X Foundations - Chpt 5 - Assessment Flashcards Preview

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Flashcards in X Foundations - Chpt 5 - Assessment Deck (50)
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1
Q

Order of Priority - ABC

A
  • Airway
  • Breathing
  • Circulation
2
Q

The first step in the nursing process

A

Assessment

3
Q

Purpose of physical assessment

A
  • evaluate current phys condition
  • detect early signs of health prob
  • establish BASELINE for future comparison
  • evaluate clients response to treatment
4
Q

The first admission assessment done by

A

RN

5
Q

4 assessment technicques

A
  • Inspection (with eyes)
  • Percussion (lightly w fingertips, tapping, usually docs)
  • Palpation (light touch. Deep palpation usually docs)
  • Auscultation (stethoscope)
6
Q

PERRLA

A

Pupils, Equal, Round, Reactive to Light, Accommodation

use pen light to assess

7
Q

COPD

A

Chronic Obstructive Pulmonary Disease

8
Q

Sounds of heart indicated by

A

S1, S2 (lub, dub)

9
Q

normal bowels sounds

A

8-30 gurgles p/minute

10
Q

Borborygmus

A

abnormal bowel/abdomen sounds

11
Q

If claiming bowel sounds absent, how do you confirm

A

listen for 1 minute per quadrant (4 min)

12
Q

Equipment needed for Physical Assessment

A
  • tongue depressor
  • pen light
  • pen/paper
  • stethoscope
  • Spygmonometer
  • watch w second hand
  • thermometer
  • scale
  • Snellen chart (eye )
  • Wong-Baker chart (faces, objectify pain)
13
Q

Approaches for collecting data

A
  • head to toe approach

- body systems approach

14
Q

A&O x 3

A

Alert and Oriented ( 1.Person, 2.Place, 3.Time)

15
Q

Where do you perform skin turgor test?

A

under clavicle. look for skin tenting (when skin stays up after you pinch it)

16
Q

Lung Sounds

A
  • Trachael
  • Bronchial (main stem bronchi)
  • Bronchovesicular (tubes and alveoli)
  • Vesicular (margin of lungs, Alveoli)
17
Q

Adventitious Lung Sounds

A

other than clear sounds

  • crackles (fluid in alveoli)
  • Gurgles (wet, noisy)
  • Wheezes
  • Rubs (pleura rubbing, leather creaking)
18
Q

Capillary refill

A

press on nail bed, blood should return in under 3 sec.

19
Q

Brawny/Turgid Edema

A

so swollen, you can’t even push it in

20
Q

Weeping Edema

A

when the interstitial fluid seeps out of pores.

21
Q

Jaeger Chart

A

EEE symbols testing vision when pt doesn’t know english alphabet or KIDS

22
Q

A&Ox3

A

Alert and Oriented to Person, Place, Time

23
Q

Assess pt in what manner

A

Head to Toe

24
Q

Ronchi

A

Rhonchi are continuous low pitched, rattling lung sounds that often resemble snoring. Obstruction or secretions in larger airways are frequent causes of rhonchi. They can be heard in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis. Rhonchi usually clear after coughing.

25
Q

Rales

A

Listen for fine crackles, which are discontinuous, popping sounds similar to velcro being pulled apart

26
Q

Percussion used to determine….

A

density (fluid, hollow etc)

27
Q

Ischemia

A

restriction in blood supply to tissues,[3] causing a shortage of oxygen and glucose needed for cellular metabolism (to keep tissue alive).[4] Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue. It also means local anemia in a given part of a body sometimes resulting from congestion (such as vasoconstriction, thrombosis or embolism).

28
Q

Pallor

A

pale

29
Q

Echinosis

A

A condition in which the red blood cells have lost their smooth outlines and come to resemble an echinus or sea urchin.

30
Q

petechiae

A

Bleeding under the skin can occur from broken blood vessels that form tiny pinpoint red dots

31
Q

erythema

A

redness of the skin

32
Q

ecchymosis

A

Blood also can collect under the tissue in a very large bruised area

33
Q

purpura

A

Purpura occurs when small blood vessels leak blood under the skin.

When purpura spots are less than 3 millimeters in diameter, they are called petechiae. Purpura spots larger than 1 centimeter are called ecchymoses.

34
Q

diaphoresis

A

profuse sweating or perspiring.

35
Q

pruritis

A

Itchy skin that makes you scratch

36
Q

Purulent Discharge

A

Pus

37
Q

Exudate

A

Seeping out. (Cyst breaks open)

38
Q

Order of Assessment

A

1) Instpection
2) Palpation
3) Auscultation
4) Percussion

39
Q

Abuse looks like

A

?

40
Q

List of Disease Processes

A

?

41
Q

Dyspnea

A

Difficulty breathing

42
Q

Orthopnea

A

difficulty breathing while lying down

43
Q

Positions

A

?

43
Q

Signs are ….

A

Objective

44
Q

Exudate

A

Seeping out, cyst breaks open, puss, serum

45
Q

Sign or symptom Objective

A

Sign

46
Q

Sign or symptoms subective

A

Symptoms

47
Q

Etiology

A

Cause of the disease

48
Q

Pruritis

A

Itchy skin

49
Q

Asthenia

A

Weak and lethargic

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