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97 Cards in this Set

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Describe Kernig’s Sign
Symptom of meningitis; patient cannot extend the leg at the knee when the thigh is flexed because of stiffness in the hamstrings
Describe Brudzinski’s Sign
One of the physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
Describe Flaccid
Relaxed, Limp, Flabby. Having defective or absent muscle tone.
Taber 769
Describe Hemiparesis
Slight paralysis on one side of the body. Usually from damage to the CNS. Also called hemiplegia.
Taber 914
Potter 937
Describe Paraplegia
Complete paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord.
Taber 1513
Quadriplegia
Paralysis of all four extremities. Usually damage to the cervical spinal cord
Taber’s 1735
Hemiplegia
Hemiplegia
Slight paralysis on one side of the body. Usually from damage to the CNS. Also called hemiparesis
Taber 914
Describe Gait
A manner of walking. Many different types
ƒæ Antalgic ¡V Pain during gate in one leg and stays on that leg for a short as possible.
ƒæ Ataxic ¡V Unsteady Staggering gate
Taber 806
Describe the components and purposes of the stethoscope.
•Essential tool for use in auscultation during a physical assessment.
•Consists of Earpieces, Biaurals (Metal tubes from earpieces to rubber tubing), Tubing, Chest Piece consisting of a Bell and a Diaphragm.
•Both the Bell and Diaphragm should have interchangeable adult and pediatric sizes
POTTER 643
Describe the purpose and legal parameters of health-related documentation.
•Main communication tool between all members of healthcare team. It should be flexible and exception based
•Communication and Continuity of Care
•Minimize Errors
•Saves Time
•Legal Documentation
•Finance/Billing
•Education Research
•Auditing/Monitoring - JCAHO
POTTER 479
What is a POMR
Problem Oriented Medical Record
Places emphasis on the clients problems.
• Major Sections Are
o Database
o Problem List
o Nursing Care Plan
o Progress Notes
POTTER 483
What is a SOAP?
Subjective
Objective
Assessment
Plan
Sometimes SOAPIE with the addition of
• Intervention and Evaluation
Potter 483
Describe Source Records
o Clients chart is arranged with each discipline (Nursing, Doctor, Social Worker) each having their own section in which to chart.
„X Advantages ¡V Easily locate the desired information
„X Disadvantage ¡V One problem might be written several different areas, making a care giver read about the same problem in several different areas.
POTTER 484
Describe Pronation
Movement of a body part so that the front faces downward. (Turning your palm down)
Describe Plantar Flexion
Movement of the foot that flexes the foot or toes downward toward the sole
Describe ulnar deviation
Ulnar – Bend wrist medially toward thumb. This is an adduction.
Potter 1436
Describe radial deviation
Radial – Bend wrist laterally toward fifth (pinky) finger. This is an abduction
Potter 1436
Describe Opposition
Touching thumb to each finger of the hand
Potter 1437
Pronation
Movement of a body part so that the front faces downward. (Turning your palm down
supination
Movement of a body part so that the front faces upward. (Turning your palm up
Potter 758
Eversion
Turning body part away from midline
Potter 758
Describe Inversion
Turning body part toward midline
Potter 758
Describe Abduction
Movement of the extremity away from the midline of the body
Potter 758
Describe Adduction
Movement of the extremity toward the midline of the body
Describe Assessment Forms
Admission
Flowsheet
Kardex
Standardized Care Plan
Potter 492
Describe Assessment Forms
Admission Form
Flowsheet or Graphics
Kardex
Describe Change of Shift Report
Oral, Audiotape, or Walking Rounds.

Provides continuity of care between one shift and the next. Not simply a reading of the chart notes, but specific ie Nurse found that client was relieved of pain with a certain technique or medication. Should follow logical sequence.

Potter 496
Describe Discharg Planning Characteristics
o Ideally began during admission and revised by Nurse as client conditions change
o Includes Client Education:
„X Food/Drug Interaction
„X Rehabilitation techniques
„X Access to Community Services
„X Reasons to Follow up with Hospital
„X Family responsibilities
„X Medication Instructions
Potter 492
Define Nursing Process
To organize and deliver care. It allows the nurse to integrate elements of CT to make judgements and take actions based on reason.
Used to identify, diagnose, and treat human responses to illness and health.
Five Steps Assessment/Nursing Diagnosis/Planning/Implementation/Evaluation
Define Assessment
Gather information about a clients condition.
Diagnosis
Identify the clients problem based on the Nursing Diagnosis system.
Describe Planning
Set goals of care and desired outcomes and identify appropriate nursing actions.
Describe Implementation
Perform the nursing actions identified in planning stage.
Evaluation
Determine if goals were met and outcomes were achieved.
Desdcribe the assessment phase of the Nursing Process.
Data Collection and then Cluster & Validate Date
Describe the Analysis Component of the Nursing Process.
-Analyze & Interpert Data
-Identify Client Needs
-Make Nursing Diagnosis
Describe the Planning Component of the Nursing Process.
-Prioritize
-Establish Client-Centered Goals
-Develop Expcted Outcomes
-Plan Nursing Care
Describe the Implementation Component of the Nursing Process.
The Action and Doing of Nursing Care
Describe the Evaluation Component of the Nursing Process.
-Assess Client Response as compared to Expected Outcome.
-Determine if EOC is met or not.
->Revise Care Plan as necessary and continue with current or newly identified implementation plan.
Define Subjective
The Clients Perceptions about their Health. (From the SUBJECT)
Potter 284
Define Objective
The Observations or measurements made by the data collector.
Potter 248
Describe Signs
Any objective evidence of manifestation of an illness. Signs are apparent to observers as opposed to symptoms.
(Taber)
Describe Validation
Gathering assessment data to validate the collected infomation to ensure accuracy. This involves comparing the data with another source.
(Potter 292-293)
Define Clustering
A set of signs or symptoms that are grouped together in a logical order.
Define Symptom
Any change in the body or its functions, as perceived by the patient. Represents the subjective experience of the disease.
(Tabers)
Discuss Temperature
The difference between the amount of heat produced by body processes and the amount lost to the environment.
What is a normal body temperature in Celcius?
36-38° C
What is the normal body temperature in Fahrenheit?
96.8° - 100.4° F
What is a normal Pulse rate?
60-100 BPM
What are normal respirations?
12-20 times each minute
What are normal SpO2 levels?
95-100
What will always cause a problem with reading a sat from the finger?
Nail polish, which prevents the light from passing through the finger.
Where can an Sp02 probe be placed?
Finger, Ear, Bridge of Nose, Toe.
Describe Normal BP.
Category Systolic Diastolic
Normal < 120 < 80
Pre-High BP 120-139 80-89
Stage 1 High BP 140–159 90–99
Stage 2 High BP > 160 > 100
Describe the Purpose and Components of General Survey.
Used for a general overview of a clients stage of wellness.

General Appearence/behavior/Apparent Age-Race-Gender/signs of distress/sob/physical or chemical abuse/body type/posture/gait/body movements/hygiene/grooming/dress/body odor/mood/speech
Describe the Four Techniques involved in physical assessment.
Inspection

Palpation

Percussion

Auscultation

(Sometimes Smell)
Define the Specifics of Inspection
Need good light , positoin and exposure of all body parts. Inspect size/shape/symmetry/position and abnormalities.
Additional light might be necessary for body cavities.
Describe the process of Palpation
Assessment through touch, client should be relaxed and positioned comfortably.
Tender or C/C areas should always be palpated last.
Warm your hands.
Light Palpation is 1/2 Inch
Deep Palpation is 1-2 Inches (We Dont do it)
Describe the process of Percussion.
Used to determine the location, size, density of underlying structures.
Striking of finger against the body part, character of sound depends on density of underlying tissue.
Tympany/Resonance/Hyperresonance/dullness/Flatness
Describe the process of Auscultation.
Listening to sounds through a stethoscope.
Always against naked skin.
Describe the Order of a NON ABD Examination
Inspection

Palpation

Percussion

Auscultation
Describe the Order of doing an ADB Examination.
Inspection

Auscultation

Percussion

Palpation
Describe Steps to prepare a client for an Examination
3 Steps

Introduce self to establish position and purpose.

Prepare room for privacy, tools

Physical Assessment
Describe Level of Consiousness
A continuum from full awakening and alertness to unresponsive.
Potter 762
Describe Orientation
The ability to comprehend and to adjust onself with regard to time, location, identity of persons
Describe Lethargic
A state of sluggishness, inactivity, and apathy.

A state of unconsciousness resembling
deep sleep.
Describe Drowsy
A state of almost falling asleep.
Describe Obtunded
Diminished arousal and awareness
Describe Aphasia
Ineffective communication - Omission or additon of letter or words, misuse of words or hesitations.
Potter 763
Describe Sensory Function
Testing done symmetrically.
Compare distal to proximal.
Vary pace of testing to avoid prediction.
Testing done with clients eyes closed to test pain, temp, vigration of the feeling senses.
Describe Motor Function Testing
Assessment of muscle tone - Flaccid, Spastic, flabby, floppy.
Test Muscle Strength
Test Coordination

(Lecture Notes)
Describe the Romberg Test
Feet together, watching for unbalanced motions.
Describe Deep Tendon Reflexes of the Biceps.
Flex clients arm up to 45 degree at elbow with palms down. Place your thumb in antecubital fossa at base of biceps and your fingers over biceps miscle. Strike triceps tendon with reflex hammer.
Shoudl see flexion of arm at elbow.
Describe Deep Tendon Reflexes of the Triceps.
Flex clients arm at elvow, holding arm across chest or hold upper arm horizontally and allow lower arm to go limp. Strike triceps tendon just above elbow.
Should see extension at elbow.
Potter 768
Describe Deep Tendon Reflexes of the Patella.
Have client sit with legs hanging freely over side of table or chair or have client lie supine and support knee in a flexed 90-degree position. Briskly tap patellar tendon just below patella.
Should see extension of lower leg
Potter 768
Describe Deep Tendon Reflexes of the Achilles.
Have client assume same position as for patellar reflex. Slightly dorsiflex clients ankle by grasping toes in palm of your hand. Strike Achilles tendon just above heel at ankle malleolus.
What are key components of Glasgow Coma Scale
Eyes Open 4-1

Best Verbal Response 5-1

Best Motor Response 6-1
Describe the Babinski Reflex
Sharp object drawn from heel to toes. To fanning normal in infants to 2 yrs, sign of brain or spinal cord injust in order persons.
Describe Clonus
An abnormality in neuromuscular activity characterized by rapidly alternating muscular contraction and relaxation.
Describe Muscle Strength Grading
0/5 No Muscle Movement
1/5 Visible Muscle Movement but no joint movement.
2/5 Movement at joint but not against gravity
3/5 Movement against gravity, but not added resistance.
4/5 Movement against resistance, but less than normal
5/5 Normal Strength
Describe Stuporuous
Altered mental status in which a person is arousable only with vigorous or unpleasant stimulation.
Describe Semi-comatose
No longer used.
Oriented
Aware of surroundings, person, place, time.
Comatose
In a coma.
Describe decorticate
Removal of all or part of the cortex of the brain.
Describe Decetrate
To eliminate cerebral brain function in (an animal) by removing the cerebrum, cutting across the brain stem, or severing certain arteries in the brain stem, as for purposes of experimentation.
Describe Lordosis
Swaygback...Increased lumbar curvature.
Describe Kyphosis
Hunchback an exageration of the posterior curvature of the thoracic spine.
Describe Scoliosis
A Lateral Curvature of the spine.
Muscle
The slight musclear resistance felt by the examiner as the relaxed extremity is passively moved through its range of motion.
Describe Involuntary Movements
Independent of, as a result of a reflex.
Describe Tremor
An involuntary movement of a port or parts of the body resulting from alternate contractions of opposing muscles.
Describe Paralysis
Loss of purposeful movement usually as a result of deurological disease, drugs, or toxins.
Describe Paresis
Slight or partial paralysis.
Assessment of Sensory Nerve Function
Pain - Soft or Dull
Temp - Two test tubes one hot / other cold
Light Touch - Voice sensation when light touch felt from cotton ball.
Position - Move Toe Up or Down
Two Point - Dual pricks brought closer.
Describe Fasciculation.
Involuntary contraction or twitching of muscle fibers visible under the skin.
Medical Dictionary
Describe Crepitus
Lots of Confusion on this one. Not finding the exact word.
-Encarta says the grating sound of a broken bone.
-Tabers shows "Crepitant" as making a crackeling sound.
-Dictionary.com says A noisy discharge of gas from the intestine

I seem to remember in Lecture Crackeling in the Lungs during Asucultation of the chest.