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21 Cards in this Set

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  • Back
Why should you use a physical assessment
to gather baseline data
to supplement, confirm, or refute data obtained in the RN history
to Confirm and ID RN diagnoses
to make clinical judgments about a client's changing health status and management
to evaluate the physiological outcomes of care
What is idiosyncrasies
one's wants, fears ect. with an RN need to know there wanting to be liked, fear of harming the client , or catching a disease
That are some common areas for palpation (p. 675)
Skin
Organs
Glands
Blood vessels
Thorax
what should an RN be looking for when palpating
sensitive, resistance, resilience, roughness, texture, and mobility
How can an RN decrease abdominal rigidity
placing the Pts arms along the side of the body
How should an RN palpate the abdominal cavity
depress about 1 cm (1/2 inch). save tender areas for last, if pt is ok deeper palpation can go 2 to 4 cm (1 to 2 inch) can be done bimanually
where is the best place for an RN (RN part of the body most sensitive to temp) to feel for temp
dorsum part of the hand
How does the RN preform percussion?
placing the middle finger of the pleximeter hand firmly against the body surface using the plxor strikes the base of the distal joint of teh pleximeter.
What are the five types of percussion sounds
Tympany, resonance, hyperresonance, dullness, and flatness (p 677)
what is auscultation in the RN scope
listening to sounds produced by the body
what part of the stethoscope is general used for what sounds
Bell is best for low-pitched sounds such as vascular and certain heart sounds, diaphragm is best for high pitched sounds such as bowel and lung sounds
What auscultation should a RN note.
Frequency
loudness
quality
duration
What is the Lub sound made by
first heart sound caused by the closure of the mitral valve
What is olfaction
Smell
What are some of the smells an RN should note/familiar with
Alcohol
Ammonia
Body odor
Feces
Foul-smelling stools in infant
halitosis
Sweet, fruity ketones
Stale urine
sweet, heavy thick odor
Musty odor
Fetid, sweet odor

P. 678
Why is hand hygiene so important
Reduces the transmission of microorganisms
What is important for examination of a client and environment?
if possible try to make the client comfortable
What is important when it come to addressing people by name?
Children should be called by their first name, parents by Mr. and Mrs.
When does the general survey of a client begin
when the RN first meets the client
What are some of the things the RN looks for in the general survey
Gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, client abuse, substance abuse
What is CAGE used for
CAGE is a set of questions used to determine if someone has a substance abuse problem , if they answer yes to two on more of the following.
Cut down, annoyed, guilty, eye-opner