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50 Cards in this Set
- Front
- Back
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How often should a pt. be assessed?
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once a shift
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name the four techniques to assess a pt.
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inspection, palpation, percussion and auscultation
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What two techniques are performed during an assessment by using fingers and hands?
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Palpation and percussion
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Why is palpation and percussion used to assess a pt.
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Abnormalities of sound
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What types of abnormalities could be found during palpation and percussion?
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Vocal fremitus
enlarged organs organ displacement chest expansion |
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What assessment technique is accomplished with a stethoscope?
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Auscultation
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During auscultation what is being assessed?
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breath sounds
heart sounds bowel sounds |
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A total client assessment begins with?
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a nursing health history
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a complete health history includes what elements?
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Biographic information
Chief complanint present health status or illness health history family history psychosocial factors nutrition domestic violence |
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age, sex, educational level are considered what type of information?
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biographic
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the condition that brought the client to health care facility is
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Chief Complaint
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onset of problem, clinical manifestations, including severity of symptoms:pain is considered?
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Present health status
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past illnesses,surgeries,
hospitalizations,allergies,otc,herbal supplements and general habits are considered? |
Health history
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age and health status of parents,siblings is considered
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family history
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cultural beliefs, spiritual beliefs that influence health mgmt. is?
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psychosocial factors
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dietary habits preferences or restrictions are
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nutrition
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domestic violence
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a JCAHO requirement
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during inspection observe?
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skin color and texture
check for lesions hair distribution can be out of bed gait stance verbal,behavioral responses mental status |
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While performing palpation determine?
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position of the organs,size and consistency.
fluid accumulation pain masses surface of hand for vibration, temperature and moisture/dry. |
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Percussion produces_____ by using the finger as a hammer.
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sound waves
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sound or tone of the vibration curing percussion is determined by?
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body area or organ percussed
Normal lung sounds liver sounds muscle sounds |
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A normal lung sound is called?
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resonance
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Liver sounds are?
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dull
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Muscle sound is?
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flat
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the bell of a stethoscope during auscultation detect____ pitched sounds?
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low
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the diaphragm of the stethoscope detects ____ pitches sounds during auscultation
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high
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a focus assessment is also called a
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shift assessment
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Level of consciousness LOC
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responds to questions of time,place,person,purpose
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sign of abnormal LOC
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Drowsy
difficult to asaken difficult answering questions memory defect irritable |
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motor responses
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eyes open
stick out tonque squeeze finger move arms and legs |
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pupil assessment
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size
shape equality reaction to light(dilate/constrict) |
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choreiform
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jerky and quick
present in Sydenham's chorea |
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flaccid posturing
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no motor response
could be to brain injury |
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athetoid
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twisting and slow
present in cerebral palsy |
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tremors
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"the shakes"
hyperthyroidism,cerebellar ataxia, parkinsonism |
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Seizures are seen in
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brain injury
heat stroke electrolyte imbalance |
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Asterixis is seen in
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metabolic encephalopathy due to kidney or liver failure
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opiate effect on pupils is
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pinpoint and fixed
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a sign that the parasympathic and sympathetic nervous systems are not in synchronization(pupils)
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unequal
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The light reflex is the most important sign for what problem
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diabetic coma
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client close eyes and can hold arms for 20 to 30 seconds he has good ____ _____
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muscle strength
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legs extended,feet extended with plantar flexion,arms internally roatated and flexed on chest may be due to lesion of corticospinal tract near cerebral hemisphere
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decorticate posturing
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arms stiffly extended and hands turned outward and flexed,legs extended with plantar flexion. may be due to lesion in diencephalon,pons or midbrain
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decerebrate posturing
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Glasgow coma scale consist of three phases, what are they?
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motor response
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motor responses glasgow coma scale responses are?
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obeys a simple command6
feels painful stimuli5 withdraws from painful stimuli4 decorticate posturing3 decerebrate posturing2 no motor response to pain1 |
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verbal responses glasgow coma scale response are?
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Oriented5
Confused conversation or disorientation of place,time,etc4 Inappropriate use of words3 responds with incomprehensive sounds2 nor verbal response1 record T if endotrach is present |
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Eye opening glasgow coma scale response are?
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Spontaneous when a person approaches4
in response to speech3 only in response to pain2 do not open even to pain1 record C if closed by swelling |
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the score of 3 on the Glasgow Coma Scale indicates
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deep coma
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if a catheter is in place check urine for:
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color,odor,consistency and amount
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ability of lens to adjust to objects at varying distances
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accommodation
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