Scott Gardner TCC Nursing Q1F04 Unit Three
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- Describe KernigÂ’s Sign
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Symptom of meningitis; patient cannot extend the leg at the knee when the thigh is flexed because of stiffness in the hamstrings - Describe BrudzinskiÂ’s Sign
- One of the physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
- Describe Flaccid
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Relaxed, Limp, Flabby. Having defective or absent muscle tone.
Taber 769 - Describe Hemiparesis
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Slight paralysis on one side of the body. Usually from damage to the CNS. Also called hemiplegia.
Taber 914
Potter 937 - Describe Paraplegia
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Complete paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord.
Taber 1513 - Quadriplegia
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Paralysis of all four extremities. Usually damage to the cervical spinal cord
TaberÂ’s 1735 - Hemiplegia
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Hemiplegia
Slight paralysis on one side of the body. Usually from damage to the CNS. Also called hemiparesis
Taber 914 - Describe Gait
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A manner of walking. Many different types
æ Antalgic ¡V Pain during gate in one leg and stays on that leg for a short as possible.
æ Ataxic ¡V Unsteady Staggering gate
Taber 806 - Describe the components and purposes of the stethoscope.
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•Essential tool for use in auscultation during a physical assessment.
•Consists of Earpieces, Biaurals (Metal tubes from earpieces to rubber tubing), Tubing, Chest Piece consisting of a Bell and a Diaphragm.
•Both the Bell and Diaphragm should have interchangeable adult and pediatric sizes
POTTER 643 - Describe the purpose and legal parameters of health-related documentation.
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•Main communication tool between all members of healthcare team. It should be flexible and exception based
•Communication and Continuity of Care
•Minimize Errors
•Saves Time
•Legal Documentation
•Finance/Billing
•Education Research
•Auditing/Monitoring - JCAHO
POTTER 479 - What is a POMR
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Problem Oriented Medical Record
Places emphasis on the clients problems.
• Major Sections Are
o Database
o Problem List
o Nursing Care Plan
o Progress Notes
POTTER 483 - What is a SOAP?
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Subjective
Objective
Assessment
Plan
Sometimes SOAPIE with the addition of
• Intervention and Evaluation
Potter 483 - Describe Source Records
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o Clients chart is arranged with each discipline (Nursing, Doctor, Social Worker) each having their own section in which to chart.
„X Advantages ¡V Easily locate the desired information
„X Disadvantage ¡V One problem might be written several different areas, making a care giver read about the same problem in several different areas.
POTTER 484 - Describe Pronation
- Movement of a body part so that the front faces downward. (Turning your palm down)
- Describe Plantar Flexion
- Movement of the foot that flexes the foot or toes downward toward the sole
- Describe ulnar deviation
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Ulnar – Bend wrist medially toward thumb. This is an adduction.
Potter 1436 - Describe radial deviation
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Radial – Bend wrist laterally toward fifth (pinky) finger. This is an abduction
Potter 1436 - Describe Opposition
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Touching thumb to each finger of the hand
Potter 1437 - Pronation
- Movement of a body part so that the front faces downward. (Turning your palm down
- supination
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Movement of a body part so that the front faces upward. (Turning your palm up
Potter 758 - Eversion
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Turning body part away from midline
Potter 758 - Describe Inversion
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Turning body part toward midline
Potter 758 - Describe Abduction
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Movement of the extremity away from the midline of the body
Potter 758 - Describe Adduction
- Movement of the extremity toward the midline of the body
- Describe Assessment Forms
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Admission Form
Flowsheet or Graphics
Kardex - Describe Change of Shift Report
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Oral, Audiotape, or Walking Rounds.
Provides continuity of care between one shift and the next. Not simply a reading of the chart notes, but specific ie Nurse found that client was relieved of pain with a certain technique or medication. Should follow logical sequence.
Potter 496 - Describe Discharg Planning Characteristics
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o Ideally began during admission and revised by Nurse as client conditions change
o Includes Client Education:
„X Food/Drug Interaction
„X Rehabilitation techniques
„X Access to Community Services
„X Reasons to Follow up with Hospital
„X Family responsibilities
„X Medication Instructions
Potter 492 - Define Nursing Process
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To organize and deliver care. It allows the nurse to integrate elements of CT to make judgements and take actions based on reason.
Used to identify, diagnose, and treat human responses to illness and health.
Five Steps Assessment/Nursing Diagnosis/Planning/Implementation/Evaluation - Define Assessment
- Gather information about a clients condition.
- Diagnosis
- Identify the clients problem based on the Nursing Diagnosis system.
- Describe Planning
- Set goals of care and desired outcomes and identify appropriate nursing actions.
- Describe Implementation
- Perform the nursing actions identified in planning stage.
- Evaluation
- Determine if goals were met and outcomes were achieved.
- Desdcribe the assessment phase of the Nursing Process.
- Data Collection and then Cluster & Validate Date
- Describe the Analysis Component of the Nursing Process.
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-Analyze & Interpert Data
-Identify Client Needs
-Make Nursing Diagnosis - Describe the Planning Component of the Nursing Process.
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-Prioritize
-Establish Client-Centered Goals
-Develop Expcted Outcomes
-Plan Nursing Care - Describe the Implementation Component of the Nursing Process.
- The Action and Doing of Nursing Care
- Describe the Evaluation Component of the Nursing Process.
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-Assess Client Response as compared to Expected Outcome.
-Determine if EOC is met or not.
->Revise Care Plan as necessary and continue with current or newly identified implementation plan. - Define Subjective
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The Clients Perceptions about their Health. (From the SUBJECT)
Potter 284 - Define Objective
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The Observations or measurements made by the data collector.
Potter 248 - Describe Signs
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Any objective evidence of manifestation of an illness. Signs are apparent to observers as opposed to symptoms.
(Taber) - Describe Validation
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Gathering assessment data to validate the collected infomation to ensure accuracy. This involves comparing the data with another source.
(Potter 292-293) - Define Clustering
- A set of signs or symptoms that are grouped together in a logical order.
- Define Symptom
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Any change in the body or its functions, as perceived by the patient. Represents the subjective experience of the disease.
(Tabers) - Discuss Temperature
- The difference between the amount of heat produced by body processes and the amount lost to the environment.
- What is a normal body temperature in Celcius?
- 36-38° C
- What is the normal body temperature in Fahrenheit?
- 96.8° - 100.4° F
- What is a normal Pulse rate?
- 60-100 BPM
- What are normal respirations?
- 12-20 times each minute
- What are normal SpO2 levels?
- 95-100
- What will always cause a problem with reading a sat from the finger?
- Nail polish, which prevents the light from passing through the finger.
- Where can an Sp02 probe be placed?
- Finger, Ear, Bridge of Nose, Toe.
- Describe Normal BP.
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Category Systolic Diastolic
Normal < 120 < 80
Pre-High BP 120-139 80-89
Stage 1 High BP 140–159 90–99
Stage 2 High BP > 160 > 100 - Describe the Purpose and Components of General Survey.
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Used for a general overview of a clients stage of wellness.
General Appearence/behavior/Apparent Age-Race-Gender/signs of distress/sob/physical or chemical abuse/body type/posture/gait/body movements/hygiene/grooming/dress/body odor/mood/speech - Describe the Four Techniques involved in physical assessment.
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Inspection
Palpation
Percussion
Auscultation
(Sometimes Smell) - Define the Specifics of Inspection
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Need good light , positoin and exposure of all body parts. Inspect size/shape/symmetry/position and abnormalities.
Additional light might be necessary for body cavities. - Describe the process of Palpation
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Assessment through touch, client should be relaxed and positioned comfortably.
Tender or C/C areas should always be palpated last.
Warm your hands.
Light Palpation is 1/2 Inch
Deep Palpation is 1-2 Inches (We Dont do it) - Describe the process of Percussion.
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Used to determine the location, size, density of underlying structures.
Striking of finger against the body part, character of sound depends on density of underlying tissue.
Tympany/Resonance/Hyperresonance/dullness/Flatness - Describe the process of Auscultation.
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Listening to sounds through a stethoscope.
Always against naked skin. - Describe the Order of a NON ABD Examination
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Inspection
Palpation
Percussion
Auscultation - Describe the Order of doing an ADB Examination.
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Inspection
Auscultation
Percussion
Palpation - Describe Steps to prepare a client for an Examination
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3 Steps
Introduce self to establish position and purpose.
Prepare room for privacy, tools
Physical Assessment - Describe Level of Consiousness
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A continuum from full awakening and alertness to unresponsive.
Potter 762 - Describe Orientation
- The ability to comprehend and to adjust onself with regard to time, location, identity of persons
- Describe Lethargic
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A state of sluggishness, inactivity, and apathy.
A state of unconsciousness resembling
deep sleep. - Describe Drowsy
- A state of almost falling asleep.
- Describe Obtunded
- Diminished arousal and awareness
- Describe Aphasia
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Ineffective communication - Omission or additon of letter or words, misuse of words or hesitations.
Potter 763 - Describe Sensory Function
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Testing done symmetrically.
Compare distal to proximal.
Vary pace of testing to avoid prediction.
Testing done with clients eyes closed to test pain, temp, vigration of the feeling senses. - Describe Motor Function Testing
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Assessment of muscle tone - Flaccid, Spastic, flabby, floppy.
Test Muscle Strength
Test Coordination
(Lecture Notes) - Describe the Romberg Test
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Feet together, watching for unbalanced motions. - Describe Deep Tendon Reflexes of the Biceps.
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Flex clients arm up to 45 degree at elbow with palms down. Place your thumb in antecubital fossa at base of biceps and your fingers over biceps miscle. Strike triceps tendon with reflex hammer.
Shoudl see flexion of arm at elbow. - Describe Deep Tendon Reflexes of the Triceps.
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Flex clients arm at elvow, holding arm across chest or hold upper arm horizontally and allow lower arm to go limp. Strike triceps tendon just above elbow.
Should see extension at elbow.
Potter 768 - Describe Deep Tendon Reflexes of the Patella.
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Have client sit with legs hanging freely over side of table or chair or have client lie supine and support knee in a flexed 90-degree position. Briskly tap patellar tendon just below patella.
Should see extension of lower leg
Potter 768 - Describe Deep Tendon Reflexes of the Achilles.
- Have client assume same position as for patellar reflex. Slightly dorsiflex clients ankle by grasping toes in palm of your hand. Strike Achilles tendon just above heel at ankle malleolus.
- What are key components of Glasgow Coma Scale
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Eyes Open 4-1
Best Verbal Response 5-1
Best Motor Response 6-1 - Describe the Babinski Reflex
- Sharp object drawn from heel to toes. To fanning normal in infants to 2 yrs, sign of brain or spinal cord injust in order persons.
- Describe Clonus
- An abnormality in neuromuscular activity characterized by rapidly alternating muscular contraction and relaxation.
- Describe Muscle Strength Grading
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0/5 No Muscle Movement
1/5 Visible Muscle Movement but no joint movement.
2/5 Movement at joint but not against gravity
3/5 Movement against gravity, but not added resistance.
4/5 Movement against resistance, but less than normal
5/5 Normal Strength - Describe Stuporuous
- Altered mental status in which a person is arousable only with vigorous or unpleasant stimulation.
- Describe Semi-comatose
- No longer used.
- Oriented
- Aware of surroundings, person, place, time.
- Comatose
- In a coma.
- Describe decorticate
- Removal of all or part of the cortex of the brain.
- Describe Decetrate
- To eliminate cerebral brain function in (an animal) by removing the cerebrum, cutting across the brain stem, or severing certain arteries in the brain stem, as for purposes of experimentation.
- Describe Lordosis
- Swaygback...Increased lumbar curvature.
- Describe Kyphosis
- Hunchback an exageration of the posterior curvature of the thoracic spine.
- Describe Scoliosis
- A Lateral Curvature of the spine.
- Muscle
- The slight musclear resistance felt by the examiner as the relaxed extremity is passively moved through its range of motion.
- Describe Involuntary Movements
- Independent of, as a result of a reflex.
- Describe Tremor
- An involuntary movement of a port or parts of the body resulting from alternate contractions of opposing muscles.
- Describe Paralysis
- Loss of purposeful movement usually as a result of deurological disease, drugs, or toxins.
- Describe Paresis
- Slight or partial paralysis.
- Assessment of Sensory Nerve Function
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Pain - Soft or Dull
Temp - Two test tubes one hot / other cold
Light Touch - Voice sensation when light touch felt from cotton ball.
Position - Move Toe Up or Down
Two Point - Dual pricks brought closer. - Describe Fasciculation.
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Involuntary contraction or twitching of muscle fibers visible under the skin.
Medical Dictionary - Describe Crepitus
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Lots of Confusion on this one. Not finding the exact word.
-Encarta says the grating sound of a broken bone.
-Tabers shows "Crepitant" as making a crackeling sound.
-Dictionary.com says A noisy discharge of gas from the intestine
I seem to remember in Lecture Crackeling in the Lungs during Asucultation of the chest.