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79 Cards in this Set
- Front
- Back
With what is the Optic nerve associated and how might test?
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Visual fields
Test = Snellen chart |
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Skin Assessment
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* Skin, hair, nails
* Inspection and palpation * Pallor - may be sign of inadequate circulation; decreased oxygen; decreased hematocrit - brown skin people = yellowish - black people = ashen gray * Cyanosis - bluish; decreased oxygen. Blue around lips and fingernails. - black people lips are pale (not red) * Jaundice - Yellow. First noticeable in sclera of eyes * Erythema - redness or rash * Skin Lesions |
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List characteristics of effective communication.
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* Rapport
* Specific objectives * Comfortable environment * Privacy * Confidentiality * Client focus * Use of nursing observations * Optimal pacing * Providing personal space |
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With what is the Glossopharyngeal nerve associated and how test?
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Swallowing ability
Test = Apply tastes on posterior tongue for identification. Ask patient to move tongue. |
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Differentiate between social and therapeutic communication.
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Therapeutic communication techniques assist the flow of communication and always focus on the client. Social Response focuses attention on the nurse instead of the client. |
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Deep Palpation
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* Done with two hands
* Top hand applies pressure while the bottom hand relaxes to perceive the tactile sensations. * Done with caution * Not indicated in patients with abdominal pain Be sensitive to verbal and facial expressions of pain. |
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List blocks to communication
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1 - Giving Reassurance - "You'll be just fine"
2 - Approving - "I'm glad to see you're cheerful today" 3 - Disapproving - "Now don't be so glum" 4 - Agreeing - "That's right. You do need to look at the bright side" 5 - Disagreeing - "No, you're wrong about that" 6 - Rejecting - "Don't think about that. It's too depressing" 7 - Denying - Pt. "I'm not worth bothering with", Nurse "Of course you are" 8 - Belittling - Pt. "I don't want to live like this" Nurse "You'll feel different in the morning" 9 - Interpreting - Underneath you really feel..." 10 - Making a stereotyped comment - "Chin up" 11 - Introducing an unrelated topic/Changing the subject 12 - Challenging - "It isn't possible for that to happen" 13 - Demanding an explanation - "Why do you feel that way?" 14 - Defending - "This is a fine institution" |
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Components of Assessing the Peripheral Vascular System (PVS)
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* - Measuring blood pressure
* - Palpating peripheral pulses * - Inspecting, palpating, and auscultating the carotid pulse * - Inspecting the jugular and peripheral veins * Inspecting the skin and tissues to determine perfusion |
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List forms of Verbal Communication
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1 - Vocabulary
2 - Denotative/connotative meaning 3 - Pacing 4 - Intonation 5 - Humor 6 - Clarity 7 - Timing and relevance |
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Percussion Sounds (p. 297 SDM)
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* Normal lung areas produce a resonance sound.
* Liver sounds are dull. * Flat sound over muscle * Flatness = dense tissue, like bones * Hollow sounds = lungs * Hyperracone (sp?) "booming" as heard in emphysema * Dullness (thud) = liver, spleen, heart * Tympany = air in belly |
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List forms of Non-verbal communication
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1 - Body language
2 - Tone 3 - Posture/Position 4 - Gestures 5 - Touch 6 - Vocal cues 7 - Physical appearance 8 - Facial expressions 9 - Distance or spatial territory |
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With what is the Auditory nerve associated and how test?
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Equilibrium
Test = assess with cerebellar functions |
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Give examples of how to facilitate active listening.
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1 - Acknowledgment - ex. "yes, go on", I hear what you're saying"
2 - Clarification - ex. "I don't understand. Can you say that a different way?" 3 - Feedback - ex. "You did that well." 4 - Focus - focusing or re-focusing on a statement. Ex. "You were telling me how hard..." 5 - Incomplete sentences - ex. "Then your relationship is one of..." 6 - Listening 7 - Minimum verbal activity - let patient lead. Ex. "go on" 8 - Mutual fit or congruence - creating harmony of verbal and nonverbal messages. 9 - Nonverbval Encouragement - ex. Nodding 10 - Open-ended questions - ex. who, what, why, where, when, how questions 11 - Paraphrase 12 - Reflection 13 - Restatement 14 - Validation - ex. "Yes, it is confusing with people around." |
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Purpose of Head to Toe Assessment
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* Obtain baseline data
* Supplement, confirm, or refute data * Make clinical judgments on patient's health status * Obtain data to help nurse establish NDx and patient care * To evaluate outcomes of healthcare and patient progress |
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List Forms of Communication
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* Interpersonal communication
* Public communication |
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With what is the Abducens nerve associated and how test?
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EOM; moves eyeball laterally
Test = assess directions of gaze |
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Which system is done in different order than IPPA?
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Abdomen
Inspection Auscultation Percussion Palpation |
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Types of Skin Lesions - (pg. 313 SDM)
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- Macules - flat locales changes in color
- Papules, plaques, nodules - solid elevated varying in size - Wheals - elevated, circumscribed, transient - Vesicles and bullae - clear, fluid-filled pockets between skin layers - Pustules - vesicles or bullae filled with exudate |
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List Means of Communication
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* Touch
* Expression * Gesture * with symbols * with words * with silence |
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What is attributed to the DUPP S2 sound?
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Closing of the Semi-Lunar valves.
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What might CRACKLES indicate?
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Air is moving through mucous or fluid.
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Head to Toe Physical Assessment
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* Begin with a general survey of the patient
* Vital Signs * General Appearance - Body build, posture * Behavior - Depressed, odd, calm, cooperative, combative...listen to speech |
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List two causes of poor communication
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1 - Ambiguity
2 - Discrepancy in a message |
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With what is the Olfactory nerve associated and how might a nurse test.
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Smell...
Ask client to close eyes and identify odors. |
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Where are Bronchial Sounds heard?
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Over the trachea, above the sternal notch
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Zones of Touch
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* Social Zone (permission not needed)
- Hands, arms, shoulders, back * Consent Zone (permission needed) - Mouth, wrists, feet * Vulnerable Zone (special care needed) - Face, neck, front of body * Intimate Zone (great sensitivity needed) - Genitalia |
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Elements of Communication
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* Referent = motivates one person to communicate with another
* Sender = the person who delivers the message * Message = info sent by the sender * Channels = means of conveying the message * Receiver = the person to whom the message is sent * Environment = The physical and emotional atmosphere present at the time of interaction * Feedback = indicates whether the meaning of the sender's message was received |
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Managed Care
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* Cost containment system
* Largest provider for health care in the U.S. * Focus on quality of care/cost of care * Controversial with health care professionals and the public * Use of health care providers who agree with payment for service * Nurses function as case managers |
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What are some characteristics of bronchial sounds (i.e. pitch, amplitude, sound, is it longer during expiration or inspiration)?
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High pitch
High amplitude Harsh, loud, tubular quality Expiration is longer than inspiration |
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Bases are at the top of the heart
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Apices (apex) is at the bottom.
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Relationships between verbal and non-verbal
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* Repeating
* Contradicting * Complementing * Accenting * Relating and regulating statements * Substituting |
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What are characteristics of bronchovesicular sounds (i.e. pitch, amplitude, sound quality, is inspiration or expiration longer in duration)?
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Moderate to high pitch
Moderate amplitude Hollow, muffled quality Inspiration and expiration are equal in duration |
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Charting for Potential Legal Problems
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* Use facts
* Do not use pat phrases. Be specific. * Be professional. Do not make interpretations. State what happened. * Chart potentially serious situations * Use correct language and medical terms. * Report problems to appropriate authorities, such as suspected child abuse. * Provide the best care you are capable of giving. |
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List the different breath sounds.
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1 - Bronchial Sounds
2 - Adventitious Sounds 3 - Bronchovesicular Sounds 4 - Normal Sounds |
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Components of the termination phase
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- ending relationship
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Define Non-Verbal Communication
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Exchange of information without the use of words; it is what is not said; "body language"
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List purposes of documentation.
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1 - Legal document
2 - Safety of patient/staff 3 - Progress (or lack of)/Response to care 4 - Evaluating that tasks are completed by assigned personnel 5 - Communication 6 - Provides continuity of care 7 - Changes in condition (SDM, p. 46) 1 - Charting communicates info, such as facts, figures, and observations to other members of the healthcare team 2 - Charting assists supervisory personnel to evaluate the staff's performance on a day by day basis for specific patients. 3 - Charting provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution. |
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What might RHONCHI indicate?
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Constricted airway; louder and coarser than wheezes.
Gurgles, may clear with a cough. |
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List the 4 phases of Therapeutic Relationship
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1 - Preinteraction
2 - Orientation (Introductory) 3 - Working 4 - Termination |
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List Psychological Barriers to Communication
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* Psychological
- Depression - Flight of ideas - Word salads - Use of the same word/phrases |
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Components of Neurological System Assessment
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* Routine Screening Test
* Mental status including level of consciousness * Cranial nerves * Reflexes * Motor function * Sensory function |
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List 4 "zones" of personal space.
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* - Public Zone = 12+ feet (strangers)
* - Social Zone - 4-12 feet * - Personal Zone - 1.5 - 4 feet * - Intimate Zone - Body - 1.5 feet |
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List purposes of the incidence report.
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- help document quality of care
- identify areas where in-service education is needed - record the details of an incident for possible legal reference |
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List Communication and factors that may influence it...
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1 - Attitude
2 - Sociocultural or ethnic background 3 - Past experiences 4 - Knowledge of the subject matter 5 - Ability to relate to others 6 - Interpersonal perceptions 7 - Environmental factors |
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List characteristics of Admission Charting.
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* What patient was like when admitted
* What medications patient is taking * OTC medications * Herbal meds * Ask about pain/symptom - "What's wrong?" |
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What might PLEURAL FRICTION RUB indicate?
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High-pitched; absence of pleural fluid.
Lower anterior; "creaking" |
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Components of the orientation phase.
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- establish rapport
- determine interventions and expectations - gather info for patient database - identify strengths and limitations - formulate NDx - set goals - develop POC - explore feelings of nurse and patient |
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List Physical Barriers to Communication
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* Physical
- Respiratory - Oral/nasal cavities - Speech center - Auditory system |
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With what is the Oculomotor nerve associated and how test?
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Extraocular eye movement (EOM)
Test = Assess six ocular movements and pupil reaction. |
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What might WHEEZES indicate?
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Constricted airways.
Wheezes will not clear with a cough. |
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List types of information to be recorded on a chart.
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Physical
Psychosocial Environmental Self-care Educational Planning Discharge Planning Cheif complaint Present Health Status Health history Family History Lifestyles Nutrition - preferences/restrictions |
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What might STRIDOR indicate?
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Inspiratory wheeze; heard in neck.
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List major components of documentation.
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1 - Nursing Process
2 - Precise measurement 3 - Pain scales 4 - Patient quotes 5 - Administration of meds/treatment 6 - Preparation for tests 7 - Signature and title 8 - NEVER document something like "patient fell" 9 - "Do not get even in the chart" 10 - Use only approved medical terminology and abbreviations 11 - Be specific, clear and concise 12 - Use correct spelling 13 - Leave no blank lines |
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List types of adventitious sounds.
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Crackles (discontinuous)
Wheezes (continuous) Rhonchi (continuous) Pleural friction rub (continuous) Stridor (continuous) |
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Components of the working phase.
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- maintain trust and rapport
- promote client insight - problem solve - overcome patient resistance - evaluate progress |
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Where are bronchovesicular breath sounds normally heard?
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Over the mainstem bronchi below the clavicles and adjacent to the sternum between scapulae.
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Components of Urinary Tract Assessment
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* Look at external urethra
* Urine output * Bladder distention * Pain |
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What does IPPA stand for?
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Inspection
Percussion Palpation Auscultation |
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Components of the Preinteraction phase.
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- Obtain available info about the client from chart, others, etc.
- Examine one's own feelings about working with the patient. |
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List three Charting Systems.
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1 - Problem-oriented
2 - Source-oriented 3 - Computer-Assisted |
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Pitch
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* Frequency of the vibrations
* Low Pitch - abnormal to heart tones * High Pitch - bronchial sounds; bowel sounds |
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Best Practice for Nursing Documentation.
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1 - Write clearly and legibly
2 - Do not erase or "white-out" 3 - To correct an error, strikeout with one line 4 - Use approved abbreviations and symbols 5 - Document close to time when collected 6 - Transcribe accurately 7 - Do not leave blank spaces 8 - Time and date each entry 9 - Document like a reporter. 10 - Do not state that incident reports have been filed 11 - Follow facility polices for documentation 12 - Use carat to add words 13 - Label late entries appropriately. 14 - Make sure all information will be picked up by a copy machine. |
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Quality
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* Subjective
* Whistling, gurgling, or snapping |
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What is attributed to the LUBB sound of S1?
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Closing of the AV valves.
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List Components of Head to Toe Assessment
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Components of Head to Toe Assessment
* General Appearance * Inspection = to look at * Palpation * Percussion = to listen * Auscultation = to listen |
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List two types of interactions
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1 - Social - occur daily; pleasantries, etc.
2 - Therapeutic - helping or encouraging the patient to communicate feelings of perceptions, fears, anxieties, frustration, expectations, and increased dependency needs. |
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List Techniques which promote effective communication
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* Rapport
* Specific objectives * Comfortable environment * Privacy * Confidentiality * Client focus * Use of nursing observations * Optimal pacing * Providing personal space |
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Where is the Peripheral Vascular System most often measured?
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* measured most often using feet (farthest point from the heart)
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List Characteristics of Inspection
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* Visual Examination
* Deliberate, purposeful, and systematic * Assess moisture, color, and texture * Assess shape, position, size, color, and symmetry |
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List characteristics of Admission Protocol.
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* Availibality of advanced directives
* The client's bill of rights is presented * Admission assessment is completed by a RN within a specified time period * All clients must be clearly identified by a legible identification band |
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Describe Percussion
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* Act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt
* Direct used for the sinuses...ASK PATIENT ABOUT PAIN * Indirect - using the finger of one hand to tap the finger of the other * Indirect used for abdomen and lungs |
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With what is the Trochlear nerve associated and how test?
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EOM, specifically moves eyeball downward and laterally
Test = assess six ocular eye movements. |
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Palpation
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* Examination using touch
* Pads of the fingers * Can assess texture, temperature, vibration, position, size, mobility of organs or masses, distension, pulsation, and pain upon pressure |
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List components of Discharge Charting.
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* Summarize patient's stay
* Patient family education * Referrals (ex. community referrals) |
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Duration
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* Long or short
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With what is the Facial nerve associated and how test?
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Facial expression; taste
Test = ask patient to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly |
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Intensity
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* Loudness or softness
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With what is the Trigemenal nerve associated and how test?
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Sensation of cornea, skin of face, and nasal mucosal
Test = Seek blink reflex by touching sclera |
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Describe Auscultation
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* Listening to sounds produced within the body
* Auscultated sounds are described according to their pitch, intensity, duration, and quality |