Term
| Collection of subjective & objective data about the client |
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Definition
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Term
| What the client says it is |
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Definition
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Term
| What you observe or directly measure. ( can be validated by another) |
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Definition
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Term
| Look at all aspects: physical, psychosocial, spiritual, ( done on initial contact) |
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Definition
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Term
| Conducted at intervols for + or - changes |
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Definition
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Term
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Definition
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Term
| This establishes relationship of trust nurse/ client relationship |
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Definition
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Term
| When conducting a health history interview the nurse should do what______ |
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Definition
| Use broad questions and watch the clients body language |
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Term
| When establishing the health history what are the esentials |
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Definition
1. need a quiet private environment
2. Biographical data
3. Reason for seeking care
4. HX of present health concern
5. Medical HX
6. Family HX
7. Lifestyle |
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Term
| What are some instruments used in an assessment |
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Definition
1. ophthalmoscope
2. otoscope
3.speculums
4. tuning fork
5. percussion hammer
6. snellen chart
7. stethoscope
8. sphygmomanometer |
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Term
| What are some possible positions that may be used in an assessment? |
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Definition
1. sitting
2. supine
3. dorsal recumbent
4. SIM'S
5. Prone
6. Lithotomy
7. Knee Chest
8. Standing |
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Term
| What are some techniques used for Physical assessment |
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Definition
1. inspection
2. palpation
3. percussion
4. auscultation
5. use only those techniques that are appropriate to the area being assessed |
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Term
| When performing a general survey what do you need to consider? |
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Definition
1. General Appearence
2. Vital Signs
3. Height/ Weight
4. Pain |
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Term
| When you are doing the general survey and are looking at General Appearance what are you assessing. |
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Definition
1. body build
2. Posture
3. hygiene
4. Mood |
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Term
| In the general survey assessing pain what needs to be assessed? |
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Definition
1. Pain 0-10
2. scale
3. location
4. duration
5. intensity |
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Term
| When inspecting the integument what do you look at or look for? |
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Definition
1. color
2. vascularity
3. lesions
4. odor |
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Term
| What should the nurse notice when they are palpating the integument? |
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Definition
1. temp
2. moisture
3. turgor
4. texture |
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Term
| When the nurse inspects the nails what are they looking for? |
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Definition
1. shape
2. angle
3. texture
4. color |
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Term
| When the nurse is inspecting the hair/ scalp what are they looking for? |
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Definition
1. Texture
2. Distribution
3. Lumps
4. Lesions
5. Infestations
6. Grooming/ Hygiene |
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Term
| What is the nurse looking for when they are inspecting the skull? |
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Definition
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Term
| What is the nurse looking at when they are assessing the face? |
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Definition
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Term
| What is the nurse looking at when they are assessing the eyes? |
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Definition
1. Symmetry
2. pupil size, shape, response, |
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Term
| What is the nurse looking for when they are inspecting the skull? |
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Definition
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Term
| What is the nurse inspecting in the face |
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Definition
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Term
| What is the nurse looking for when inspecting the eyes? |
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Definition
1. symmetry
2. Pupil size
3. Pupil shape
4. Pupil response
5. Iris color
6. Sclera color
7. Vision
8.Accomodation
9. Convergence
10. Eye Movement |
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Term
| What is the nurse looking for when she inspects the ear? |
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Definition
1. Placement
2. Shape
3. Hearing |
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Term
| What is the nurse looking for when inspecting the nose? |
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Definition
1. position
2. patency
3. drainage |
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Term
| What is the nurse looking for when inspecting the mouth? |
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Definition
1. Mucous membrane (color/ moisture
2. Teeth |
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Term
| What is the nurse looking for when inspecting the pharynx? |
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Definition
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Term
| What is the nurse looking for when inspecting the neck |
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Definition
1. trachea palpated in midline
2. no masses |
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Term
| What is the nurse inspecting the chest for? |
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Definition
1. Color
2. Contour
3. Breathing patterns |
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Term
| What does the nurse palpate the chest for? |
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Definition
1. Warmth
2. Moisture
3. Tenderness
4. Masses |
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Term
| When inspecting the chest the nurse may |
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Definition
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Term
| When auscultating the thorax what sounds is the nurse listening for? |
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Definition
1. Bronchial sounds
2. Bronchovesicular sounds
3. Vesicular sounds
4. Adventitious sounds |
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Term
| What is meant by bronchial sounds? |
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Definition
| Sounds heard over trachea |
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Term
| What is meant by bronchovesicular sounds |
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Definition
| Sounds heard over mainstream bronchus |
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Term
| What is meant by Vesicular sounds |
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Definition
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Term
| What is meant by Adventitious sounds? |
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Definition
1. Crackles- fine or course. course known as Rhonchi
2. Wheezes- high pitched and musical
3. Sonorous wheezes- deeper, snoring |
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Term
| What do you inspect when assessing the heart? |
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Definition
1. inspection for apical impulse
2. palpate for pulsations
3. auscultate heart sounds |
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Term
| What is the nurse assessing or looking for when auscalating heart sounds? |
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Definition
1. S1 lub
2. S2 dub
3. Aortic, pulmonic, tricuspid, and mitral areas |
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Term
| When inspecting the breasts/ Axilla what is the nurse looking for? |
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Definition
1. size
2. shape
3. symmetry
4. color
5. texture
6. lesions
7. Areola/ nipples: size, shape, discharge, inversion |
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Term
| When palpating the breast/ axilla what is the nurse looking for? |
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Definition
1. Each Quadrant
2. Tail of spence
3. Compress nipple
4. Nodes in Axilla |
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Term
| When inspecting the Abdomen it is important to note the order of________ |
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Definition
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Term
| When inspecting the abdomen the nurse needs to look at________ |
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Definition
1. Color
2. Contour
3. Pulsation
4. Umbilicus |
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Term
| When auscultating the abdomen the nurse needs to listen for ___________ |
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Definition
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Term
| When the nurse purcuss the abdomen what are they looking for |
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Definition
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Term
| When the nurse palpates the abdomen the nurse is feeling for __________ |
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Definition
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Term
| When inspecting the female genitalia the nurse looks at what? |
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Definition
1. the external genitalia
2. Uses the speculum to visualize the inside vagina |
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Term
| When inspecting the male genitalia the nurse does what______- |
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Definition
1. inspects external
2. Palpates scrotum for masses |
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Term
| When ispecting the urine the nurse looks for what______ |
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Definition
1. color
2. Clarity
3. odor
4. amount |
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Term
| When inspecting the endocrine |
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Definition
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Term
| When inspecting peripheral vascular extremities what is the nurse looking for? |
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Definition
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Term
| When the nurse is palpating the peripheral vascular what is she feeling for? |
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Definition
1. peripheral pulses
2. capillary refill |
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Term
| When assessing peripheral vascular the nurse may also check for swelling or____ |
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Definition
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Term
| When inspecting the muscles the nurse looks for |
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Definition
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Term
| When palpating the muscles the nurse feels for |
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Definition
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Term
| When inspecting the bones the nurse looks for |
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Definition
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Term
| When palpating the bones the nurse feels for___________- |
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Definition
1. tenderness
2. crepitus
3. heat
4. swelling |
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Term
| When the nurse is assessing the neurological they are assessing____________? |
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Definition
Mental status
a. orientation
b. loc
c. memory
d. reasoning
e. language
2. Cranial Nerve Function
3. Mortor Function: balance, gait, coordination
4. Sensory Function: Pain, Light touch, Vibration
5. Reflexes
6. Glascow Coma Scale |
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Term
| What is assessed and looked for when assessing the Glascow Coma Scale |
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Definition
1. Assesses level of consciousness
2. Three Parameters: Eye Opening, Motor Response, Verbal Response
3 Score of 7 or less designates Coma
4. Top score is 15
page 647 table 25-10 |
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