JohnO-1610-2

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With what is the Optic nerve associated and how might test?: Visual fields
Test = Snellen chart
Skin Assessment: * Skin, hair, nails
* Inspection and palpation
* Pallor - may be sign of inadequate circulation; decreased oxygen; decreased hematocrit
- brown skin people = yellowish
- black people = ashen gray
* Cyanosis - bluish; decreased oxygen. Blue around lips and fingernails.
- black people lips are pale (not red)
* Jaundice - Yellow. First noticeable in sclera of eyes
* Erythema - redness or rash
* Skin Lesions
List characteristics of effective communication.: * Rapport
* Specific objectives
* Comfortable environment
* Privacy
* Confidentiality
* Client focus
* Use of nursing observations
* Optimal pacing
* Providing personal space
With what is the Glossopharyngeal nerve associated and how test?: Swallowing ability
Test = Apply tastes on posterior tongue for identification. Ask patient to move tongue.
Differentiate between social and therapeutic communication.: Therapeutic communication techniques assist the flow of communication and always focus on the client.

Social Response focuses attention on the nurse instead of the client.
Deep Palpation: * Done with two hands
* Top hand applies pressure while the bottom hand relaxes to perceive the tactile sensations.
* Done with caution
* Not indicated in patients with abdominal pain

Be sensitive to verbal and facial expressions of pain.
List blocks to communication: 1 - Giving Reassurance - "You'll be just fine"
2 - Approving - "I'm glad to see you're cheerful today"
3 - Disapproving - "Now don't be so glum"
4 - Agreeing - "That's right. You do need to look at the bright side"
5 - Disagreeing - "No, you're wrong about that"
6 - Rejecting - "Don't think about that. It's too depressing"
7 - Denying - Pt. "I'm not worth bothering with", Nurse "Of course you are"
8 - Belittling - Pt. "I don't want to live like this" Nurse "You'll feel different in the morning"
9 - Interpreting - Underneath you really feel..."
10 - Making a stereotyped comment - "Chin up"
11 - Introducing an unrelated topic/Changing the subject
12 - Challenging - "It isn't possible for that to happen"
13 - Demanding an explanation - "Why do you feel that way?"
14 - Defending - "This is a fine institution"
Components of Assessing the Peripheral Vascular System (PVS): * - Measuring blood pressure
* - Palpating peripheral pulses
* - Inspecting, palpating, and auscultating the carotid pulse
* - Inspecting the jugular and peripheral veins
* Inspecting the skin and tissues to determine perfusion
List forms of Verbal Communication: 1 - Vocabulary
2 - Denotative/connotative meaning
3 - Pacing
4 - Intonation
5 - Humor
6 - Clarity
7 - Timing and relevance
Percussion Sounds (p. 297 SDM): * Normal lung areas produce a resonance sound.
* Liver sounds are dull.
* Flat sound over muscle
* Flatness = dense tissue, like bones
* Hollow sounds = lungs
* Hyperracone (sp?) "booming" as heard in emphysema
* Dullness (thud) = liver, spleen, heart
* Tympany = air in belly
List forms of Non-verbal communication: 1 - Body language
2 - Tone
3 - Posture/Position
4 - Gestures
5 - Touch
6 - Vocal cues
7 - Physical appearance
8 - Facial expressions
9 - Distance or spatial territory
With what is the Auditory nerve associated and how test?: Equilibrium
Test = assess with cerebellar functions
Give examples of how to facilitate active listening.: 1 - Acknowledgment - ex. "yes, go on", I hear what you're saying"
2 - Clarification - ex. "I don't understand. Can you say that a different way?"
3 - Feedback - ex. "You did that well."
4 - Focus - focusing or re-focusing on a statement. Ex. "You were telling me how hard..."
5 - Incomplete sentences - ex. "Then your relationship is one of..."
6 - Listening
7 - Minimum verbal activity - let patient lead. Ex. "go on"
8 - Mutual fit or congruence - creating harmony of verbal and nonverbal messages.
9 - Nonverbval Encouragement - ex. Nodding
10 - Open-ended questions - ex. who, what, why, where, when, how questions
11 - Paraphrase
12 - Reflection
13 - Restatement
14 - Validation - ex. "Yes, it is confusing with people around."
Purpose of Head to Toe Assessment: * Obtain baseline data
* Supplement, confirm, or refute data
* Make clinical judgments on patient's health status
* Obtain data to help nurse establish NDx and patient care
* To evaluate outcomes of healthcare and patient progress
List Forms of Communication: * Interpersonal communication
* Public communication
With what is the Abducens nerve associated and how test?: EOM; moves eyeball laterally
Test = assess directions of gaze
Which system is done in different order than IPPA?: Abdomen

Inspection
Auscultation
Percussion
Palpation
Types of Skin Lesions - (pg. 313 SDM): - Macules - flat locales changes in color
- Papules, plaques, nodules - solid elevated varying in size
- Wheals - elevated, circumscribed, transient
- Vesicles and bullae - clear, fluid-filled pockets between skin layers
- Pustules - vesicles or bullae filled with exudate
List Means of Communication: * Touch
* Expression
* Gesture
* with symbols
* with words
* with silence
What is attributed to the DUPP S2 sound?: Closing of the Semi-Lunar valves.
What might CRACKLES indicate?: Air is moving through mucous or fluid.
Head to Toe Physical Assessment: * Begin with a general survey of the patient
* Vital Signs
* General Appearance - Body build, posture
* Behavior - Depressed, odd, calm, cooperative, combative...listen to speech
List two causes of poor communication: 1 - Ambiguity
2 - Discrepancy in a message
With what is the Olfactory nerve associated and how might a nurse test.: Smell...
Ask client to close eyes and identify odors.
Where are Bronchial Sounds heard?: Over the trachea, above the sternal notch
Zones of Touch: * Social Zone (permission not needed)
- Hands, arms, shoulders, back
* Consent Zone (permission needed)
- Mouth, wrists, feet
* Vulnerable Zone (special care needed)
- Face, neck, front of body
* Intimate Zone (great sensitivity needed)
- Genitalia
Elements of Communication: * Referent = motivates one person to communicate with another
* Sender = the person who delivers the message
* Message = info sent by the sender
* Channels = means of conveying the message
* Receiver = the person to whom the message is sent
* Environment = The physical and emotional atmosphere present at the time of interaction
* Feedback = indicates whether the meaning of the sender's message was received
Managed Care: * Cost containment system
* Largest provider for health care in the U.S.
* Focus on quality of care/cost of care
* Controversial with health care professionals and the public
* Use of health care providers who agree with payment for service
* Nurses function as case managers
What are some characteristics of bronchial sounds (i.e. pitch, amplitude, sound, is it longer during expiration or inspiration)?: High pitch
High amplitude
Harsh, loud, tubular quality
Expiration is longer than inspiration
Bases are at the top of the heart: Apices (apex) is at the bottom.
Relationships between verbal and non-verbal: * Repeating
* Contradicting
* Complementing
* Accenting
* Relating and regulating statements
* Substituting
What are characteristics of bronchovesicular sounds (i.e. pitch, amplitude, sound quality, is inspiration or expiration longer in duration)?: Moderate to high pitch
Moderate amplitude
Hollow, muffled quality
Inspiration and expiration are equal in duration
Charting for Potential Legal Problems: * Use facts
* Do not use pat phrases. Be specific.
* Be professional. Do not make interpretations. State what happened.
* Chart potentially serious situations
* Use correct language and medical terms.
* Report problems to appropriate authorities, such as suspected child abuse.
* Provide the best care you are capable of giving.
List the different breath sounds.: 1 - Bronchial Sounds
2 - Adventitious Sounds
3 - Bronchovesicular Sounds
4 - Normal Sounds
Components of the termination phase: - ending relationship
Define Non-Verbal Communication: Exchange of information without the use of words; it is what is not said; "body language"
List purposes of documentation.: 1 - Legal document
2 - Safety of patient/staff
3 - Progress (or lack of)/Response to care
4 - Evaluating that tasks are completed by assigned personnel
5 - Communication
6 - Provides continuity of care
7 - Changes in condition

(SDM, p. 46)
1 - Charting communicates info, such as facts, figures, and observations to other members of the healthcare team
2 - Charting assists supervisory personnel to evaluate the staff's performance on a day by day basis for specific patients.
3 - Charting provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution.
What might RHONCHI indicate?: Constricted airway; louder and coarser than wheezes.

Gurgles, may clear with a cough.
List the 4 phases of Therapeutic Relationship: 1 - Preinteraction
2 - Orientation (Introductory)
3 - Working
4 - Termination
List Psychological Barriers to Communication: * Psychological
- Depression
- Flight of ideas
- Word salads
- Use of the same word/phrases
Components of Neurological System Assessment: * Routine Screening Test
* Mental status including level of consciousness
* Cranial nerves
* Reflexes
* Motor function
* Sensory function
List 4 "zones" of personal space.: * - Public Zone = 12+ feet (strangers)
* - Social Zone - 4-12 feet
* - Personal Zone - 1.5 - 4 feet
* - Intimate Zone - Body - 1.5 feet
List purposes of the incidence report.: - help document quality of care
- identify areas where in-service education is needed
- record the details of an incident for possible legal reference
List Communication and factors that may influence it...: 1 - Attitude
2 - Sociocultural or ethnic background
3 - Past experiences
4 - Knowledge of the subject matter
5 - Ability to relate to others
6 - Interpersonal perceptions
7 - Environmental factors
List characteristics of Admission Charting.: * What patient was like when admitted
* What medications patient is taking
* OTC medications
* Herbal meds
* Ask about pain/symptom - "What's wrong?"
What might PLEURAL FRICTION RUB indicate?: High-pitched; absence of pleural fluid.

Lower anterior; "creaking"
Components of the orientation phase.: - establish rapport
- determine interventions and expectations
- gather info for patient database
- identify strengths and limitations
- formulate NDx
- set goals
- develop POC
- explore feelings of nurse and patient
List Physical Barriers to Communication: * Physical
- Respiratory
- Oral/nasal cavities
- Speech center
- Auditory system
With what is the Oculomotor nerve associated and how test?: Extraocular eye movement (EOM)
Test = Assess six ocular movements and pupil reaction.
What might WHEEZES indicate?: Constricted airways.

Wheezes will not clear with a cough.
List types of information to be recorded on a chart.: Physical
Psychosocial
Environmental
Self-care
Educational Planning
Discharge Planning
Cheif complaint
Present Health Status
Health history
Family History
Lifestyles
Nutrition - preferences/restrictions
What might STRIDOR indicate?: Inspiratory wheeze; heard in neck.
List major components of documentation.: 1 - Nursing Process
2 - Precise measurement
3 - Pain scales
4 - Patient quotes
5 - Administration of meds/treatment
6 - Preparation for tests
7 - Signature and title
8 - NEVER document something like "patient fell"
9 - "Do not get even in the chart"
10 - Use only approved medical terminology and abbreviations
11 - Be specific, clear and concise
12 - Use correct spelling
13 - Leave no blank lines
List types of adventitious sounds.: Crackles (discontinuous)
Wheezes (continuous)
Rhonchi (continuous)
Pleural friction rub (continuous)
Stridor (continuous)
Components of the working phase.: - maintain trust and rapport
- promote client insight
- problem solve
- overcome patient resistance
- evaluate progress
Where are bronchovesicular breath sounds normally heard?: Over the mainstem bronchi below the clavicles and adjacent to the sternum between scapulae.
Components of Urinary Tract Assessment: * Look at external urethra
* Urine output
* Bladder distention
* Pain
What does IPPA stand for?: Inspection
Percussion
Palpation
Auscultation
Components of the Preinteraction phase.: - Obtain available info about the client from chart, others, etc.
- Examine one's own feelings about working with the patient.
List three Charting Systems.: 1 - Problem-oriented
2 - Source-oriented
3 - Computer-Assisted
Pitch: * Frequency of the vibrations
* Low Pitch - abnormal to heart tones
* High Pitch - bronchial sounds; bowel sounds
Best Practice for Nursing Documentation.: 1 - Write clearly and legibly
2 - Do not erase or "white-out"
3 - To correct an error, strikeout with one line
4 - Use approved abbreviations and symbols
5 - Document close to time when collected
6 - Transcribe accurately
7 - Do not leave blank spaces
8 - Time and date each entry
9 - Document like a reporter.
10 - Do not state that incident reports have been filed
11 - Follow facility polices for documentation
12 - Use carat to add words
13 - Label late entries appropriately.
14 - Make sure all information will be picked up by a copy machine.
Quality: * Subjective
* Whistling, gurgling, or snapping
What is attributed to the LUBB sound of S1?: Closing of the AV valves.
List Components of Head to Toe Assessment: Components of Head to Toe Assessment
* General Appearance
* Inspection = to look at
* Palpation
* Percussion = to listen
* Auscultation = to listen
List two types of interactions: 1 - Social - occur daily; pleasantries, etc.
2 - Therapeutic - helping or encouraging the patient to communicate feelings of perceptions, fears, anxieties, frustration, expectations, and increased dependency needs.
List Techniques which promote effective communication: * Rapport
* Specific objectives
* Comfortable environment
* Privacy
* Confidentiality
* Client focus
* Use of nursing observations
* Optimal pacing
* Providing personal space
Where is the Peripheral Vascular System most often measured?: * measured most often using feet (farthest point from the heart)
List Characteristics of Inspection: * Visual Examination
* Deliberate, purposeful, and systematic
* Assess moisture, color, and texture
* Assess shape, position, size, color, and symmetry
List characteristics of Admission Protocol.: * Availibality of advanced directives
* The client's bill of rights is presented
* Admission assessment is completed by a RN within a specified time period
* All clients must be clearly identified by a legible identification band
Describe Percussion: * Act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt
* Direct used for the sinuses...ASK PATIENT ABOUT PAIN
* Indirect - using the finger of one hand to tap the finger of the other
* Indirect used for abdomen and lungs
With what is the Trochlear nerve associated and how test?: EOM, specifically moves eyeball downward and laterally
Test = assess six ocular eye movements.
Palpation: * Examination using touch
* Pads of the fingers
* Can assess texture, temperature, vibration, position, size, mobility of organs or masses, distension, pulsation, and pain upon pressure
List components of Discharge Charting.: * Summarize patient's stay
* Patient family education
* Referrals (ex. community referrals)
Duration: * Long or short
With what is the Facial nerve associated and how test?: Facial expression; taste
Test = ask patient to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly
Intensity: * Loudness or softness
With what is the Trigemenal nerve associated and how test?: Sensation of cornea, skin of face, and nasal mucosal
Test = Seek blink reflex by touching sclera
Describe Auscultation: * Listening to sounds produced within the body
* Auscultated sounds are described according to their pitch, intensity, duration, and quality

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