Term
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Definition
| A sign is objective data, something you can measure |
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Term
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Definition
| A symptom is subjective data, a patient's thoughts and feelings. |
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Term
| What is a chief complaint? |
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Definition
| The reason given for seeking care. |
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Term
| What are the nursing process steps? |
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Definition
| Assessment, diagnosis, planning, implementing, and evaluation. |
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Term
| Name the purposes of the Health History |
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Definition
| Provide subjective database; identify pt strenghts; indentify pt's problems (potential or actual); and identify supports, teaching needs, and referral needs |
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Term
| Identify parts of Health History and what data is obtained in each part |
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Definition
| What the pt tells me (biographical data, past health history, family history); What the pt feels (ROS); what the patient thinks is important |
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Term
| In what order does the Health History go? |
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Definition
| 1. Biographical data; 2. Reason for seeking health care; 3. Currect health status (use PQRST)(Symptoms analysis); 4. Patient's history (allergies, medications); 5. Family history (+Genogram); 6. Review of Systems; 7. Psychosocial profile; 8. Ethnic considerations; 9. Developmental considerations |
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Term
| What does P in PQRST stand for? |
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Definition
| Precipitating factors - asking Qs to find out what happened before problem occured and factors that influence the problem currently. |
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Term
| What does Q in PQRST stand for? |
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Definition
| Quantity vs Quality. Defining the problem and how often it is a problem. |
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Term
| What does R in PQRST stand for? |
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Definition
| Region vs Radiating. Asking them to point to where the problem is and asking if it leads to anywhere else |
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Term
| What does S in PQRST stand for? |
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Definition
| Severity - grading the symptom |
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Term
| What does the T in PQRST stand for? |
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Definition
| Timing - ask when symptoms started and how often it occurs as well as how long. |
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Term
| What are the techniques of physical assessment? |
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Definition
| Inspection, palpation, percussion and ausculation |
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Term
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Definition
| Using one's senses of sight, hearing and smell to examine the Pt. Can be directly or indirectly with tools. |
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Term
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Definition
Using sense of touch to examine pt.
Light vs Deep palpation. Light = gentle. Deep = more than .5 inch. |
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Term
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Definition
| Repeated tapping of an object/area to analyze the density of a structure |
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Term
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Definition
| Assessing via the sense of hearing. (Judge the easiness of hearing and duration). |
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Term
| What is the correct method for taking a tympanic temperature? |
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Definition
1. Insert the probe snugly into the external, angle the thermometer toward pt jaw line. Pull pinna up and back to straighten canal in adult.
2.Then push trigger and note the reading. |
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Term
| What makes the S1 heart sound? |
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Definition
| Mitral and tricuspid valve closure |
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Term
| What makes the S2 heart sound? |
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Definition
| Aortic and pulmonary valve closure |
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Term
| What makes the S3 heart sound? |
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Definition
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Term
| What makes the S4 heart sound? |
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Definition
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Term
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Definition
| The difference between systolic and diastolic pressure. |
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Term
| What does a high PP indicate? |
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Definition
| Decreases elasticity in arterial walls or increased intracranial pressure. |
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Term
| What does a low PP indicate? |
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Definition
| Indicative of a patient going into shock or heart failure |
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Term
| What are anthropometric measurements? |
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Definition
| Measurements that analyze one's body fat composition through noninvasive means of using a scale to measure heigh, weight, skin fold thickness, and bodily circumference |
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Term
| What are the causes of a murmur? |
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Definition
| A murmur is caused by stenosis (stiffened valve) or non fully closed valves that allow backflow. The actual murmur sound is caused by turbulence in blood. |
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Term
| What is the system for grading murmurs? |
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Definition
Grade 1 = soft, heard only in quiet conditions.
Grade 2 = soft, heard under noisy conditions
Grade 3 = easily heard, prominent murmur
Grade 4 = loud, associated with thrill
*Diastolic murmurs are only graded up to 4
Grade 5 = loud, heard with edge of stethoscope (thrill)
Grade 6 = very loud, heard with stethoscope 5 to 10 mm off chest, plus thrill. |
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Term
| Describe the process of measuring the jugular venous pressure |
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Definition
*This is an indirect means of measuring right atrial pressure.
1. Place ruler vertically over heart, at the angle of Louis
2. Place another ruler horizontally reaching from point of highest jugular vein pulsation
3. Measure with the vertical ruler the distance from the bottom portion of the horizontal ruler. |
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Term
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Definition
This is a test for abnormal voice sounds.
Have patient say "eee" and it will sound like "aaa" over affected area. |
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Term
| What is an adventitious breath sound? |
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Definition
| Sounds that are superimposed over normal breath sounds. |
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Term
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Definition
| Air bubbling through fluid, like mucus membranes. Usually occurs at inspiration. |
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Term
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Definition
| Results from air trying to go through a narrow passageway. A narrow passageway can be caused by either tumur or mucus. Usually accompanies asthma. |
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Term
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Definition
| Noise made when pleural layers rub together |
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Term
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Definition
| Harsh, high pitched continous sound that results from upper airway obstruction |
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Term
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Definition
| Sound heard on expiration as patient forces retained air out of lungs. |
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Term
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Definition
| Normal percussion note heard on adult lungs. |
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Term
| What is the purpose of percussion? |
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Definition
| Percussion is used to asses the density of the underlying tissue. |
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Term
| What is diaphragmatic excursion? |
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Definition
| Measuring the distance of that the diaphragm moves from inspiration to expiration. |
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Term
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Definition
| Heard over the lung tissue where air si trapped, i.e. emphysema |
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Term
| What are abnormal findings when percussing chest? |
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Definition
| Dullness, hyperresonance. |
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Term
| What is whisper pectoriloquy? |
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Definition
| Have patient whisper "1, 2, 3"; There will be a clearer transmission of whispered voice sound over affected area. |
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Term
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Definition
| A test for abnormal voice sounds. Have patient say "1,2,3"; clearer transmission of spoken voice sound over affected area. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Prolong gasping inspiration and short ineffective expiration |
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Term
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Definition
| Faster and deeper, and then slower breathing alternated with periods of apnea. |
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Term
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Definition
| Fast and deeper respirations without pauses. |
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Term
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Definition
| A normal breath sound; High pitched, usually accompanies a short inspiratory phase and long expiratory phase. |
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Term
| What is bronchovesicular? |
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Definition
| Moderate sounding, medium pitched, equal inspiratory and expiratory phase. |
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Term
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Definition
| Soft, low pitched sound. Accompanies long inspiratory phase and short expiratory phase. (Most common). |
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Term
| What is the process for ascultating for bruits? |
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Definition
| Auscultate the carotid artery. |
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Term
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Definition
| An audible, low pitched sound createdby turbulent flow. |
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Term
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Definition
| Results from increased capillary pressure that shifts fluid from capillaries to tissues. Can accompany right sided CHF. |
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Term
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Definition
| The difference between the radial and apical pulse |
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Term
| What is a bounding pulse? |
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Definition
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Term
| What is the grading system of pulses? |
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Definition
3+ = bounding
2+ = brisk, normal
1+ = diminishe, weak
0 = absent, unable to palpate |
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Term
| Where is the temporal pulse located? |
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Definition
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Term
| Where is the posterior tibialis pulse located? |
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Definition
| Behind medial malleolus of ankle. |
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Term
| Where is the femoral pulse located? |
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Definition
| Below inguinal ligament in groin. |
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Term
| Where is the popliteal pulse located? |
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Definition
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Term
| Where is the dorsalis pedis pulse located? |
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Definition
| Dorsum of foot/top of foot. |
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Term
| What is the grading scale for muscle strength? |
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Definition
Strength is graded on a scale of 0 to 5.
0 = no muscle contraction
1 = trace of contraction
2 = active movement with gravity eliminated
3 = active movement against gravity
4 = active movement against gravity and little resistance
5 = active motion against full resistance. |
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Term
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Definition
| A test for carpel tunnel's syndrome. Push hands dorsally against each other. If tingling occurs after 30 secs, test is postive. |
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Term
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Definition
| A test for carpal tunnel syndrome. Percuss over median nerve, test is postivie if tingling occurs in pointer and/or thumb of same hand. |
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Term
| What is the purpose of percussion? |
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Definition
| Allows you to assess the density of the underlying lung tissue. Also helps you to determine if tissue is solid or filled with liquid/air. |
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Term
| What is the process for percussion of the lungs? |
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Definition
| Percuss over intercostal spaces. Begin percussing anterior thorax, lateral thorax, and then posterior thorax. Finish by assessing diaphragmatic excursion (making the two marks). |
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Term
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Definition
| Moving in a circular fashion. |
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Term
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Definition
| Moving of hand towards ulnar side. |
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Term
| What is radial deviation? |
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Definition
| Moving of hand towards radial side. |
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Term
| What is the best position for the assessment of the lungs? |
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Definition
| By having the patient sit. |
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Term
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Definition
| An increase in anterior to posterior diameter. |
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Term
| What is tactile fremitus? |
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Definition
| Assessing a patient by palpating chest or back. (Hate pt say "99" and assess for equal balance of vibration). |
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Term
| What are the characteristics of an apical pulse? |
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Definition
| Strongest pulse. Should be the site of PMI (point of maximum impulse). |
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Term
| What does the P wave represent? |
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Definition
| Depolarization (contraction) of the atria |
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Term
| What does the P-R interval represent? |
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Definition
| The period of time from P wave to beginning of QRS... the traveling of the action potential. |
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Term
| What does the QRS complex represent? |
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Definition
| Ventricular depolarization (contraction) |
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Term
| What does the ST segment represent? |
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Definition
| Isoelectric period... entire ventricle depolarized. |
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Term
| What does the T wave represent? |
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Definition
| Ventricular repolarization |
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Term
| What does the QT interval represent? |
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Definition
| Both ventricular depolarization and re polarization. |
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Term
| What is the Romberg test? |
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Definition
| Test for a patient's balance. Have pt stand with feet together with eyes open, then closed, and then closed with a nudge. |
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Term
| How does one assess the spine? |
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Definition
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Term
| How does one assess for kyphosis? |
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Definition
| Have patient bend at the waste and inspect the back in the cervical/thoracic region |
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Term
| How does one assess for lordosis? |
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Definition
| Have patient stand against wall and try to see if you can slide your hand behind the back. |
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Term
| How does one assess for scoliosis? |
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Definition
| Have patient stand with minimal clothing and look at back. |
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Term
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Definition
| An exaggeration of the normal posterior curvature of the spine (humpback) |
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Term
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Definition
| Abnormal anterior convexity of the lumbar spine (sway back). |
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Term
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Definition
| Lateral curvature of spine |
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Term
| What are the five auscultatory sites? |
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Definition
| Aortic (S2), Pulmonic (S2), Erb's Point (?), Tricuspid, and Mitral. |
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Term
| Where can one find the Aortic auscultatory site? |
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Definition
| 2nd intercostal space, right sternal border |
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Term
| Where can one find the Pulmonc auscultatory site? |
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Definition
| 2nd intercostal space, left sternal border. |
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Term
| Where can one find the Erb's point? |
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Definition
| 3rd intercostal space, left sternal border |
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Term
| Where can one find the Tricuspid auscultatory site? |
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Definition
| 4th and 5th intercostal space, left sternal border |
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Term
| Where can one find the Mitral auscultatory site? |
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Definition
| 5th intercostal space, left mid-clavicular line. |
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Term
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Definition
| When ventricles contract (pulmonic and aortic valves open) |
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Term
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Definition
| When the ventricles relax (tricuspid and mitral valve open) |
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Term
| What is assessed when one assesses cerebellar function |
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Definition
| Balance, coordination, and accuracy of movement. |
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Term
| What tests are used to assess balance? |
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Definition
| Gait, tandem walk, heel and toe walking, deep knee bend, hop on one foot, and Rhomberg test |
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Term
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Definition
| Heel-to-toe/drunk driver test |
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Term
| What tests are used to assess coordination? |
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Definition
| Rapid alternating movements, finger thumb opposition, toe tapping, and heel down shin. |
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Term
| What tests are used to assess accuracy of movement? |
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Definition
| Finger to nose and point to point localization. |
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Term
| What is the grading system for edema? |
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Definition
| Edema is assessed on a four-point scale... Press over dorsum of foot and compare: 1+ = 2mm depression, 2+ = 4mm depression (15 secs), 3+ = 6mm depression (>1minute), 4+ = 8mm (>2minutes) |
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Term
| What is assessed when assessing joints? |
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Definition
| ROM, condition of skin, deformity, swelling, crepitus, redness, warmth, stability and pain. |
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Term
| In what order is ROM assessed? |
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Definition
| Jaw, head, waist, shoulders, arms, hands, thumb, knee and leg. |
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