Term
| When doing health history assessment, what 4 areas of information do you want to cover? |
|
Definition
| biographical data, history o resent illness, past medical/surgical history (including allergies, meds, hospitalization) family history |
|
|
Term
| What does the nurse ask at the beginning of the interview? |
|
Definition
| chief complaint (CC) the reason for visit |
|
|
Term
|
Definition
| provoking factors, quality, region and radiation, severity, timing, understanding. |
|
|
Term
| What is some information about surgeries that you should inquire from your patients? |
|
Definition
| cosmetic scars, if they have certain organs, why the surgery was done |
|
|
Term
| Why does the nurse ask about biological family history? |
|
Definition
| To determine if the patient is at risk for certain conditions that are genetic. |
|
|
Term
| What are the guidelines for interview and health history? |
|
Definition
| Don't give false reassurance, focus on the patient, don't overuse jargon, don't use biased questions (you don't use drugs do you), use positive non-verbal communication techniques, be aware of how the patient is responding during interview. |
|
|
Term
| Before beginning your assessment what tasks should be performed? |
|
Definition
| wash hands, don PPE if required, offer comfort, protect privacy of patient, introduce yourself. |
|
|
Term
| what are the 4 skills for physical assessment? |
|
Definition
| inspection, palpation, percussion, auscultation. |
|
|
Term
|
Definition
| viewing the patient visually |
|
|
Term
|
Definition
| technique of pressing on patient's tissues to evaluate texture, temperature, dampness, organ location and size. |
|
|
Term
|
Definition
| tapping on a body part and listening for the sound that is emitted. |
|
|
Term
|
Definition
| listening with a stethoscope to various body parts. |
|
|
Term
| Where is flatness percussion sounds heard? |
|
Definition
| muscle, bone, dense tissue. |
|
|
Term
| Where is dullness percussion sounds heard? |
|
Definition
| organs or masses, (kidney, liver). When a patient has pneumonia, this sound is heard in the lungs. |
|
|
Term
| where is the percussion sound of tympany heard? |
|
Definition
| distended abdomen with gas, loud intensity, drum-like |
|
|
Term
| When do you use the bell end of the stethoscope? |
|
Definition
| To listen to heart sounds which are low pitched. |
|
|
Term
| When do you use the diaphragm of the stethoscope? |
|
Definition
| lungs and bowels, high pitched sounds. |
|
|
Term
| During an assessment, what are the aspects of general appearance you should look for? |
|
Definition
| Appears stated age, LOC, skin color, nutritional status, mobility/gait/ROM, speech/articulation, facial expression/mood, hygiene |
|
|
Term
| What are questions about comfort to ask your patient? |
|
Definition
| Are you having pain, do you have to use the bathroom, are you comfortable? |
|
|
Term
| What does FLACC stand for and what is it used for? |
|
Definition
| Face, Leg movement, Activity, Cry, Consolability. Its used for infants and young children who can't use other scales. |
|
|
Term
| If an unconscious person is in a decorticate position what could this mean? |
|
Definition
| They are having deep pain expressed by abnormal flexion that is spontaneous or in response to a stimuli. |
|
|
Term
| If an unconscious person is in a decerebrate position what could this mean? |
|
Definition
| they are having deep pain expressed by abnormal extension that is spontaneous or a response to a stimuli |
|
|
Term
| What does PERRLA stand for? |
|
Definition
| pupils are equal, round, reactive to light and accommodation. |
|
|
Term
| What are abnormal findings in an eye exam? |
|
Definition
| unequal pupils, sluggish to light, absent reaction to light. |
|
|
Term
| What are the three components of the glasgow scale? |
|
Definition
| eye opening, verbal response, motor response. |
|
|
Term
| What is the maximum score a patient can achieve on the glasgow scale? |
|
Definition
|
|
Term
| What does a nurse do to check a patient's limb strength? |
|
Definition
| Assess hand grasp and leg strength if its normal, weak, or absent. |
|
|
Term
| How do you check for a patients ability to sense light touch? |
|
Definition
| rub there arm with a cotton ball with there eyes closed. |
|
|
Term
| How do check stereognosis? |
|
Definition
| if patients ability to recognize familiar objects. Close their eyes and put a quarter in their hand. |
|
|
Term
| If you ask a patient what they had for lunch, what are you assessing? |
|
Definition
|
|
Term
| If you ask a patient, when were you last seen by a health care professional, what are you assessing? |
|
Definition
|
|
Term
| During an assessment, a patient may loose interest because of a weak attention span but what might this also demonstrate? |
|
Definition
|
|
Term
| Why would a nurse check the gag reflex? |
|
Definition
| To make sure a patient can swallow and not aspirate when doing so. |
|
|
Term
| What is the concept definition of neural regulation? |
|
Definition
| The processes by which the nervous system activates, coordinates and controls the functions of the body. |
|
|
Term
| What is the concept definition of cognition? |
|
Definition
| Ability to think, learn, reason, perceive, and remember |
|
|
Term
| If a patient is Alert and Orientated x 3, what information does the patient know? |
|
Definition
|
|
Term
| What is the concept definition of sensory perception? |
|
Definition
| The process of recognition and interpretation of environmental stimuli. |
|
|
Term
| How does a nurse check for extraocular movement? |
|
Definition
| Have the patient keep their head still, and follow a pen with only their eyes. Go left, right, up, down, and an X motion. |
|
|
Term
| When a nurse does an ear exam what does he/she include? |
|
Definition
| hearing (whisper test), any discharge, lesions, tenderness, checking for hearing aides. |
|
|
Term
| What is the concept definition of communication? |
|
Definition
| The exchange of information, thoughts, and feelings between individuals, families and groups through verbal, nonverbal and written forms. |
|
|
Term
| What does joint commission require for a patient that speaks another language then the nurse? |
|
Definition
| an interpreter, family can not be used as interpreters. |
|
|
Term
| What is the concept definition of perfusion? |
|
Definition
| Exchange of blood, gases, fluids between the vessels, tissues and organ systems. |
|
|
Term
| What are some perfusion assessment questions? |
|
Definition
| Energy level, fatigue, dizzy, swelling. |
|
|
Term
| What are some physical things that you would want to look for in checking perfusion? |
|
Definition
| skin color (cyanotic, mottled, pink mucous membranes), skin moisture, skin temperature. |
|
|
Term
| What are the location sites for checking pulse? |
|
Definition
| temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial. |
|
|
Term
| Where do you check capillary refill and how long should it take for the color to change? |
|
Definition
| finger or toes, 3 seconds |
|
|
Term
|
Definition
| apical pulse, 5th intercostal space midclavicular line left side. |
|
|
Term
| What is the first heart sound heard? |
|
Definition
| s1 (lub) closure of mitral and tricuspid at the same time. |
|
|
Term
| what is the second heart sound heard? |
|
Definition
| s2 (dub) closure of pulmonic and aortic valves at the same time. |
|
|
Term
| Where is s1 sound best heard? |
|
Definition
|
|
Term
| Where is the s2 sound best heard? |
|
Definition
|
|
Term
|
Definition
| blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels |
|
|
Term
| What is Jugular vein distension checking for? |
|
Definition
|
|
Term
| How do you check for JVD? |
|
Definition
| Inspect the neck while patient is at a 30-45 degree angle, turn head slightly. |
|
|
Term
| What are the types of edema? |
|
Definition
| pitting, brawny, non-pitting. |
|
|
Term
|
Definition
| Leaves an indent in the tissue with pressure |
|
|
Term
|
Definition
| chronic edema, discolored extremity, does not pit with pressure. |
|
|
Term
| What is non-pitting edema? |
|
Definition
| swelling is evident, but no pit is formed with pressure. |
|
|
Term
|
Definition
| edema collected in the patient's lowest body part. if a patient sits for a long period of time, they may develop edema in feet, ankles, or legs. |
|
|
Term
| What does HOMANS sign check for? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| what is +4 on the edema chart? |
|
Definition
| deep pitting, indentation lasts a long time, area is very swollen. |
|
|
Term
| What is the concept definition of oxygenation? |
|
Definition
| The process that maintains oxygen levels necessary for the survival of living cells. |
|
|
Term
| What do you access when looking at the nose and upper airway? |
|
Definition
| lesions, drainage, redness, nares patent, palpation of maxillary sinuses. |
|
|
Term
| What is included in a neck inspection? |
|
Definition
| Symmetry to each side, lymph nodes, and any irregularites in the trachea. |
|
|
Term
| What does a barrel shape chest indicative of? |
|
Definition
| lungs have increased in size, due to emphysema. |
|
|
Term
| When a person is normally breathing they use the _______________muscle. In disstress, a patient may use _______________. |
|
Definition
| Diaphragm, intercostal muscles, abdominal muscles, or other accessory muscles. |
|
|
Term
| What are the 3 normal breath sounds |
|
Definition
| Bronchial, bronchovesicular, vesicular |
|
|
Term
| How is a lung accessment performed? |
|
Definition
|
|
Term
| What would crackle sound indicate? |
|
Definition
| Fluid in the lungs or atelectasis (collapse of alveoli due to hypoventilation) |
|
|
Term
| What is pleural friction rub? |
|
Definition
| dry, grating sounds as the pleural cavity is rubbing against. |
|
|
Term
|
Definition
| gurgles, loud low-pitches, coarse, rumbling. |
|
|
Term
| What is a dry cough indicative of? |
|
Definition
| Cardiac problems, allergies, HIV infection... |
|
|
Term
| What is a moist cough indicative of? |
|
Definition
| infection and may be accompanied by sputum. |
|
|
Term
| What does clubbing of the extremities represent? |
|
Definition
| chronic condition of oxygen deficiency. not a reversible condition. |
|
|
Term
| What are the different types of oxygen equipment? |
|
Definition
| Nasal canula, face mask, facial oxygen tent, non-rebreather, venturi mask. |
|
|
Term
| What do you assess during a mouth exam? |
|
Definition
| Teeth (dentures, missing teeth) Gums ( bleeding or inflamed) lips (cracks, lesions) Oral mucosa (pink, moist and intact) |
|
|
Term
| What is the order of assessment when assessing bowel sounds? |
|
Definition
| Inspection, auscultation, percussion, palpation. |
|
|
Term
| What part(s) of the large intestine is found in the right lower quadrant, and what major organ(s) are found here? |
|
Definition
| Ascending colon. appendix |
|
|
Term
| What part(s) of the large intestine is found in the right upper quadrant, and what major organs are found here? |
|
Definition
| ascending colon/transverse colon. liver, gallbladder, stomach, pancreas |
|
|
Term
| What part(s) of the large intestine is found in the left upper quadrant, and what major organs are found here? |
|
Definition
| transverse colon/descending colon. spleen, pancreas, liver. |
|
|
Term
| What part(s) of the large intestine is found in the left lower quadrant, and what major organs are found here? |
|
Definition
| Descending colon/sigmoid colon. none besides small intestines |
|
|
Term
| During inspection of the abdomen, what are you looking for? |
|
Definition
| fat, fetus, fibroid (benign tumor/ or mass in the uterus) fluid, flatus ( the 5 f's of why abdomen may be extended) scars, masses, ostomies, striae (stretch marks) |
|
|
Term
| What are the 4 contour shapes of the abdomen? |
|
Definition
[image]
flat, scaphoid, rounded, protuberan |
|
|
Term
| What is the order of checking bowel sounds? |
|
Definition
| Lower right, upper right, upper left, lower left. |
|
|
Term
| If bowel sounds are not heard in one of the quadrants, how long do you listen for before determining there aren't any? |
|
Definition
|
|
Term
| How can bowel sounds be described? |
|
Definition
| Normal, audible absent, hyperactive, hypoactive. |
|
|
Term
| What is the normal findings of palpating the abdomen? |
|
Definition
| Non-distended, soft/firm, non-tender |
|
|
Term
| What is the minimum urinary output? |
|
Definition
| 30ml per hour (50ml per hour is better) |
|
|
Term
| What do you want to note about a patients urine? |
|
Definition
| color, clarity, odor, and sediment if there is any. |
|
|
Term
| How do you check if a patient has a full bladder? |
|
Definition
| Palpation or bladder scanner |
|
|
Term
| What is the normal bladder capacity? |
|
Definition
|
|
Term
| When documenting a patient's output, it is important to compare the results to the ___________. |
|
Definition
|
|
Term
| What do you want to assess about a patient's bowel movements? |
|
Definition
| how many, pattern (once a day, every other) watery/formed, hard/soft, color, shape, presence of blood. If it is liquid measure in ml. |
|
|
Term
| What are the different physician orders of mobility? |
|
Definition
| BR (bedrest), BRP (bedrest with bathroom priveleges), up ad lib, ambulate with assistance, OOB (out of beed), OOB with assist |
|
|
Term
| What are the ways of assessing a patient's mobility? |
|
Definition
| ROM, muscle strength, muscle tone, gait, balance, cramps, stiffness, spasms, swelling, pain |
|
|
Term
| For assessing upper body strength, what can you ask the patient to do? |
|
Definition
| Squeeze your fingers of both hands and compare the patient's right to left strength. Tell the patient to push their hand while you resist. |
|
|
Term
| For testing lower body strength, what can a nurse do? |
|
Definition
| the nurse places his/her hands at the planter surface of the balls of the patient's feet and asks the patient to "push my hands away". Also, you ask the patient to raise their foot off of the bed and touch your hand with their toes |
|
|
Term
| What are characteristics of a patient's psychosocial integrity? |
|
Definition
| Behavior, mood, thought processes, coping |
|
|
Term
| When a patient has an IV what must you chec? |
|
Definition
| Type of fluids, rate of infusion, expire date and time, complications (IV site) |
|
|
Term
| What is infiltration of an IV? |
|
Definition
| Fluid is perfusing outside the vein into the interstitial space. Causes swelling and pain. |
|
|
Term
|
Definition
| Inflammation of the vein. Vein may be hard, painful, and red. |
|
|
Term
| When must a nurse check a patient's IV site? |
|
Definition
|
|
Term
| During a snapshot assessment what are you doing? |
|
Definition
| checking: abc's, LOc, safety, pt. position, equipment attached to patient, patients belongings in reach, call light |
|
|
