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175 Cards in this Set

  • Front
  • Back
(def)

includes biographical data, nursing health history, chief complaint, present illness, past medical history, health patterns, and Review of systems
Nursing Interview
(def)

The answer to the question "What is troubling you?" or "Can you tell me the reason you came to the hospital today?". This should be recorded in the client's own words.
Chief Complaint
(def)

a subjective statement made by a patient describing the most significant or serious symptoms or sings of illness or dysfunction that caused him or her to seek health care
Chief Complaint
Would behavioral examination data be considered subjective or objective?
objective
(def)

physical examination (baseline) as the client enters the health care system
Initial Exam
(def)

ongoing physical examinations; used to assess an area of concern or evaluate an intervention
focused
What 3 things are included in a comprehensive physical examination?
- Nursing Interview
- Health History
- Physical Examination
(def)

a systematic, orderly process by which the nurse collects objective data about the client's body, mind, and spirit. It is a critical investigation and evaluation of the client's present status.
physical examination
What are the 6 purposes of the data collected during a physical examination?
- evaluate the client's present state of health
- supplement, confirm, or refute data obtained in the nursing history
- develop (plan) individualized client care
- evaluate the outcomes of care
- make clinical judgments about the client's health status
- identify areas for health promotion and disease prevention
(def)

comparing data with another source
validation
As a student, we are responsible for knowing _______ _______ for the client's age, sex, and condition in life.
normal findings
The student nurse (and professional RN) is responsible for collecting data in a professional manner using _____ _______.
proper technique
The student nurse (and professional RN) must _____ and _____ data collected. Additionally, you should be able to identify trends and changes.
validate and analyze
As a student nurse, you should be able to identify normal findings from what?
abnormal findings
What should you do (as a student nurse) as soon as you obtain data that is significantly different or abnormal?
report these findings to your Clinical Instructor as soon as data is obtained
What does the abbreviation WNL mean?
within normal limits
How should you introduce yourself to the client on the first visit?
Greet the client professionally, handshake (if culturally acceptable), smile, clearly state your name and title.
What would you say your title is when you introduce yourself to a client.
Student Nurse @ CSN
In preparing the client for assessment, you should always offer a time frame and offer the client an opportunity to do what?
use the restroom
What are some standard procedures when you are preparing the client for assessment? (5)
- inform client what will be done (where, when, why)
- verify identity using agency protocal
- state that information is confidential
- determine if any positions are contraindicated for the client
- provide privacy (even in a private room)
Most examinations are performed in what position?
Low Fowlers or a sitting position
What is the normal time frame for an examination?
15-20 minutes
What approach will you use in Basics when doing a physical exam?
Cephalocaudal (head to toe)

(see handout and Text, 566, Box 30-1)
True/False:

You should NEVER ask visitors to leave when doing a PE.
FALSE- Always provide privacy by asking visitors to leave the room **remember to close drapes and the door**
True/False:

You should wash your hands before and after performing a PE.
True
All information obtained in the PE should be professionally communicated in the ________ ________ and to the appropriate healthcare team members in a timely manner.
medical information
What is the ideal position for the nurse when performing a PE?
on the nurse's dominant hand side of the client
True/False:

You do not need to clean your stethoscope between patients because it does not come in contact with body fluids.
FALSE - you should always clean between patients
What part of the stethoscope should be used to assess high pitched sounds? low pitched?
high pitched = diaphragm
low pitched = bell
What are the techniques of examination in the order which they should be performed?
1. Inspection
2. Palpation
3. Percussion (not performed in basics)
4. Auscultation
True/False:

You can alter the order of the PE if the client is experiencing pain/discomfort in a certain region.
True
Which technique of examination?

visual examination; to look, to smell
Inspection
Which technique of examination?

The nurse observes shape, color, size, position, movement, symmetry, equality, congruency, etc
Inspection
What is the difference between symmetry and equality?
symmetry refers to shape/size

equality is a measurement/amount
Which technique of examination?

using the sense of touch; to feel, to stroke the surface of an area to detect its characteristics such as temperature, vibration, turgor, texture, masses, etc.
palpation
Should the tips or the pads of the fingers be used for palpation? Why?
pads - high concentration of sensory nerve endings at the pads which are most sensitive to tactile discrimination
What are the 2 types of Palpation?
- Light
- Deep (not practiced in Basics)
Describe the technique of light palpation?
place the hand parallel to the client's skin surface and press gently while moving in a circle
Which technique of examination?

striking the body to elicit sounds that indicate whether tissue is solid, fluid-filled, or air-filled
percussion
Which technique of examination?

Listening to sounds produced in the body; aided by the use of a stethoscope which focuses and amplifies sound
auscultation
How long should the tubing of your stethoscope be?
12-14 inches
The legal implication of all documentation must include evidence that the nurse has followed the _______ ________ and complied with the ________ ___ ________ _______ in that state.
followed the nursing process and complied with the standard of nursing practice in that state
What is the first thing you should observe when you walk into the room?
the position that the client is in and the client's current activity, consciousness

(ex. low fowlers, talking with visitor, awake)
How do you check a client's level of alertness?
Check their response to stimuli
If a client responds to the nurse's entrance to the room, what level of alertness would be documented?
Spontaneous
If a nurse has to call the name of a patient to obtain their attention, what level of alertness would be documented?
verbal/speech
If a nurse must touch the client to gain their attention, what level of alertness would be documented?
tactile
If you cannot gain the attention of a client via verbal or tactile stimulus, what is the next method you can use to gauge alertness?
painful stimulus
What is documented if the client does not respond to any method of stimulation?
Not alert to stimuli
The following example questions would be asked to a client to check what during the PE?

"State your full name." and "What is the name of the city we are in?" and What month is it?"
orientation
What 3 things to you want to check that a client is oriented to?
person, place, and time
If a client is Awake, Alert and Oriented at the top levels in each, how should this be documented? What if there is an abnormality in any of these?
If all is normal, document as AAO x 3. If any is considered abnormal, it should be documented as noted by the nurse (ex. awake, alert to verbal, oriented)
True/False:

A significant change in level of consciousness is not an immediate concern.
FALSE- one of the most significant signs that a person is in distress is a change in their level of consciousness
What are the 1st 2 things you should you do if you notice a significant change in a person's level of consciousness not related to sleep?
quickly assess their neurological system (and related system if you SUSPECT it may be the cause) followed by a quick set of vital signs
You assess a client's level of consciousness and vital signs and find both significantly worse than previous assessments. What is your next action?
You activate the emergency response team / call for help
Signs of distress are often evaluated using the ABCs of distress evaluation. What are they?
- Airway
- Breathing
- Circulation
- Change in level of Consciousness
- Complaint
(def)

breathe with a whistling or rattling sound in the chest, as a result of obstruction in the air passages
wheeze
(def)

a harsh vibrating noise when breathing, caused by obstruction of the windpipe or larynx.
stridor
(def)

difficulty breathing
dyspnea
(def)

medical term for mucous
sputum
(def)

bloody sputum
hemoptysis
(def)

bluish discoloration of the skin and mucous membranes
cyanosis
What causes cyanosis?
excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule
(def)

the passage of a fluid through a specific organ or an area of the body
perfusion (tissue circulation)
(def)

an inadequate blood supply to an organ or part of the body, esp. the heart muscles.
ischemia
What are some tell tale signs of ischemia (poor tissue perfusion)?
- cyanosis (bluish tint to the skin)
- grayish ashen tint in dark skinned individuals
- pallor
- diaphoresis
What complaint is often associated with ischemia?
pain in the area of ischemia
Why does an individual experience pain in the area of ischemia (ex. chest pain when there is ischemia in the coronary artery)?
because of the production of lactic acid
True/False:

A severe change in LOC is acceptable when a client has received a sedative or pain medication.
FALSE- A minor change is acceptable, however any major change in LOC should be assessed immediately.
(def)

reddening of the face and neck; may be prolonged as seen with fever or the use of certain drugs
flush
(def)

patchy areas of blue
mottled
(def)

skin moist with perspiration; the secretion of sweat, especially profuse secretions associated with an elevated body temperature, physical exertion, exposure to heat, or mental/emotional stress
diaphoresis
(def)

a statement made by the client regarding any symptom or problem (ex. pain, SOB, nausea, etc.)
complaint
What should you do if the client expresses a complaint that is NEW?
follow the nursing process, started with doing a focused assessment on the region of complaint
A patient complains of dizziness. What would be the next course of action by the nurse?
- focused neurological exam
- quick set of vitals
- interpret data to determine if further action is necessary
True/False:

The proper way to assess a client who is complaining of SOB is to do a complete head-to-toe exam.
FALSE- You will do a focused exam on the area of complaint and vital signs. This is NOT the time for a complete head-to-to exam.
True/False:

The use of accessory muscles for breathing could indicate distress.
True
Part of the Physical Examination is listing any adjunct equipment in the room. What are some examples of adjunct equipment?
- oxygen delivery systems
- nasogastric tubes
- tubes
- anti-embolic hosiery
- wound dressings
What should you always look for when assessing adjunct equipment?
make sure that it isn't causing a problem for the client
Identifying if there are people at the bedside, personal effects, etc. is an example of which part of the PE?
Environment
A patient has a history of smoking and regularly using tanning beds. What effect do you think this will have on actual age vs. apparent age?
Apparent age will likely be older than actual age
Why is it important to note height and weight upon admission?
- for medications (many calculated by weight)
- establish a baseline for future comparisons
Rapid weight gain often indicates what?
fluid gain
What is the normal range for body shape/size?
proportionate height and weight, well nourished
What is considered abnormal for body shape/size?
- thin
- emanciated (very thin)
- obese
What type of changes would you expect to see in Body Shape/Size of elderly clients?
- loss of subcutaneous fat
- decreased muscle mass
Describe normal posture.
- erect, upright
- shoulders slightly rounded when sitting
- relaxed
Describe abnormal posture.
- stooped
- slumped
- leaning to right or left side
- tensed
What types of changes would you expect to see in the posture of the elderly?
- forward bending
- stooped with flexion at the hips, knees, and elbows
Describe normal gait.
- coordinated and steady
- head and face leading the body
- arms swinging freely at the side
Describe abnormal gait.
- unsteady
- holds on to support
- uses assistive devices
(def)

a gait described as rigid with slow, small steps that progresses to fast and forward-leaning with small steps; difficult to stop moving forward once moving
propulsive gait
What disease is associated with a propulsive gait?
Parkinson's
What concern would you have as a nurse for a person with an abnormal gait, such as a propulsive gait?
client is at risk for falls
What changes in gait would you expect to see in the elderly?
- smaller steps and strides
- head and face may look downward
- cautious
What independent order would you write for a client with a propulsive gait?
- assist while walking (ambulating)
Describe normal movement.
- smooth, purposeful
- coordinated
Describe abnormal movement.
- involuntary movements
- tics, tremors, seizures
- paralysis
(def)

a localized uncoordinated, uncontrollable twitching of a single muscle group innervated by a single motor nerve or filament that may be palpated and seen under the skin (muscle twitch)
fasciculation
What type of body/breath odor would you expect to find normally in a client?
none
A fetid, foul odor in the axillae or perineal area may be a result of what?
poor hygiene (results in bacterial growth in wet, moist regions)
(def)

offensive breath resulting from poor oral hygiene, dental or oral infections, ingestion of certain foods, use of tobacco, and some systemic diseases
halitosis
(def)

tooth disease causes by interaction of food with bacteria that causes plaque; tooth cavities
dental caries
What are 5 possible causes of halitosis?
- poor oral hygiene
- dental caries
- sinusitis
- old blood
- pneumonia
A sweet, fruity breath odor may be indicative of what?
diabetic acidosis with a build-up of ketones
Breath that smells of alcohol may be caused by what? (2)
- ingestion of alcohol
- acid-base imbalance (ketosis)
A foul, sickeningly sweet breath odor may indicate what? (2)
- 'Pseudomonas' pneumonia
- lung infection
What 8 things will you look at when assessing the client's physical presence?
1. Environment
2. Adjunct equipment
3. Actual Age vs. Apparent Age
4. Body shape/size
5. Posture
6. Gait
7. Movement
8. Body and Breath Odor
What 3 things will you assess when examining a client's psychological presence?
1. Dress, grooming and personal hygiene
2. Mood, Affect, and Manner
3. Language and Speech Pattern
Describe normal "dress, grooming, and personal hygiene".
- clean
- neat
- appropriately dressed for climate
Describe abnormal "dress, grooming, and personal hygiene".
- disheveled
- unkempt
- unshaven
An abnormal appearance, such as being unshaven or unkempt, may be indicative of what?
- lack of interest in appearance
- inability to perform ADLs
What change might you expect to see in "dress, grooming, and personal hygiene" in the elderly?
Older adults have a decrease in SC tissue and may dress warmer than expected for weather (ex. sweaters)
Describe normal "Mood, Affect, and Manner".
- engaged
- smiles appropriately
Describe abnormal "Mood, Affect, and Manner".
- sad
- euphoric
- anxious
- hostile
- angry
- tearful
- flat/blunt
- withdrawn
You are assessing a client, and they seem upset and withdrawn. Would you note this information immediately, or is there another action you should take prior to notation?
- You should validate this information first. Ex. "You seem upset?" Simply noting you perception without validating would be a subjective notation.
Describe normal language and speech patterns.
- clear
- strong
- fluent
- sensible
- relevant
- inflections in pitch, rate, volume
- respond to questions/commands without hesitation
Describe abnormal language and speech patterns.
- incoherent
- slow
- slurred
- mumbled
- very loud/rapid
- dysphasia
(def)

abnormal neurological condition in which language is not understood
sensory dysphasia (aphasia)
(def)

abnormal neurological condition in which words cannot be formed or expressed
motor dysphasia (aphasia)
What changes may you see in the elderly regarding language and speech patterns?
- loss of voice quality and range
- may be slower to respond
What is a normal body mass index?
20-25
What should you as a nurse do to ensure that height and weight is measured properly when accuracy is essential?
- use the same scale
- take measurements at the same time of day
- make sure client is wearing similar kind of clothing and no footwear
A client experiences an unexpected and significant weight loss. What 2 things should you note?
- the time frame the loss occurred
- the amount of weight loss
What is the procedure for assessing the skin?
Inspect all areas and palpate the non-mucous membrane skin surfaces
What is considered normal for skin color?
uniform (light to dark pink) (light to dark brown)
Caucasian skin is documented as what color? African Americans?
- pink
- brown
What are normal variations in skin color?
- birthmarks
- freckles
- moles (nevi)
What are color neutral regions of the body for diagnosing cyanosis?
- nail beds
- lips
- mouth
- buccal mucosa
- mucous membranes
- conjunctiva
- palms
- soles of the feet
Pallor, or loss of color, may exhibit how in a dark-skinned individual?
the person may appear ashen gray
How should you assess for pallor in a dark-skinned individual?
- assess the conjunctiva, lips, palms
Give 4 examples of situations that may cause pallor.
- inadequate circulation
- anemia (inadequate hemoglobin)
- decreased oxygenation of hemoglobin
- general poor health
What is preferential perfusion?
Major organs are perfused first (often due to a drop in blood pressure)
What change would you expect to see in the skin due to preferential perfusion?
pallor
What should you do if you notice a client suddenly go pale?
take a set of vitals
How does diaphoresis relate to a drop in blood pressure?
Often a drop in blood pressure will result in excessive sweating due to vasodilation
(def)

yellow-orangish skin, sclera, and mucous membranes
jaundice
Jaundice is caused by excess _______.
bilirubin
What part of the body should be assessed if you suspect jaundice in a dark-skinned individual?
hard palate
What is a key symptom in many liver of hemolytic diseases?
jaundice
(def)

redness of the skin
erythema (hyperemia)
What are some reasons for erythema?
- increased blood flow
- fever
- inflammation
- rashes
- hypertension
- excessive alcohol intake
Darker pigmentation along the course of a vein may indicate what?
IV drug use
True/False:

Body art and piercing do not need to be documented.
False- You must document piercings/tattoos. You don't need to describe, simply note what is present and where. (ex. tongue piercing x 1, tattoo on left shoulder)
(def)

brown age spots due to sun exposure
senile lentigo
What are some normal changes in skin color you would expect to see in the elderly?
- senile lentigo (age spots)
- pallor in the absence of anemia
- skin may appear thin and translucent
Skin moisture refers to the skin's ________ and _________.
hydration and oiliness
(def)

a small, bright red, clearly circumscribed vascular tumor on the skin. Occurs most often on the trunk but can be anywhere; common lesion; more than 85% of people over 45 yrs. of age have several
cherry angioma
When assessing temperature with your hand, should you use your palm or the back of your hand?
back of your hand
Skin should be acceptably dry (no diaphoresis), however some exceptions may occur in what regions of the body?
- hands
- face
- axillae
- skin folds
What are some abnormalities in the moisture of the skin?
- abnormally dry (causes flaking, scaling)
- abnormally oily
What may be some causes of abnormally dry skin?
- smoking
- sun exposure
- stress
- dehydration
- underactive glandular function (such as hypothyroidism)
Abnormally oily skin may be caused by what?
- puberty
- overactive gland function (ex. hyperthyroidism)
What are some causes of Diaphoresis?
- sudden drop in BP resulting in poor tissue perfusion **serious**
- attempt to lower body temperature (Ex. fever break (lysis) stage)
- anxiety
- increase BMR
- pain
How do you assess skin temperature during a PE?
use the dorsal surface of the hand, comparing upper and lower extremities
Describe normal skin temperature.
Warm
Describe abnormal skin temperature
cool or cold
What may be a cause of cool or cold skin to the touch.
decreased blood circulation (perfusion)
What are some findings you may expect to see in the skin temperature of older adults?
- extremities cooler to touch
- decreased perspiration
What is the procedure for assessing the skin's surface texture?
stroke the skin surface with the pads of the fingers
Describe normal skin texture.
smooth, soft, consistent; elbows, palms and soles are rougher/thicker
Describe abnormal skin texture.
rough, taut (tight), indurated (hardened), scarred
(def)

reflection of the skin's elasticity and state of hydration
turgor
Describe the procedure for checking skin turgor.
grasp with fingers and lift skin, then release it. Use the areas of the sternum or clavicle.
Describe normal skin turgor.
Supple; when released, the skin quickly snaps back to pre-tested position
Describe abnormal skin turgor.
Sluggish; peaked; tented
What are normal changes that you expect to find in skin turgor of the elderly?
- sluggish due to decreased elasticity and SC tissue
- wrinkled
- sagging
What are we looking for when examining the skin's vascularity?
- visible superficial blood vessels
- ecchymosis (bruising)
- bleeding
Normally, you should not see ecchymosis unless what has occurred?
trauma or injury
What is the medical term for "bruise"?
ecchymosis
What effect to vascularity is expected with anticoagulants?
ecchymosis, excessive bleeding
Describe abnormal vascularity.
- spider veins, varicose veins
- unexplained bruising/bleeding
- petechiae
(def)

pinpoint red-purple spots caused by small hemorrhages
petechiae
Petechiae may indicate what? (4)
- bleeding disorder
- liver disease
- drug reactions
- infections
What changes would you expect to see in skin vasculartiy of the elderly?
- bruises easily due to loss of subcutaneous tissue and fragile capillary walls