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FUN 12 & 18
Physical Assessment & Phlebotomy Skills
Question | Answer |
---|---|
Objective data | Data perceived by the examiner , can be seen, heard, and measured, and can be verified by more than one person |
Subjective data | Data perceived by the patient; examiner is unaware of symptoms unless patient describes senstion |
Chronic | Develops slowly & persist over a long period, often for a persons lifetime |
Remission | Partial or complete disappearance of clinical & subjective characteristics of a disease |
Acute | Begins abruptly with marked intensity of severe signs & symptoms and then often subsides after a period of treatment |
Anorexia | Lack of appetite that results in the ability to eat. Can occur in many disease conditions |
Asthenia | A condition of debility, loss of strength & energy depleted vitality |
Cyanosis | Bluish discoloration of the skin & mucous membranes caused by an increase of de-oxygenated hemoglobin in the blood |
Diaphoresis | Secretion of sweat, especially the profuse secretions associated with elevated body temp, physical exertion, exposure to heat, mental/emotional stress |
Dyspnea | SOB or difficulty in breathing that is sometimes caused by certain heart & lung conditions, strenuous activity, or anxiety |
Ecchymosis | Discoloration of an area of the skin/mucous membrane caused by extra vasation of blood into the subcutaneous tissue as a result of trauma to underlying blood vessels or by fragility of the vessel walls (bruise) |
Edema | Abnormal accumulation of fluid in the interstitial spaces |
Erythema | Redness or inflammation of the skin or mucous membranes that result in dilation & congestion of superficial capillaries |
Fetid | Pertaining to something that has a foul, putrid, or offensive odor (aka malodorous) |
Orthopnea | Abnormal condition in which a person has to sit or stand to breathe deeply or comfortably; occurs in many respiratory & cardiac symptoms |
Pallor | Unnatural paleness or absence of color in the skin; often results from decreases in hemoglobin & RBC |
Pruritis | Symptom of itching & an uncomfortable sensation that leads to urge to scratch (allergy, infection, jaundice, increased serum urea, skin irritation) |
Purulent drainage | creamy, viscous, pale yellow/yellow green fluid exudate; result of fluid remain of liquefied necrosis tissue |
Sallow | Pertaining to an unhealthy, yellow color, usually said of a complexion or skin |
When a patient is sitting, what areas are assessed? | Head & neck, back, posterior thorax & lungs, anterior thorax & lungs, breast, axillae, heart, V/S and upper extrememties |
When a patient is in supine, what areas are assessed? | Head & neck, anterior thorax & lungs, breast, axillae, heart, abdomen, extremities, pulses |
When a patient is in dorsal recumbent position, what areas are assessed? | Head & neck, anterior thorax & lungs, breast, axillae, heart & abdoment |
When a patient is in lithotomy position, what areas are assessed? | Female genitalia & genital tract |
When a patient is in sims position, what areas are assessed? | Rectum & vagina |
When a patient is in prone position, what areas are assessed? | Musculoskelatal system |
What a patient is in lateral recumbent position, what areas are assessed? | Heart |
When a patient is in knee-chest position, what areas are assessed? | Rectum |
Inspection | Visually inspect the patients body & observe moods, including all responses and nonverbal behaviors |
Palpation | Use hands & sense of touch to gather data, hands are sensitive to texture, temperature, and moisture & thus help determine the quality of an area |
Auscultation | Process of listening to sounds produced by the body. Nurse will listen to cardiovascular system, respiratory system, and digestive system |
Percussion | Use of fingertips to tap the body's surface to produce vibration & sound. These sounds indicate density of the underlying tissue & helps physician/NP locate body organs & structures |
What is the first step in initiating the nurse-patient relationship? | Have an accepting posture, relaxed, eye level, & pleasant facial expression. Introduce, include name, position & purpose of the interview. Must be established before proceeding with the nursing health history |
Why is it important for the nurse to convey feelings of compassion and concern while at the same time remaining objective? | Patient must feel that the information being sought is truly important and demonstrates an interest in the patients state of wellness |
List some ways the nurse can help to promote communication during the patient interview? | Use nonjudgmental language, encourage the patient to clarify without feeling threatened |
What are the categories the nurse should assess during the nursing health history? | Habits & lifestyle, biographic data, persistent illness/health concerning, family history, psychosocial/cultural history, reason for seeking healthcare, health history, environmental history, and review of systems |
What is the review of systems (ROS)? | Systematic method for collecting data on all body systems |
When should the initial nursing physical assessment talk place? | As soon after admission as possible (some facility's policies state, within the first 24hrs of admission) |
What is the LPN's role in patient assessment? | Ongoing assessment with RN |
What is the order of head to toe assessment? | Neurological, V/S, GCS, skin & hair, head & neck, mouth & throat, eyes, ears, nose, chest, lungs, heart, vascular system, gastrointestinal, genitourinary system, rectum, legs & feet |
What supplies should the nurse have on hand when performing the physical assessment? | Penlight/flashlight, stethoscope, BP cuff, thermometer, gloves, watch w/second hand, scissors, black pen, tongue depressor |
Cognition | Ability to think |
What does the acronym PERRLA stand for? | Pupils equal, round, reactive to light, and accomodation |
What does accommodation mean and how is it assessed? | Eyes constrict to light & when focusing on an object; nurse ask the patient to follow examiner's finger/pen light while it is brought in towards the patients eyes directly between the eyes |
Describe assessment of the skin & hair; what would be normal/abnormal findings? | Observe skin for color, temp, moisture, texture, turgor, & evidence of injury or skin lesions. Normal - skin tones vary w/race, heredity, & sun exposure. Abnormal - any skin lesions, evidence of any other skin issues, tenting (decreased skin turgor) |
What is skin turgor? | Refers to elasticity of skin |
Describe crackles | Produced by fluid in bronchioles & alveoli; are short, discrete, interrupted, crackling, or bubbling sounds that are most commonly heard during inspiration |
Describe wheezes | Sounds produced by the movement of air through narrowed passages in the tracheo-bronchial tree |
Describe sonorous wheezes | Have a lower pitched, coarser, gurgling, snoring quality, and usually indicates the presence of mucus in trachea and the large airways |
What causes the "lubb-dubb" sound of the heart? | Closure of the atrioventricular and the semilunar valves, respectively |
How is the strength of the pulse measured? | 0 - absent, 1+ - thready, 2+ - weak, 3+ -normal, 4+ - bounding |
How is the capillary refill test performed? | Firmly press fingernail/toe nail for 5 seconds, release and estimate speed at which the blood returns to fingernail/toe nail |
What does physical assessment of the abdomen include? | Listening to bowel sounds, assessment of the abdomen, and percussion of the abdomen |
What causes decreased bowel sounds? | NPO, inactive bowel sounds - peristalsis is not present |
What is borborygmus? | Hyperactive bowel sounds |
What do you always do before palpation? | Auscultate |
Carotid bruit | Abnormal "swishing" sounds heard of organs, glands, arteries |
How long do you auscultate heart sounds, noting rate & rhythm? | 1 full minute |
What is the normal adult heart rate? | 60-100bpm |
Adventitious | Abnormal breath sounds |
When performing head to toe assessment, what is important to inquire about while assessing chest & abdomen? | Cough, sputum production, or shortness of breath on exertion |
What is a result of dehydration? | Decreased skin turgor or "tenting" |
What do you palpate for in the feet? | Strength & equality of pedal pulses |
What do you assess for in the feet? | Pedal pulses, edema, capillary refill |
How are pedal pulses compared & how do you chart them? | Compared bilaterally; charted as present, equal, strong/weak bilaterally |
What does 1+ mean in edema? | Barely perceptible; pitting is 2mm |
What does 2+ mean in edema? | Mild; pitting 4mm; rebounds 10-15 seconds |
What does 3+ mean in edema? | Moderate; pitting 6mm, last for 30 seconds to less than 1 minute |
What does 4+ mean in edema? | Severe; deep pitting 8mm, last as long as 2 to 5 minutes |
Compression from external devices may occur; when performing neurovascular assessment, what is important to remember? | Pulselessness, Paresthesia, Paralysis, Polar temperature, Pallor, Puffiness (edema), Pain |
Arteries | Blood vessels that carry blood away from the heart |
Veins | Blood vessels that return blood to the heart |
Capillaries | Microscopic vessels that link arterioles to venules; site where nutrients, waste, and hormones are exchanged blood & tissue |
What is the function of the capillaries? | To release chemicals, including O2, glucose, hormones, and nutrients that will be used by the surrounding tissues |
Venipuncture | Most common method, involves inserting a hollow-bore needle into the lumen of a large vein to obtain a specimen |
List special conditions that could put the patient under going venipuncture at risk | Anticoagulant therapy, low platelet count, bleeding disorders, presence of arteriovenous shunt/fistula, have had breast or axillary surgery performed on that side |
How do safety devices and features protect health care workers? | Provides a barrier between the hands & needle, allow or require workers hand to remain behind needle at all times, and are simple to operate & necessitate little training to use effectively |
The nurse should never ___________ needles and must always discard them in ______________________ close to the patient. | Recap / puncture resistant container |
When are blood samples drawn? | When there are symptoms of fever & chills that often accompany bacterium are present |
Where are the specimens are drawn from? | Two different sites |
How is the diagnosis confirmed? | When both cultures grow an infecting agent |
Can you draw from an IV? | No, unless sepsis in the catheter is suspected |
What should be held until cultures are drawn? | Antibiotic therapy |
When it comes to safety, what position must you never draw blood from? | Standing |
What conditions indicate an arm should not be used for venipuncture? | Arm on the side of a mastectomy, with paralysis, with hemodialysis access site, or with an IV site |
How long can a tourniquet stay in place? | 1 to 2 minutes |
What types of veins should be avoided during venipuncture? | Small & narrow veins are usually fragile, weak veins are soft & do not rebound, sclerosed veins are hard and rigid, veins that are easy to roll when palpated are difficult to successfully pierce with needle |
What do you label collections tubes with & when? | Patients identifying information, before being sent to the lab |
To prevent hemolysis, how do you rotate tubes when additives are present? | Gently roll back and forth 8 to 10 times |
What are the most common veins for venipuncture? | Cephalic vein, basilica vein, and median cubital vein |