Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
10 Cards in this Set
- Front
- Back
|
What are the components of the health assessment?
|
- Nursing interview (biographical data, nursing health history, chief complaint, present illness, past medical history, health patterns, and ROS)
- Behavioral Examination - Physical Examination (initial and focused) - Comprehensive (all 3 components) |
|
|
What is the definition of a physical examination?
|
- a systemic, orderly process by which the nurse collects objective data about the client's body, mind, and spirit
- critical investigation and evaluation of client's PRESENT status |
|
|
What is the student nurse's responsibility during the physical examination?
|
- recognize normal from abnormal
- use proper technique - identify changes/trends - validate and analyze - discuss clinical significance - communicate significant data - document within normal limits (WNL) |
|
|
What is validation?
|
- comparing data with another source
- knowing normal findings for the client's age, sex, condition in life |
|
|
What are "fowlers?"
|
- semi-fowlers: client is supine but bed is lifted at head
- high: anything above 45% - mid: 45% angle - most examinations are performed in low fowlers or a sitting positiong |
|
|
What is the timeframe for a physical examination?
|
15-20 minutes
|
|
|
What does the inspection technique consist of?
|
- visual examination, to observe, to look, to notice, to smell
- observe shape, size, color, position, movement, symmetry, equality |
|
|
What does the palpation technique consist of?
|
- 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 - use of the pads of the fingers to palpate |
|
|
What are the different types of palpation?
|
- Light: maintain skin contact while moving in a circle, compressing 1-2 cm
- Deep: not practiced in Basics |
|
|
What is percussion?
|
- involves striking the body to elicit sounds that indicate whether tissue is solid, fluid-filled, or air-filled
|
