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