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45 Cards in this Set

  • Front
  • Back
What is the importance of a physical assessment
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
Nursing interventions may be related to...
prevention
advocacy
treatment
return to the community
Things to note when first seeing patient
1) general survey
2) physical presence
3) psychological presence
4) visible distress
4 types of health histories
1) emergency - most important things
2) complete - upon admission
3) Focus-specific concern
4) follow up
Percussion sounds
flat
dull
tympany
resonance
hyperresonance
Components of timing used to describe symptom experience
onset
frequency
duration
CAGE screening tool
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?
4 A's of smoking cessation
Ask
Advise
Assist
Arrange
HITS screening tool
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?
What are the components of routine practices?
must be used with each patient for every encounter:

-handwashing
-gloves
-mask, eye protection, face shield
-gowns
-accomodation
patient care equipment
-environmental control
What does light palpation reveal?
skin texture and moisture
overt, large, or superficial masses
fluid
muscle guarding
superficial tenderness
What is direct vs. indirect auscultation?
direct - listening with unaided ear
indirect - listening with stethoscope
What sounds do the bell and diaphragm transmit?
bell - low
diaphragm - high
Things to observe in a general survey - physical presence
stated age vs. apparent age
general appearance
body fat
stature
motor activity
body and breath odours
Things to observe in a general survey - psychological presence
dress, grooming, personal hygiene
mood and manner
speech
facial expressions
Things to observe in a general survey - distress
laboured breathing
painful facial expression, sweating, physical protection of painful area
serious or life-threatening occurences
sign of emotional distress or anxiety
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)
What is tachypnea?
>20 breaths/min in adult
What is bradypnea?
<12 breaths/minute in adult
What is apnea?
absence of spontaneous breathing for 10 or more seconds
factors affecting pulse rate - physiological
SA node
parasympathetic/vagal stimulation of ANS (decreases)
sympathetic stimulation of ANS (increases)
baroreceptor sensors - detect changes in BP
factors affecting pulse rate
age
gender (female higher)
activity
emotional status
pain
environmental factors
stimulants
medications
disease state
stress
fever
hemorrhage
3 and 4 point scales for measuring pulse volume
3pt scale
0 - absent
1+ - thready/weak
2+ - normal
3+ - bounding

4pt
0 - absent
1+ - thready/weak
2+ - normal
3+ - increased
4+ - bounding
Pulse sites
temporal
carotid
apical
brachial
radial
femoral
popliteal
posterior tibial
dorsalis pedis
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)
What is tachycardia?
>100 bpm in adult
What is bradycardia?
<60 bpm in adult
What is asystole?
absence of pulse
Factors affecting respiratory rate
exercise
stress
increased altitude
medications
Components of pulse to observe
rate
rhythm
volume
site
factors affecting temperature
circadian rhythm patterns (0.5-1 deg fluctuation throughout day)
hormones
age
exercise
stress
environmental extremes
temperature measurement methods
oral
axillary
rectal
tympanic
When does hyperthermia occur?
body temperature >38.5 degrees
When does hypothermia occur?
body temperature <34
Oral temperature normal range
36-38 deg
rectal temperature normal range
36.7-38 deg (usually 0.4 higher than oral)
axillary temperature normal range
35.4-37.4 (usually 0.6 lower than oral)
What are you listening for when taking BP?
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
What is systolic pressure in BP?
pressure exerted on arterial walls when ventricles are contracting
What is the diastolic pressure in BP?
pressure in arteries when ventricles are relaxed and filling
Average BP in adult
<120/<80

-decreases with age
What is nociceptive pain?
from somatic or visceral stimulation
Types of pain
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
factors affecting pain
sex
age
previous experience with pain
cultural expectations
Pain scales for children
oucher (faces)
Baker FACES pain intensity scale