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100 Cards in this Set
- Front
- Back
What type of data is the physical exam?
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Objective data
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What is the student nurse's responsibility regarding the physical exam?
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Recognizing the normal from the abnormal
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How does a student nurse recognize the normal from the abnormal?
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-use proper technique
-identify changes and trends -validate & analyze data -discuss clinical significance of data -communicate significant data -document w/i normal limits (WNL) |
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What type of data is the physical exam?
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Objective data
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What is the student nurse's responsibility regarding the physical exam?
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Recognizing the normal from the abnormal
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How does a student nurse recognize the normal from the abnormal?
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-use proper technique
-identify changes and trends -validate & analyze data -discuss clinical significance of data -communicate significant data -document w/i normal limits (WNL) |
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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
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Chief Complaint
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Systematic orderly process by which the nurse collects objective data about the client's body, mind and spirit. It is time oriented (collects data about the present time)
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Physical Examination
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Objective data
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data that is observed or measured
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Low Fowler's Position
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Sitting Position
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Timeframe for the physical examination
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15-20 minutes
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You should always allow a client an opportunity to _____________ before beginning a physical exam.
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Urinate
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Three important aspects of the physical exam
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1. provide privacy
2. close the door and the drapes 3. positioning |
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Visual examination; to observe, to look, to notice, to smell. The nurse notices or observes shape, size, color, position, movement, symmetry, equality, etc.
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Inspection
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DEF.
do the patient's words match his or her behavior |
congruence
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DEF.
appearance, do both sides look the same |
symmetry
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DEF.
term used when you can actually measure the amount of something and compare |
equality
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Using the sense of touch; to feel, to stroke the surface of an are to detect its characteristics such as temperature, vibration; turgor; texture; masses, etc.
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Palpitation
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What part of the fingers should be used in palpitation? Why?
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the pads of the fingers. There is a high concentration of sensory nerve endings at the pads which are most sensitive to tactile discrimination.
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What type of palpitation is 1-2 cm with the hand parallel to the client's skin surface, maintaing skin contact while moving in a circle
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Light or superficial palpitation
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Involves striking the body to elicit sounds that indicate whether tissue is solid, fluid-filled or air-filled. (Not practices in Basics)
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Percussion
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Listening to sounds produced int he body; aided by the use of a stethoscope which focuses and amplifies sound
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Auscultation
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With a stethoscope, high-pitched sounds are heard best with the
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Diaphragm
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With a stethoscope, low-pitched sounds are heard best with the
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Bell
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What is used for difficult to hear pulses and to hear fetal heart tones (it augments sound)
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Doppler
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What is AAOx3?
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Documentation for Awake, Alert, Oriented x3 (person, place, time)
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List of Initial Observations as it pertains to the physical exam:
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-Position of Patient
-Client Activity or Interaction -Response to stimuli -Signs of Distress |
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Define awake as it pertains to response to stimuli:
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Are the patient's eyes open
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5 levels of alertness as it pertains to response to stimuli:
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-spontaneously respond to the nurse's entry
-Verbal (did the nurse have to call his name) -Tactile (did the nurse have to touch the patient) Painful stimuli (pinch b/t the fingers) -No response to stimuli |
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In reference to orientation, how do you test for person, place and time?
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-What is your full name?
-What city (or state) are we in? -What time of day is it? What month? Year? |
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List of signs of distress:
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-Airway/Breathing
-Circulation -CHANGE in level of consciousness (LOC) -Complaint |
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DEF
states that there is difficulty in breathing; SOB; may use accessory muscles; works hard to breathe |
Dyspnea
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production of secretions in coughing
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sputum
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bloody sputum
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hemoptysis
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tissue perfusion (ashen gray)
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ischemia
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Wheezing or stridor (crowing)
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restrictive sounds as it pertains to airway noises
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blue; blue-gray
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cyanotic; cyanosis
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patchy areas of blue
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mottled
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pale
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pallor
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reddish blue
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flushed
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skin moist with perspiration
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diaphoretic
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any medical equipment or devices in use for the patient
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Adjunct Equipment
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Very thin
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emaciated
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rigid small slow steps, then fast forward leaning small steps; difficult to stop (may be seen with Parkinson's)
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Propulsive gait
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axillae
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armpits
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mouth odor possibly from poor oral hygiene
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halitosis
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cavities
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dental caries
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difficulty with speech or difficulty understanding the spoken word
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dysphasia
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Bluish color or hypoxia in the nail beds, lips, mouth or buccal mucosa or mucous membranes (in dark skinned: look at conjunctiva, palms, soles of feet)
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cyanotic
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loss of color due to inadequate circulating blood or hemoglobin (anemia); or decrease oxygenation of the hemoglobin; or general poor health status (in dark skin may appear ashen gray) assess in conjunctive, lips and palms
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pallor
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Cyanosis in a light skin (pink) person looks ... In a brown person
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-looks dusky blue
-looks ashen gray esp. on lips and tongue |
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yellow orange skin, sclera, mucous membranes (mm); on dark skinned person will be the hard palate; caused by excess bilirubin from liver or hemolytic diseases
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jaundice
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red; increased blood flow; inflammation; rashes
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erythema
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brown age spots due to sun exposure
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senile lentigo
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perspiration
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diaphoresis
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The skin is considered this when released is quickly snaps back to pretested position
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supple
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bruising
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ecchymosis
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pinpoint red-purple spots caused by small hemorrhages; may indicate bleeding disorder, liver disease, drug reaction, infections
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petechiae
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the abnormal presence of fluid int he body
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Edema (or effusion)
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edema around the eyes
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periorbital edema
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edema in brain
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cerebral edema
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edema in pericardial sac
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pericardial effusion
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edema in intrapleural space
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pleural effusion
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edema in abdominal cavity
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ascites
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Generalized edema (all over)
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anasarca
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When an indention remains with edema
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pitting edema
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Edema is affected by gravity and therefore is commonly seed in...
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dependent areas (legs, sacrum, scrotum)
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an abnormal (pathological) area of the skin
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lesion
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A,B,C,D as it pertains to lesions
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A-asymmetrical or uneven shape
B-border irregularity C-change in color; odd color; elevated D-diameter>6mm (pencil eraser) |
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small raised red papules
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cherry angiomas
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partial or complete hair loss
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alopecia
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nearsightedness
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nyopia
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farsightedness
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hyperopia
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lens of eye is unable to change shape to accommodate close vision; has difficulty reading small print; starts around 45 yrs
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presbyopia
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When an indention remains with edema
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pitting edema
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Edema is affected by gravity and therefore is commonly seed in...
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dependent areas (legs, sacrum, scrotum)
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drooping of the eye lid over the pupil
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ptosis
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an abnormal (pathological) area of the skin
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lesion
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A,B,C,D as it pertains to lesions
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A-asymmetrical or uneven shape
B-border irregularity C-change in color; odd color; elevated D-diameter>6mm (pencil eraser) |
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small raised red papules
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cherry angiomas
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partial or complete hair loss
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alopecia
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nearsightedness
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myopia
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farsightedness
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hyperopia
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lens of eye is unable to change shape to accommodate close vision; has difficulty reading small print; starts around 45 yrs
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presbyopia
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drooping of the eye lid over the pupil
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ptosis
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bilateral gray ring outlining the iris; made of lipid deposits; benign
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Arcus senilis
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PERRLA
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-Pupils Equal
-Round -React to Light -Accommodation (consensual response) |
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Dilation of pupils
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mydriasis (remember both have D's)
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constriction of pupils
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miosis (remember constriction and miosis both have o's)
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wax in the external ear canals
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cerumen
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hearing deficit
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presbycusis
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ringing in ears
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tinnitus
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red large gums
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Gingival hyperplasia
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no teeth or number of teeth missing
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Edentulous
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cavities
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caries
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Unequal sounds or an incorrect sound heard in an airway location
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adventitious sounds
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miosis
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pupils constrict (miotic effect)
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mydriasis
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pupils dilate (midriatic effect)
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First heart sound is created by the...
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closure of the mitral and tricuspid valves (systole)
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Second heart sound is created by the...
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closure of the aortic and pulmonic valves (diastole)
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