - physiological
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SA node
parasympathetic/vagal stimulation of ANS (decreases) sympathetic stimulation of ANS (increases) baroreceptor sensors - detect changes in BP |
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factors affecting pulse rate
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age
gender (female higher) activity emotional status pain environmental factors stimulants medications disease state stress fever hemorrhage |
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3 and 4 point scales for measuring pulse volume
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3pt scale
0 - absent 1+ - thready/weak 2+ - normal 3+ - bounding 4pt 0 - absent 1+ - thready/weak 2+ - normal 3+ - increased 4+ - bounding |
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Pulse sites
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temporal
carotid apical brachial radial femoral popliteal posterior tibial dorsalis pedis |
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Pulse rate - normal
1) newborn 2) 1 year 3) 3 years 4) 6 years 5) 10 years 6) 14 years 7) adult |
1) newborn (100-170)
2) 1 year (80-160) 3) 3 years (80-120) 4) 6 years (70-115) 5) 10 years (70-110) 6) 14 years (60-110) 7) adult (60-100) |
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What is tachycardia?
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>100 bpm in adult
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What is bradycardia?
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<60 bpm in adult
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What is asystole?
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absence of pulse
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Factors affecting respiratory rate
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exercise
stress increased altitude medications |
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Components of pulse to observe
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rate
rhythm volume site |
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factors affecting temperature
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circadian rhythm patterns (0.5-1 deg fluctuation throughout day)
hormones age exercise stress environmental extremes |
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temperature measurement methods
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oral
axillary rectal tympanic |
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When does hyperthermia occur?
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body temperature >38.5 degrees
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When does hypothermia occur?
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body temperature <34
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Oral temperature normal range
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36-38 deg
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rectal temperature normal range
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36.7-38 deg (usually 0.4 higher than oral)
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axillary temperature normal range
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35.4-37.4 (usually 0.6 lower than oral)
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What are you listening for when taking BP?
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1st sound - systolic pressure, force needed to pump blood out of heart
absence of sound when cuff pressure is released enough for normal blood flow - diastolic reading |
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What is systolic pressure in BP?
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pressure exerted on arterial walls when ventricles are contracting
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What is the diastolic pressure in BP?
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pressure in arteries when ventricles are relaxed and filling
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Average BP in adult
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<120/<80
-decreases with age |
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What is nociceptive pain?
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from somatic or visceral stimulation
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Types of pain
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cutaneous - stimulation of cutaneous nerves, burning,
somatic - often from MSK injuries visceral - from organ injuries referred - perceived in a location other than where pathology is occuring |
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factors affecting pain
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sex
age previous experience with pain cultural expectations |
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Pain scales for children
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oucher (faces)
Baker FACES pain intensity scale |