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FUN 12 & 18

Physical Assessment & Phlebotomy Skills

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
Created by: tandkhopkins
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