Assessment 16 Flashcards

Terms Definitions
abdomin/o
abdomen
late adulthood
65+
palpable vibration
fremitus
 
palpatation
anterior-symmetric chest expansion-lumps and tenderness-tactile fremitusposterior-symmetric expansion-spinous processes-tactile fremitus-tenderness, moisture, temperature, masses, lesions and crepitus
97-98%
normal pulse oximetery
concerned with independence
early adulthood
-ectomy
excision or surgical removal
s2
higher pitch heart sound
silence
particularly important for open-ended questions
which lung is more narrow?
left
 
cephalhematoma
subperiosteal hemorrhage, which is also a result of birth trauma. soft, fluctuant, and well defined over one cranial bone because the periosteum holds the bleeding in place
maceration
softening of tissue from soaking
patrick test
tests external hip rotation
Sources of Data:
Client
Family/Significant Other
Health Care Team Members
Medical Records
Other Records
Literature Review
Nurse's Experience
summary
final review of the patients statements by the interviewer
where does the trachea begin?
cricoid cartilage
 
seborrheic keratosis
raised, thickened areas of pigmentation that look crusted, scaly, and warty.looks dark, greasy, and "stuck on"-trunk, face, and hands-not cancerous
 
pneumothorax
free air in pleural space-spontanious, trauma, or tensioninspection-deviated trachea-unequal chest expansion-cyanosispalpatation-tactile fremitus-decreased or absentpercussion-hyperressonantauscultation-absent breath sounds
Keloid
hypertrophic (excessive growth) of a scar, beyond normal healing
kidney stones
Costovertebral angle tenderness may indicate..
hyperresonance
lower-pitched, booming sound, has too much air is present, ex. emphysema and pneumothorax
Cue
information you acquire through the use of the senses
setting up and managing a household
early adulthood
levels of auditory system
peripheral, brainstem, cerebral cortex
pulse oximetry
normal 97-98%; varies depending on hemoglobin level, acid base balance, and ventilatory status
 
 
pruritus
any skin itching? is this mild (prickling, tingling) or intense (intolerable)
does it awaken you from sleep
where is the itching? when did it start?
any other skin pain or soreness? where?
 
acrochordons
skin tags, overgrowth of normal skin that form a stalk
 
Anatomy 
 
Lungs
Left and right pleural cavities on either side of the mediastinum contain the lungs.Left lung has 2 lobes, right has 3 separated by fissures, oblique on both and horizontal on rightBorders:-anterior-apex- 3-4cm above inner third of claviclesbase-rests on diaphragm at about the 6th rib midclavicularLaterally-apex of axilla to 7-8th ribposteriorly-c7 apex, t10 base, base lowers to t12
 
empathy
viewing the world from the other person's inner frame of reference while remaining yourself, recognizing and accepting the other person's feelings without criticism
Furuncle
an infected boil/skin lesion from an infected hair follicle
Murphy's sign
cholecystitis is suspected if the clietn experiences pain and abuptly stops breathing during palpation
thymus gland
this functions more in a child
Back channeling
includes active listening prompts such as "all right" and "uh-huh". encourages client to give more details.
Questions that limit the client's answers to one or two words such as "yes" or "no" or a number or frequency of a symptom.
Close-ended questions
what is the most common reason people seek healthcare?
joints
subjective questions to ask about muscles?
pain (cramps), weakness
what is the increase in carbon dioxide in the blood called?
hypercapnia
 
excessive bruising
any excess bruising? where on the body?
how did this happen?
how long have you had it?
 
abnormal findings in head size/contour
hydrocephaluspagets disease of bone-osteitis deformansacromegaly
 
10 traps of interviewing
providing false assurance or reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing, using professional jargon, uising leading or biased questions, talking too much, interrupting, using "why" questions
grade 4
murmur that is loud and associated with a thrill
tricuspid (right side) and mitral/bicuspid (left side)
the two atrioventricular valves 
size in the thoracic cavity
what influences pulmonary function?
Data about client's home and working environments with emphasis on determining the client's safety.
Environmental History
health effects of violence
injury, chronic health problems, more visits = more costs
Cranial nerves checked with the eye
3- occulomotor, 4-trochlear, 6-abducens
what is the term for a decrease in oxygen in the blood?
hypoxemia
 
hair, skin, and nails
 
subjective data
previous history of skin disease (allergies, hives, psoriasis, eczema)
change in pigmentation
change in mole (size or color)
excessive dryness or moisture
pruritus
excessive bruising
rash or lesion
medications
hair loss
change in nails
environmental or occupational hazards
self-care behaviors
 
Subjective data
 
What the person says about him or herself
tinels sign
tapping on the median nerve where it passes through the carpal tunnel
R wave
S1 coincides with what wave on an electrocardiogram?
adventitious sounds
added sounds not normally heard in the lungs
Recording the nursing health history, assessment datat in a clear, concise manner using appropriate terminology.
Documentation of History Findings
what is the normal and pre-clubbing degree markers?
normal- 160 pre-clubbing- 180
what arteries are in the leg?
politeal, femoral, dorsalis pedis, posterior tibial
What best describes the hot/cold theory of wellenss?
 
the humors must be balanced
at T9 or T10
where do you test for symmetrical chest expansion?
what to check for in a physical assessment for violence
bruises, lacerations, burns, abrasions, incisions, stab wounds, hematoma
what makes up the wrist and carpals?
radiocarpal joint, midcarpal join, metacarpophalangeal joints, interphalangeal joints
what cannot be done if a lymphnode has been removed in an arm?
BP or IV
left sided heart failure
signs of this are evident in pulmonary system
confidential (never leave a computer unattended), accurate and complete, organized, timely (time of entry must reflect the time that you did it), and concise
what are the principles of documentation?
how often should you check cholesterol?
every five years after you turn 20
subjective questions to ask the patient
history of skin disease? change in pigmentation? mole? dryness or moisture? itching? bruising? rash or lesion? medications? hair loss? change in nails? envir. or occup. hazards? self-care behaviors? delay in wound healing? pain? frequent falls? changes in feet/toenails? diabetes or peripheral vascualr disease?
 
 
excessive dryness of moisture
any change in the feel of your skin: temperature, moisture, texture
any excess dryness? is this seasonal or constant?
 
seborrhea-oily
xerosis-dry
1. solid- liver, kidneys, etc.
2. hollow- the shape depends on the contents (bladder, stomach, colon, etc.)
what are the two types of viscera?
head, face, and neck observations is aging adult
temporal arteries may look twisted and prominent, senile tremors, lost teeth may make lower face look smaller, slow range of motion
in the intercostal spaces... not on top of the ribs
where do you percuss on the chest?
what are the major functions of the respiratory system?
supply oxygen to body for energy, remove carbon dioxide, maintain homeostasis (acid-base balance) of arterial blood, maintain heat exchange
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