Module 6 terms nuring (CH 26)

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first?

Examine the fontanels and sutures

Order of listening to heart sounds

APE TO MAN = aortic, pulmonic, tricuspid, mitral

when takin bp at home as a patient, how many times should they take their reading

3 then average them

cardinal movements, convergence and accommodations

4 & 6 nerves

S2 sounds are loudest at the

Base

Crackles

Bubbling, crackling, popping Low- to high-pitched, discontinuous sounds Auscultated during inspiration and expiration Opening of deflated small airways and alveoli; air passing through fluid in the airways

A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis is the highest priority?

Deficient fluid volume

When completing an assessment of a healthy adolescent client, which measure would be most appropriate?

Gather information from the parents and adolescent; then assess the adolescent in private

Stridor

Harsh, loud, high-pitched Auscultated on inspiration Narrowing of upper airway (larynx or trachea); presence of foreign body in airway

optic nerve

II

pupils cranial nerves

III

6 P's of neurovascular assessment

Pain Pulse Paralysis Pallor Paresthesia (pens and needles sensations) Pressure

You are palpating a patient's precordium. Which of the following is an expected clinical finding?

Palpable pulsation over the mitral area

A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?

Palpation

ongoing partial health assessment:

also known as a follow-up assessment, it is one that is conducted at regular intervals during care of the patient; concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions

Friction Rub

Rubbing or grating Loudest over lower lateral anterior surface Auscultated during inspiration and expiration Inflamed pleura rubbing against chest wall

Rhonchi (Sonorous Wheeze)

Sonorous or coarse; snoring quality Low-pitched, continuous sounds Auscultated during inspiration and expiration Coughing may clear the sound somewhat Air passing through or around secretions

Cheyne-Stokes respiration

alternating periods of deep and shallow breathing followed by periods of apnea; regular

diaphoresis:

an excessive amount of perspiration, such as when the entire skin is moist

A nurse is assessing the spine of a client with kyphosis. Which of the following would the nurse expect to observe about the client's posture?

The shoulder and upper back curves forward

precordium:

anterior surface of the chest wall overlying the heart and its related structures

which valves make the sound of s2

aortic and pulmonic valves

S1 sounds are loudest at the

apex

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor?

a normal pattern in infants of this age

waist circumference:

a numerical measurement of the waist, used to assess an individual's abdominal fat and establish ideal body weight

adventitious breath sounds:

abnormal breath sound heard over the lungs

edema:

accumulation of fluid in extracellular spaces

percussion:

act of striking one object against another for the purpose of producing a sound; used to assess the location, shape, size, and density of body tissues

Rate is affected by

age & gender exercise , emotions, pain temperature body position blood oxygenation blood pressure and blood volume

focused health assessment:

assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient

cyanosis:

bluish coloring of the skin and mucous membranes

convergence

bring penlight towards face

comprehensive health assessment:

broad health assessment that includes a complete health history and physical assessment; it is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments

normal breath sounds (locations)

bronchial/tubular bronchovesicular vesicular

Say "ah"

checking for pallet to move

which valves make the sound of s1

closing of tricuspid and mitral valves

ecchymosis:

collection of blood in subcutaneous tissues that causes a purplish discoloration

health history:

collection of subjective information that provides information about the patient's health status

Delayed capillary refill time is a sign​ of:

dehydration low perfusion

accommodation

dilate when look away, constrict when they look back at you

sibilant rhonchi

high pitched musical wheezes

Health history

subjective data

nystagmus

jerky-appearing involuntary eye movement

auscultation:

listening for sounds within the body

palpation:

method of examining by feeling a part of the body with the fingers or hand

What are bowel sounds?

noise you get from parastalses

bronchovesicular breath sounds:

normal breath sounds heard over the mainstem bronchus; they are moderate blowing sounds, with inspiration equal to expiration

vesicular breath sounds:

normal sound of respirations heard on auscultation over peripheral lung areas

Physical assessment

objective data

Signs

objective data, or what can be measured-seen, felt, heard, smelled, weighted

pallor:

paleness of the skin

poor grip strength is a sign of

paralysis hemiplegia stroke

review of systems:

physical examination of all body systems in a systematic manner as part of the nursing assessment

inspection:

purposeful and systematic observation

Pulse is assessed for

rate, rhythm, amplitude

body mass index (BMI):

ratio of height to weight

erythema:

redness of the skin

activities of daily living (ADLs):

self-care activities such as eating, bathing, dressing, and toileting

extra ocular movements

six cardinal movements

petechiae:

small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure

physical assessment:

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems

turgor:

tension of the skin determined by its hydration

instrumental activities of daily living (IADLs):

the activities of daily living needed for independent living

bronchial breath sounds:

those heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration

emergency health assessment:

type of rapid focused assessment conducted when addressing a life-threatening or unstable situation

jaundice:

yellow appearance of the skin

Symptoms

· subjective data, or what the patient tells you