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Nur 103


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Stage I---Staging of pressure ulcers
increased redness
Stage III---Staging of pressure ulcers
damage to subcutaneous tissue
what is the purpose of a health assessment
to identify a client's heath problems
Objective data
data retrieved from the nurses perspective (what the nurse sees)
Edema grading 3+
indentation of 5 to 10mm
What does initial observation include
physical apperance, hygiene, body structure, emotoional /mental status, behavior
Components of a stethoscope
earpiece, binaurals, tubing, head
Erikson's 8 stages of human development
Inancy, Toddlerhood, Preschool,Middle Childhood, Adoleence, Young Adulthood, Middle Adulthood, Older Adulthood
Purpose of the oximetry
to estimate the arterial o2 saturation in the blood
Contextual Subtheory
The role of the external environment in determining what constitutes intelligence in a particular situation
0-2yr--though dominated by physical manipulation of objects & events
Subjective data
a collection of data/information from what the client states
What is direct percussion
striking a finger or hand directly against the clients body
Common positions during examination
sitting and supine
light palpation
used to assess skin, pulsations and tenderness
Stage IV---Staging of pressure ulcers
invasion of deeper tissue/bones
deep palpation
used to dertermine organ size and contour
Industry vs. Inferiority
Middle Childhood---(6 to 11yr)
Edema grading 2+
indentation < 5mm
Erikson's Theory
believed that the ego was the primary seat of personality functioning and that society and culture influenced behavior
Developmental Task
A drive from within the individual to develop in such a way to attain a goal
cephal caudal
head to toe
Identity vs. Role Confusion
Name the 2 types of legions
Primary, Secondary
Stage II---Staging of pressure ulcers
abrasion or blister
Trust vs. Mistrust
Infancy ---(1 yr)
Experiential Subtheory
A person's learning through life experiences, conbined with insight & creativity, affects the person's thinking
What is indirect percussion
both hands are used directly against the body
Formal Operations
11-15yr---True logical thought & manipulation of abstract concepts emerge
legions appear as small, reddish, purple pinpoints
Sternberg's 3 Pronged Theory
Componential Subtheory, Experiential Subtheory, Contextual Subtheory
Listening to sounds produced by the body
Ego Integrity vs. Despair
Older Adulthood---65 to ----yr)
Which surface of the hand is better for assessing temp
dorsal surface
2-7yr--Functions symbolically using language as a major tool
How a person preceives and processes information
Edema grading 1+
Barely visible
What are the different types of palpation
light, deep, bimanual
Autonomy vs. Shame & Doubt
Toddlerhood---(1 to 3yr)
Componential Subtheory
internal analytic mental mechanisms
Initiative vs. Guilt
Preschool---(4 to 5yr)
Why is percussion used?
1. Maps out location & size of an organ, 2. signals the density of a structure, 3. detects abnormal mass, 4. elicites pain, 5. deep tendon reflex
What are the 4 physical assessment techniques
inspection, palpation, percussion, auscultation
What is palpation used to assess
texture, temp, moisture, organ size/location, swelling, vibration of pulsation, crepitation, lumps, tenderness
middle finger that is used to strike during indirect percussion
Mental Status
degree of competence that a person shows in intellectual, emotional, psychological and personality functioning
Tripod position
when a client with difficulty breathing may sit forward bracing thier arms on thier knees
Intimacy vs. Isolation
Young Adulthood---(20 to 35)
Concrete Operations
7-11yr--Mental reasoning processes assume logical approaches to solving concrete problems
Tapping skin with short, sharp stroke
What are BADL's
dressing, toileting, bathing, eating, and ambulating
Generativity vs. Stagnation
Middle Adulthood---(35 to 65yr)
Piaget's Level of Cognitive Development
Sensorimotor, Preoperational, Concrete Operations, Formal Operations
What are the 2 types of percussion
direct, indirect
What is inspection
a visual examination of the body; including movement, posture, and smell
What are IADL's
preparing meals, shopping, administering meds, paying bills
Head components of a stethoscope
bell and diaphragm
5 Percussion Tones
Tympany--abdomen, Resonance--lung, Hyperresonance--hyperinflated lung, Dullness--liver, Flatness--bone/muscle

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