Assessment NURS 113 Final Exam Review
Terms
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- Differentiate between subjective and objective data. (page 2)
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· Subjective data-i.e. what the person says about himself or herself during history taking.
· Objective data-i.e. what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination. - Differentiate between signs and symptoms (page 84)
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· A symptom is a subjective sensation that the person feels from the disorder.
· A sign is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports. -
Explain the process of prioritizing problems/care.
In what order and why would you prioritize the following problems:
- diabetic teaching
- respiratory distress
- small laceration on foot
- post operative pain -
-respiratory distress
-post operative pain
-small laceration on foot
-diabetic teaching - Describe and list in order the 5 steps of the nursing process
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- Assessment
- Diagnosis
- Planning
- Implementation
5. Evaluation - Purpose of a Review of Systems (page 87)
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- To evaluate the past and present health state of each body system
- To double-check in case any significant data were omitted in the present illness section
- To evaluate health promotion practices - Review proper history taking and the therapeutic, non therapeutic responses/behaviors that would impact effective communication
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- What is the appropriate response (or next question) to a person who states they are allergic to a particular medication
- What type of response do you have?
- Important questions to ask surrounding tobacco use (page 91)
- Personal Habits- Tobacco, alcohol, street drugs: “Do you smoke cigarettes (pipe, use chewing tobacco)?†“At what age did you start?†“How many packs do you smoke per day?†“How many years have you smoked?†Record the number of packs smoked per day (PPD) and duration, e.g., 1 PPD x 5 years. Then ask, “Have you ever tried to quit?†and “How did it go?†to introduce plans about smoking cessation.
- Describe the 5 methods/techniques of physical assessment. (page 162-164)
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- Inspection-Inspection is concentrated watching.
- Palpation-Applies your sense of touch to assess these factors: blah, blah, blah
- Percussion-Is tapping the person’s skin with short, sharp strokes to assess underlying structures.
- Ausculation-Is listening to sounds produced by the body… - Which techniques always comes first (page 162)
- "Inspection always comes first."
- Describe the purpose of percussion (page 162)
- - The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.
- Describe the assessment technique used to assess for the presence of crepitus, swelling, and pulsations (page 162)
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- Palpation applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.
- Fingertips-best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps. - What is the name of the equipment used to assess for pulsations that cannot be palpated (such as the pedal pulse)
- (from notes) "Doppler for pedal pulse hand held transducer picks up sound of pulse wave" "The Dopple technique is used to locate the peripheral pulse sites..."(page198)
- What is the sound you will hear with a Doppler? (page 198)
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- The listener hears a whooshing pulsatile beat.
- For BP measurement, the Doppler technique will augment Korotkoff’s sounds. - You are preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How would you proceed with the examination.
- - I would take care of her SOB. I would assess her airway and breathing and proceed with a detailed examination of what is exacerbating her problems.
- Which part of the stethoscope is used to assess a murmur and bruit
- - The bell endpiece has a deep, hollow cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs.
- Describe a murmur and bruit
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·A murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall.
·A bruit indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels. - What is the proper procedure in measuring a patient’s weight when a sequence of weights is needed, in terms of the clothing, type of scale, time of day. (page 178)
- ·Use a standardized balance or electronic standing scale. Instruct the person to remove his or her shoes and heavy outer clothing before standing on the scale. When a sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time. Record the weight in kilograms and in pounds.
- Classic signs/symptoms of respiratory distress (ie, acute asthma episode) (page 478)
- - Increased respiratory rate, shortness of breath with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostals spaces. Expiration labored, prolonged. When chronic may have barrel chest.
- Explain the rationale for using a blood pressure cuff that is of appropriate size for the patient arm (page 184)
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· The cuff size is important; using a cuff that is too narrow yields a falsely high BP because it takes extra pressure to compress the artery.
· Too small cuff= false high reading. Too big cuff=false low reading. - Define Korotkoff sounds, ausculatory gap. (page 184-187)
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· Rapidly inflate the cuff to the maximal inflation level you determined. Then deflate the cuff slowly and evenly, about 2mm Hg per heartbeat. Note the points at which you hear the first appearance of sound, the muffling of sound, and the final disappearance of sound.
· "...Inflate the cuff until the artery pulsation is obliterated and then 20 to 30 mmHg beyond. This will avoid missing an auscultatory gap..." Sounds temporarily disappear during end of phase I, then reappear in phase II. Common with hypertension. If undetected, results in falsely low systolic or falsely high diastolic reading. - Explain the rationale of palpating pressure prior to auscultating. (page 185)
- · This will avoid missing an ausculatory gap, which is a period when Korotkoff’s sounds disappear during auscultation.
- Describe the process and purpose of taking postural vital signs (page 187)
- · Take serial measurements of pulse and blood pressure when: you suspect volume depletion; when the person is known to have hypertension or is taking antihypertensive medications; or when the person reports fainting or syncope. Have the person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and then repeat the measurements with the person sitting and then standing. For the person who is too weak or dizzy to stand, assess supine and then sitting with legs dangling. When the person is changed from supine to standing, normally a slight decrease (less than 10 mm Hg) in systolic pressure may occur.
- Differentiate between acute and chronic pain
- · Acute<6 months<Chronic
- Differentiate between and List descriptors for neuropathic and nociceptive pain (page 209-210)
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· Neuropathic pain implies an abnormal processing of the pain message. It is this type of pain that is most difficult to assess and treat. Pain is often perceived long after the site of injury heals.
· Nociception is the term used to describe how noxious stimuli are typically perceived s pain. Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation. - Name of scale used to assess a child’s pain quantity
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- Wong-Baker FACES Scale (Children)
- CRIES Scale for Neonates -
Review the questions to ask for a symptom analysis of pain
(quality, duration, location, etc,,,,,) -
1. Where is your pain?
2. When did your pain start?
3. What does your pain feel like?
4. How much pain do you have now?
5. What makes your pain better or worse?
6. How does pain limit your function or activities?
7. How do you usually behave when you are in pain? How would others know you are in pain?
8. What does this pain mean to you? Why do you think you are having pain? - Symptoms of phantom leg pain
- · Pain is sustained on a neurochemical level that cannot be identified by x-ray, computerized axial tomography. The abnormal processing of the pain impulse can be continued by the peripheral r central nervous system. Exact mechanisms are unclear to date.
- Signs and symptoms of chronic hypoxia (seen in emphysema)
- · Increased anteroposterior diameter. Barrel chest. Use of accessory muscles to aid respiration. Tripod position. Shortness of breath, especially on exertion. Respiratory distress. Tachypnea. Decreased tactile fremitus and chest expansion. Hyperresonant. Decreased diaphragmatic excursions. Decreased breath sounds. May have prolonged expiration. Muffled heart sounds secondary to overdistention of lungs.
- How is skin turgor assessed and implications of decreased skin turgor
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· Pinch up a large fold of skin on the anterior chest under the clavicle. Mobility is the skin’s ease of rising, and turgor is its ability to return to place promptly when released. This reflects the elasticity of the skin.
· Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or “tents†and stands by itself. - Review the chest location (where do we listen or feel) and corresponding anatomy (Heart valves, base and apex of heart, lung lobes, bases, apices of lungs, apical impulse)
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· Aortic-2nd intercostal space right sternal border
· Pulmoni-2nd intercostals space left sternal border
· Tricuspid-5th intercostals space left sternal border
· Mitral-5th intercostal space midclavicular line (same for apex) - Proper sequence for auscultating heart sounds
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· Aortic
· Pulmonic
· Tricuspid
· Mitral - Define a thrill (page 505)
- · A thrill is a palpable vibration. It feels like the throat of a purring cat. The thrill signifies turbulent blood flow and accompanies loud murmurs. Absence of a thrill however, does not necessarily rule out the presence of a murmur.
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Review the adventitious lung sounds and implications (reasons) for each
Read pages 474-475. -
· Wheeze-high pitched, musical squeaking sound. Implies diffuse airway obstruction. (bronchi obstruction) from acute asthma or chronic emphysema
· Crackles (fine/coarse)
o Fine-discontinuous, high-pitched, short crackling, popping sounds heard during inspiration. Pneumonia, heart failure.
o Coarse-low pitched, bubbling and gurgling sounds that start early in inspiration. Pulmonary edema, pneumonia.
· Atelectatic crackles-sounds like fine crackles and disappear after the first few breaths. Happens in aging adults, bedridden persons, or in persons just aroused from sleep.
· Pleural friction rub-Superficial sound that is coarse and low pitched. Sounds like two pieces of leather are being rubbed together. Implies pleuritis, accompanied by pain with breathing.
· Stridor-High pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest implies. Croup and acute epiglottis in children, and foreign inhalation, obstructed airway. - Direction of blood flow through the heart
- Inferior/Superior Vena Cava to RA to RV to Pulmonary Artery to Lungs to Pulmonary Veins to LA to LV to Aortic to Body
- Best places on chest to heart S1, S2
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· S1-loudest at the apex (Mitral valve)
· S2-loudest at the base (aortic valve) - Major risk factors for heart disease
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o High blood pressure, smoking, high cholesterol levels, obesity, diabetes.
o Women-oral contraceptives and post menopausal hormones - Location of the posterior tibial, and dorsalis pedis pulse
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o Posterior tibial-between the medial malleolus and Achilles tendon in the lateral side of the leg in the groove
o Dorsalis pedis-just lateral to and parallel with extensor of big toe - Purpose of the Profile sign
- o To detect early clubbing. Occurs with congenital cyanotic heart disease and bacterial endocarditis.
- Implications of a positive homan’s sign.
- · Implies deep vein thrombosis, superficial phlebitis, Achilles tendonitis, gastrocemius
- Signs and symptoms of venous stasis
- · Firm, brawny, edema, coarse, thickened skin, brown pigment discolorations, petehia, dermatitis. Increased venous pressure.
- Signs and symptoms of arterial insufficiency
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· White-pallor
· Black-ashen gray, dull, cool to palpation - Describe the vascular problem that results in pitting edema (page 546)
- · Heart failure
- Differentiate brawny and pitting edema
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· Brawny edema-unilateral or bilateral edema, occlusion of a deep vein, occurs with lymphatic obstruction
· Pitting edema-Bilateral, occurs with occlusion with heart failure, diabetic neuropathy, and hepatic cirrhosis - Abdominal anatomy in relationship to quadrants (page 565)
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- Define aphasia, dysphagia
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· Aphasia-Loss of the ability to speak or write coherently or to understand speech or writing due to a brain attack.
· Dysphagia-Difficulty swallowing - Define hepatomegaly
- · Enlarged liver
- Signs and symptoms of cerebellum dysfunction (page 714)
- · Ataxia, lurching forward of affected side while walking, rapid alternating movements are slow and arrhythmic, finger to nose test reveals ataxia and tremor with overshort or undershoot, and eyes display course nystagmus.
- Signs and symptoms of cerebrum dysfunction (page 662)
- · Damage to any of these specific cortical areas (frontal, parietal) produces a corresponding loss of function: motor weakness, paralysis, loss of sensation, or impaired ability to understand and process language
- Differentiate between vertigo, syncope and dizziness
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· Vertigo-Rotational spinning (objective vertigo) room spins (subjective) you’re spinning
· Syncope-Fainting, loss of consciousness
· Dizziness-Lightheaded, swimming sensation, like feeling faint - What pupil changes may indicate increasing ICP (P.702)
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· Visual field loss, papilledema, optic atrophy. Decrease in peripheral vision, glaucoma
- Nonreactive Pupil is Ominous. Increasing ICP Puts Pressure on Cranial Nerve III - Signs and symptoms of parkinsonism (P.711)
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· Tremor, rigidity, akinesia
· Slower monotonous speech and diminutive writing
· Body tends to stay immobile. Facial expressions is flat, staring, expressionless. Excessive salivation. Reduced eye blinking. Posture is stopped; equilibrium is impaired; loses balance easily. Gait; steps are short and shuffling.
- Rest Tremors that Disappear with Voluntary Movement - Describe the scale and purpose of measuring the Glasgow coma scale
- · Objective assessment that defines the level of consciousness by giving it a numeric value. 7 or less reflects a coma. 15 is best.
- Process to evaluate accommodation and consensual response
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· Consensual-PERRLA-pen light. Observe Both Pupils Dilate
· Accommodation-focus on a distant object and then bring it closer to nose. Observe Convergence of Pupils - Cranial nerve effected in bells palsy
- · Facial Nerve #7
- Cranial nerve effected in trigeminal neuralgia
- · Trigeminal #5
- Indicators important in determining a patients LOC (P.701)
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- Person – Name, Occupation
- Place – City, Country
- Time – Day, Month, Year -
Define: (page 253)
Pustule-Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne. -
Vesicle-Elevated cavity containing free fluid, up to 1cm. Clear serum flows if wall is ruptured. Examples: herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis.
Macule-Solely a color change, flat and circumscribed, of less than 1cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.
Papule-Something you can feel, i.e., solid elevated, circumscribed, less than 1cm diameter, due to superficial thickening in the epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca) - Normal percussion sound noted over healthy lung tissue
- · Resonance
- Normal percussion sound heard over air filled areas in the abdomen
- · Tympany
- Tenderness over the R L Q may indicate what disorder(s)
- · Appendicitis
- Percussion sound noted over areas of pneumonia
- · Flat/dull
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Define the following terms:
Pleural Effusion, Pharyngitis, Atelectasis, Tachypnea, Dyspepsia, Cholecystitis, Guarding, Peritoneal Irritation, Orothopnea vs. Orthostatic Hypotension -
- Pleural Effusion – Excess Fluid in Pleural Space
- Pharyngitis
- Atelectasis – Collapsed Section of Alveoli or Entire Lung
- Tachypnea – Rapid Shallow Breathing
- Dyspepsia -
- Cholecysittis
- Guarding
- Peritoneal Irritation – Rough Grating Sound Like Two Pieces of Leather Rubbing
- Orthopnea – Difficulty Breathing Lying Down
- Orthostatic Hypotension – Loss of BP From Lying to Standing - Warning signs of colon cancer
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- Change in Bowel Habits
- Weight Loss
- Blood in Stool