Q1 nursing > chapter 30 Melissa > Flashcards

chapter 30 Melissa Flashcards

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0
Q

What type of data do you collect through the health history interview?

A

Subjective data about a patient’s condition

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1
Q

A complete health assessment involves what?

A

A nursing history and behavioral and physical examination

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2
Q

When performing a health assessment how would you collect objective data?

A

By observing a patient’s behavior and overall presentation. Also through a head-to-toe body system review during the physical examination.

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3
Q

Why is a physical examination conducted?

A

As an initial evaluation in triage for emergency care; for routine screening to promote wellness behaviors and preventative health care measures; to determine eligibility for health insurance, military service, or a new job; or to admit a patient to a hospital or long-term care facility.

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4
Q

A physical examination is used to do what?

A
  • Gather baseline data about the patient’s health status.
  • Support or refuse subjective data obtained in the nursing history.
  • Identifying confirm nursing diagnoses.
  • Make clinical decisions about a patient’s changing health status and management.
  • Evaluate the outcomes of care.
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5
Q

Five important things to consider when performing an examination and history on a patient?

A
  • The patient’s health beliefs
  • The use of alternative therapies
  • Nutrition habits
  • Relationship with family
  • Comfort with physical closeness
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6
Q

When preparing for an examination a nurse should consider what 6 things?

A
  • Infection control
  • Environment
  • Equipment
  • Physical preparation of the patient
  • Psychological preparation of the patient
  • Assessment of age groups
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7
Q

When considering infection control a nurse should do what?

A
  • Wear gloves on all patients and if a patient has excessive drainage or there is a risk of splattering from a wound, additional personal protective equipment such as isolation gowns or eye shield should be used.
  • Identify any latex allergies in the patients and use equipment items that are latex free if such allergies exist.
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8
Q

What environmental factors should a nurse consider when preparing for an examination?

A
  • Privacy such as an examination room with the door shut or patient’s room with the curtain pulled shut.
  • Adequate lighting to illuminate body parts
  • Eliminate extra noise
  • Take precautions to prevent interruptions from others
  • Room must be warm
  • An examination table with head elevated 30 degrees
  • A small pillow to help with head and neck comfort
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9
Q

When preparing for an examination, what are some things a nurse can do to prepare the equipment that will be used?

A
  • Arrange any necessary equipment so that it is readily available and easy to use
  • Warm the diaphragm of the stethoscope between the hands before applying to the skin
  • Be sure that equipment functions properly before using it
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10
Q

Physical preparation of the patient includes what?

A

-Physical comfort needs are met: empty their bladder and/or bowels before examination
~ collection of urine or fecal specimens occur at this time

  • Provide a proper dress or draping to the patient to provide privacy and allow proper time for them to change
  • Provide extra blankets or eliminate drafts in the room so the patient can stay warm
  • Help position patient so body parts are accessible but make sure the patient remains comfortable
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11
Q

How would a nurse psychologically prepare a patient for an examination?

A
  • Thoroughly explain the purpose and the steps of each assessment
  • Encourage the patient to ask questions
  • During the examination, watch the patient’s emotional responses and body movements

-Postpone the examination if the patient is unwilling to cooperate
~ results are more accurate when the patient can cooperate and relax

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12
Q

When preparing for an examination, why is assessment of age group so important?

A

Your approach will vary with each age group

  • Children: Show sensitivity and anticipate the child’s anticipation of the examination as a strange and unfamiliar experience
  • Older adults: Do not always exhibit the expected signs and symptoms. Some take longer to be interviewed and examined due to sensory and physical limitations. Provide adequate space for walkers/wheelchairs. Be aware of closets restroom.
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13
Q

8 positions for examination?

A

1) Sitting
2) Supine
3) Dorsal recumbent
4) Lithotomy
5) Sims’
6) Prone
7) Lateral recumbent
8) Knee-chest

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14
Q

What areas are assessed in the sitting position?

A
  • Head
  • Neck
  • Back
  • Posterior thorax and lungs
  • Anterior thorax and lungs
  • Breast
  • Axillae
  • Heart
  • Vital signs
  • Upper extremities
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15
Q

What areas are assessed in the supine position?

A
  • Head and neck
  • Anterior thorax and lungs
  • Breast
  • Axillae
  • Heart
  • Abdomen
  • Extremities
  • Pulses
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16
Q

What areas are accessed in the dorsal recumbent position?

A
  • Head and neck
  • Anterior thorax and lungs
  • Breasts
  • Axillae
  • Heart
  • Abdomen
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17
Q

What areas are accessed in the lithotomy position?

A
  • Female genitalia

- Genital tract

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18
Q

What areas are accessed in the sims’ position?

A
  • Rectum

- Vagina

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19
Q

What areas are assessed in the prone position?

A
  • Musculoskeletal system
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20
Q

What areas are assessed in the lateral recumbent position?

A
  • Heart
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21
Q

What areas are assessed in the knee-chest position?

A
  • Rectum
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22
Q

During an inspection what are three things you should do to distinguish normal from abnormal findings?

A
  • Carefully look
  • Listen
  • Smell
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23
Q

During an inspection, what are three things you should do to distinguish normal from abnormal findings?

A
  • Carefully look
  • Listen
  • Smell
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24
Palpation allows a nurse to do what?
Make judgments about expected and unexpected findings of the skin or underlying tissue, muscle, and bones.
25
What are the two types of palpations?
- Light : Place the hand on the body part being examined pressing inward about 1cm ( 1/2 inch ). It allows the patient the chance to identify areas of tenderness. - Deep: Depress the area under examination approximately 4 cm ( 2 inches ), using one or both hands. It is used to examine the condition of organs such as those in the abdomen.
26
What do you do when you access percussion?
Tap the skin with the fingertips to vibrate underlying tissues and organs.
27
What is auscultation?
- Involves listening to sounds the body makes to detect variations from normal. - Becoming more proficient inosculation occurs by knowing the types of sounds each body structure makes and the location in which the sounds are heard best.
28
What are four things that help describe osculation?
- Frequency - Loudness - Quality of the sound - Duration
29
When a patient enters the examination room, what are some things to be aware of when assessing their general appearance and behavior? (12 items)
- gender and race - age - signs of distress - gait (ambulatory) - body movements - hygiene and grooming - dress - body odor - affect and mood - speech - signs of patient abuse - substance abuse
30
When is the best time to measure a patient's vital signs?
After completing the general survey and before beginning positional changes or movements. * more accurate
31
Why is it important to measure the height and weight of a patient?
- Height and weight reflect a person's general health status. - To identify if he or she is at a healthy weight, overweight, or obese - Assess trends in weight changes compared with height for signs of poor health - Standardize tables help reveal the normal expected adult wait for a given height
32
What are the different types of scales available for weighing a patient?
- Standing scale for weight bearing patients * The standard platform scale * The electronic scale - Bed and chair scales are available for patients who are unable to bear weight - Electronic hospital beds with built-in electronic scales for weighing patients who are not able to get out of bed - Basket or platform scale to weigh infants
33
The integumentary system refers to what?
- Skin - Hair - Scalp - Nails
34
Assessment of the skin reveals a patient's health status related to what?
Oxygenation, circulation, nutrition, local tissue damage, and hydration.
35
What is cyanosis?
Bluish discoloration in the lips, nailbeds, palpebral conjunctivae and palms.
36
The best site to inspect for jaundice?
On the patient's sclera
37
What is erythema and what does it indicate?
Red discoloration indicating circulatory changes
38
What does indurated mean?
Hardened skin
39
What is turgor?
Refers to the elasticity of the skin
40
What is Petechiae?
Non-blanching, pinpoint-size, red or purple spots on the skin caused by small hemorrhages in the skin layers
41
What are two common causes of Edema?
Direct trauma and impairment of venous return
42
Alopecia is what?
Hair loss
43
The three types of lice are?
- pediculus humanus capitis ( head lice ) - pediculus humanus corporis ( body lice ) - pediculus pubis ( crab lice )
44
The condition of the nails reflects what?
General health, state of nutrition, a person's occupation, and habits of self-care.
45
An examination of the head and neck include assessment of what?
Head, eyes, ears, nose, mouth, pharynx, and neck.
46
What is hyperopia?
Farsightedness: a person is able to clearly see distant objects but not close objects
47
What is myopia?
Nearsightedness: a person's ability to clearly see close objects but not distant objects
48
What is presbyopia?
Impaired near vision in middle-age and older adults, caused by loss of elasticity of the lens and associated with the aging process.
49
What is retinopathy?
A noninflammatory I disorder resulting from changes in retinal blood vessels. It is a leading cause of blindness.
50
What is strabismus?
A congenial condition in which both eyes do not focus on an object simultaneously
51
What are cataracts?
And increased opacity of the lens, which blocks light rays from entering the eye. Cataracts are one of the most common I disorders.
52
What is glaucoma?
Intraocular structural damage resulting from elevated intraocular pressure. Without treatment the disorder leads to blindness.
53
What is mascular degeneration?
Blurred central vision often occurring suddenly, caused by progressive degeneration of the center of the retina. There is no cure.
54
What is nystagmus?
An involuntary, rhythmical oscillation of the eyes, occurs as a result of local injury to eye muscles and supporting structures or a disorder of the cranial nerves innervating the muscles.
55
What is ptosis?
An abnormal drooping of the lid over the pupil
56
What does the abbreviation PERRLA mean?
Pupils equal, round, reactive to light, and accommodation.
57
What is arcus senilis?
A thin white ring along the margin of the iris
58
What is an otoscope used for?
To observe the deeper structures of the external and middle ear
59
What are the three types of hearing loss?
- a conduction loss: Interprets soundwaves as they travel from the outer ear to the cochlea of the inner ear * Swelling of the auditory canal and tears in the tympanic membrane - a sensorineural loss: Involves the inner ear, auditory nerve, or hearing centers of the brain. - a mixed loss: Involves a combination of conduction and sensorineural loss
60
What is ototoxicity?
Injury to auditory nerve resulting from high maintenance doses of antibiotics
61
What are the two types of tuning fork tests?
Weber's and Renne - Weber's: Hold fort at its base and tap it lightly against heel of palm. Place base of vibrating fork on midline vertex of patients head or middle of forehead. Ask patient if he or she hears the sound equally in both ears or better in one ear. - Renne: Place stem of vibrating tuning fork against patients mastoid process. Begin counting the interval with your watch. Ask patient to tell you when he or she no longer hears the sound; Note number of seconds. Quickly place still-vibrating times 1 to 2 cm ( 1/2 to 1 inch ) from ear canal and ask patient to tell you when he or she can no longer hear the sound. Continue counting time the sound is heard by air conduction. Compare number of seconds the sound is heard by bone conduction versus air conduction.
62
What is excoriation?
Local skin breakdown of the naris
63
What are polyps?
Tumorlike growths
64
When inspecting the lips, what should you look for?
- Color - Texture - Hydration - Contour - Lesions
65
What do cherry-colored lips indicate?
Carbon monoxide poisoning
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