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unit 2 reviewer

QuestionAnswer
to collect subjective and objective data about a patient to determine his/her overall level of physical. purpose of health assessment
a type of assessment that is conducted when a patient first enters a healthcare settings, with information providing a baseline for comparing later assessment. comprehensive assessment
a type of assessment that is conducted at regular intervals (eg, at the beggining of each home visit or each hospital shift. ongoing partial assessment
a dilusional belief that others can hear or know what the client is thinking thought broadcasting
the first thing that a nurse will assess when assessing mental status general appearance and behavior
the capacity to understand and reason cognition
the process by which information and experiences are stored and retrieved memory
the outward expression of the client's emotional state affect
the ability to interpret one's environment and situation correctyly and to adopt one's behavior and decisions accordingly judgement
the ability to understand the true nature of one's situation and accept some personal responsibility for the situation insight
recognition of person, place and time orientation
pervasive and enduring emotional state mood
a dilusional belief that others are putting ideas or thought into client's head- tha the ideas are not those of the client thought insertion
a dilusional beliefs tha others are taking the client's thoughts away and the client is powerless to stop it thought withdrawal
flow of unconnected words that convey no meaning to the listener word salad
diminished visual acuity presbyopia
excess fluid in the tissues, may cause difficulty in lifting the skin fold. Characterized by swelling with tauts and shiny skin, maybe the result of overhydration, heart failure,kidney failure,trauma or periphiral vascular disorder edema
what are the physiologic changes of aging 1.presbyopia 2.increased sensitivity to glare 3. decreased accomodation, depth perception and color descrimination
what are the physiologic chnages of aging 4. decreased ability to adjust to darkness 5. increased incidents of cataracts.
difference between the systolic and diastolic reading. it is an early sign of shock. pulse pressure
what is the difference between apical and radial pulse....0 means normal pulse deficit
irregular heart beat, abnormal or irregular heart rhythm arrhytmia = dysrhythmia
abnormal elevated pulse, or above 100 beat/min tachycardia
abonormal low pulse rate , or below 60 bradycardia
information experiences or known only by the patient and obtained from the patient during the health history subjective data
what is the word used to describe cyanosis in dark skinned people which describes an ashen gray dusky
is a tool used to assess a patient's skin risk for skin breakdown braden scale
what areas are assessed in the braden scale mental status/ sensory, continence/moisture, nutritional status, mobility and activity level,
includes all the pertinent patient information collected by the nurse and other healthcare professional enabling a comprehensive, effective plan of care to be designed and implemented for the patient database
disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts loose associations
term used when there is no abnormal disruption in the skin surface. a disruption maybe a trauma or injury such as laceration or a surgical incission, lesion or open sore intactness
is a thickening and roughness of skin texture. described as a circumscribed lesion or change in skin integrity with errythema, thickening and scaly patches psoriasis
loss of sensation such as numbness, tingling, abnormal feeling paresthesia
wandering off the topic and never providing the information requested tangential thinking
imaginary lines used to describe location planes
coronal plane, anterior or ventral, posterior or dorsal ex. the vertebrae are posterior to the sternum frontal plane
begins with the first contact witht he patient, assess patient's appearance, general behavior, ability to speak clearly and responses to questions. include cognitive status, orientation, memory, level of consciousness, abstract thinking mental status assessment
the ability to execute complex mental processes cognition
ability to cognitively retrieve and report previously stored information memory
lateral plane, lateral and medial, another common medical term is bilateral which refers to both sides of the body ex. the hip is lateral to the sternum sagittal plane
cross-sectional plane, superior or cephalic, inferior or caudal ex. the chest is superior to the abdomen transverse plane
ask to repeat a series of numbers, 3..6..9, say the names of three unrelated objects such as chair, spoon, boat. ask the patient to repeat them. about 5 mis. later ask the patient to recall the three words immediate memory
nurses uses this interview technique to allow the patient a wide range of possible responses e. what did your doctor tell you about your need for hospitalization? open-ended questions or comments
a type of assessment that includes communication of events, comprehending the meaning of events, attentiveness, concentration, demostration of immediate, recent and remote memory, processing information and decision making cognitive assessment
the ability to make judgements and choose between two or more alternatives decision making
refers to person's enduring and prevailing state mood
the ability to make associations or interpretations; like peroverbs ex. the early bird gets the worm. another ex. Don't count your chicken before the're hatched abstract thinking
when the heart contracts and the blood is pumped under high pressure into the aorta and the pulmonary arteries systole
when the blood pressure drops, the ventricles rests and fills, this gives the lowest pressure reading called? diastole
when ventricle contracts the reading will be the highest pressure called? systole
what is the force of blood against the arterial walls. it rises as the ventricles contracts blood pressure
what factors affect respiratory rate age,exercise,increased altitude,respiratory disease,anemia,anxiety,acute pain (resp. rate up)
gradual increase the gradual decrease in depth of respirations followed by a period of apnea cheyne-stokes respiration
periods of no breathing apnea
difficult or labored breathing dyspnea
labored breathing when lying flat but relieved by sitting up orthopnea
more than normal amount of air is entering and leaving the lungs hyperventilation
what do nurses assess with respiratory rate rate ( tachypnea or bradypnea), depth ( shallow,normal or deep), rhythm( regular or irregular)
in clients with chronic lung disease, what signals the brain to increase the rate and depth of ventilation hypoxemia
what could be fatal to a client with chronic lung disease because of their low levels of arterial oxygen that stimulus the client to breath administering high level of oxygen
during a normal, relaxed breath, a person inhales 500 ml of air. this is referred to as? tidal volume
pulmonary respiration that involves movement of air into lungs and out of the lungs respiration
when should the apical be assessed when the peripheral pulses are irregular, feeble or extremely rapid
when should the apical be assessed before giving medications that can alter heart rate rhythm
when should the apical be assessed when assessing infant's or young children's pulses because their peripheral pulses are deep and difficult to palpate accurately
the increased excretion of urine diuresis
events in human that recur at 24 hour intervals circadian rhythms
difference between the apical and radial pulse rate pulse deficit
force of blood against arterial walls blood pressure
use of oral thermometers is contraindicated to the following infants, patients receiving oxygen therapy, unconscious patients
what are the integumentary system skin, nail, hair and scalp
the window to overall health status, provides data to systemic and local problems, largest organ in the body skin
functions of skin protection, sensation, temperature regulation, excretion & secretion, absorption
in what order are the assessment techniques used interview, inspection, palpation, percussion and auscultation
when does ausculation comes second when doing an assessment when assessing abdominal due to bowel sound
fully awake, oriented to person, place and time; responds to all stimuli including verbal commands Awake and alert
is the degree of wakeness or the ability of a person to be aroused consciousness
example of memory that asks about client's birthday, wedding anniversary or place of birth remote memory
example of memory that asks client what they ate for breakfast or who brought them in the hospital recent memory
can identify self and others, identifies correct day, month and year,correct senitive orientationason, current events, and where they are cognitive orientation
the ability to identify person, place, time accurately. also referred to as levels of awareness cognitive orientation
is the resistance to blood flow determined by the tone of the vascular musculature and diameter of blood vessels peripheral vascular resistance
REMEMBER!!!!! healthy arterues have elastiity that allows them to stretch and distend ventricular contraction or systole and recoil back to their original size during ventricular resting or distole Important to understand
number of heart beats in one minute heart rate
amount of blood ejected from left ventricle with one heart beat stroke volume
the volume of blood pumped from the left ventricle throught the circulation in one minute cardiac output
cardiac output formula CO = SV x HR
how do you assess an apical pulse rate? what location and how much? using stethoscope over apex or tip of the heart between 5th or 6th intercostal space on the L midclavicular line for full minute
when do you take the radial and apical pulse simultaneously when a patient has dysrhytmia
the difference between the apical and radial is called pulse deficity
what regulates the involuntary control of respirations respiratory center in brain stem
pulse areas on the neck under sternocleidomastoid muscle carotid pulse
inner aspect of wrist or thumb size radial pulse
pulse behind the knee popliteal
pulse in the inner aspect of the ankle posterior tibial
pulse in the inguinal area femoral
pulse in the anticubital fossa brachial pulse
pulse on the top of the foot between the great and first toe dorsalis pedis
nurses uses this interview technique to allow the patient a wide range of possible responses, encourage free responses, prevents patients from answering only yes or no open - ended questions
ask to repeat three series of numbers 3,6,9...then ask the patient to repeat it after 5 minutes immediate memory
what re areas assessed in the braden scale sensory, moisture, activity, mobility
includes all the pertinent patient information collected by the nurses and other healthcare professionals enabling a comprehensive, effective plan of care to be designed and implemented for the patient database
is a tool used to assess a patient's skin risk for the skin breakdown braden scale
the ability to understand the true nature of one's situation and accept some personal responsibility for the situation insight
diminished visual acuity presbyopia
excess fluid in the tissues may be result of over hydration, heart failure, kidney failure, truma or peripheral vascular disease edema
yellow color of the skin resulting from liver and gall bladder disease, some types of anemia and hemolysis. develops first in the sclera of the eyes and then in the skin and mucous membrane jaundice
a collection of blood in the subcutaneous tissues causing red discoloration eccymosis
approximately 60-70 ml of blood enter the aorta with each ventricular contraction. this is called stroke volume
most commonly assessed parts body to palpate brachial, apical and carotid pulses
most commonly pulse used in an emergency carotid pulse
the number of pulsations in a minute is called pulse rate
the volume of blood pumped by the heart in one minute is called cardiac output
whitish patch areas on the skin, possible cause of depigmentation due to congenital or autoimmune disease vitiligo
paleness of the skin, often results from inadequate amt of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues pallor
the flow of unconnected words that convey no meaning to the listener word salad
gradual increase then gradual decrease in depth of respirations followed by a period of apnea cheyne stokes respirations
periods of no breathing apnea
difficult or labored breathing dyspnea
labored breathing when lying down flat but relieved by sitting up orthopnea
more than normal amt of air is entering and leaving the lungs hyperventilation
during a normal, relaxed breath, a person inhales 500 ml of air. this is referred to as tidal volume
pulmonary ventilation ( breathing) that involves movement of air into lungs ( inspiration) and out of the lungs ( expiration) respiration
cannot be aroused even with use of painful stimuli; may have some reflex activity ( such as gag reflex); comatose
is an standardized assessment tool that assesses level of consciousness glasgow coma scale
what are the parameters that was assessed in the level of consciousness eye opening, motor response, verbal response
validates what the nurse believes is heard and observed validating questions
the conscious and deliberate use of 5 physical senses to gather data information observation
the act of confirming or verifying data validation
type of ulcer with a localized area of tissues necrosis decubitis ulcer
type of ulcer that is caused by the chronic venous insufficiency especially to the leg venous stasis ulcer
an opening in the skin that causes loss od epidermis, dermis and even deeper layers of tissue ulcer
appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name lethargic
unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movement stuporous
is ahigh pitched sound heard on inspiration when there is a narrowing of the upper airway atridor
fine to coarse crackling (ronchi) sounds made as air moves through wet secretions crackles
a position located at the left sternal border and the third intercostal space where both S1 and S2 can be heard erb's point
S1 sound "lub' represents the closing of the mitral and tricuspid valves and is heard over where? mitral or apical valve
S2 sound is dub and can heard where? aortic and pilmonic valves
what kind of edema caused by venous insufficient oxygenation peripheral edema
the period from one heartbeat to the begginning of the next. there are two phases-systole and diatole cardiac cycle
is a collection of subjective data that provide a detailed profile of the patient's health status health history
pu filled, superficial skin such as acne pustule
small elevated solid mass such as a mole. <0.5 cm papule
group of coalesced papules .0.5 cm plaque
area is raised and red macular papular rash
the ability to focus on a specific stimilus concentration
what are the signs of normal pupils black, round, regular equal in size 93-7mm) and iris clearly visible
what is PERRlA, used when assessment of pupillary reaction is normal in all tests pupils equal round and reactive to light and accomodation
is a type of rapid focused assessment conducted to determine potentially fatal situations like assessing airway emergency assessment
the examination of patient for objective data that may better define the patient's condition and help the nurse in planning care physical assessment
cloudy pupils indicate what cataracts
dilated pupils indicates what type of eye disease glacauma, trauma, neurological disorders, eye medications, withdrawal from opioids
constricted pupils indicate what type of problem inflammation of the iris or opioid intoxication
type of sensation in order to determine cutaneous sensory function. ability to determine cold vs. warm, rough vs smooth tactile sensation
excessive perspiration which can be related to fever, exercise, anxiety, cardiac or respiratory problems or obesity diaphoresis
adequacy of blood flow through the small vessels of the extremities to maintain tissue function peripheral tissue perfussion
specimen drawn from an artery that provides information about PaO2 and PaCO2 and acid base balance Arterial Blood Gases
non invasive technique that measures the oxygen saturation (spo20 of arterial blood. Normal is 95% or greater pulse oximetry
made by air passing through moisture in small air passages and alveoli fine crackles
when they are made by air passing through moisture in the bronchules, bronchi and trachi, also called ronchi coarse crackles
irregular, superficial area of skin edema/hives. it may be often be a result of an allergic reaction wheal
begins with the first contact with the patient. assess patient's appearance, general behavior, ability to speak clearly and responses to questions. include cognitive status, orientation, memory , level of consciousness, abstract thinking, mood mental health status
describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction pulse amplitude
how to assess pulse amplitude palpating the flow of blood through an artery
elevated, encapsulated lesion in the dermis or subcutaneous layer filled with liquid or semi-solid material. it is deeper and don't involve the epidermal area cyst
is the preferred term used when documenting scab crusting
is the correct way to describe a wound that contains pus purulent drainage
large, fluid filled elevation like a burn bulla
large flat non palpable change in skin color patch
purple discoloration purpera
medium elevated solid mass such as wart nodule
fluid filled elevation ,0.5cm, small superficial skin elevation like herpes, chicken pox, shingles vesicle
large elevated mass tumor
sitting up at a 45 degree angle semi fowler's position
sitting up at a 90 degree angle, promotes greatest lung expansion high fowlers position
alteration in the angle between the nail and its base that is caused by the chronic lack of oxygenation. often sees in patient with COPD and emphysema nail clubbing
soft, low pitched sounds auscultated over the lung periphery or base vesicular breath sound
bronchial or tubular breath sounds are heard over trachea
can be heard over trachea, high pitched expiration longer than inspiration bronchial sounds
moderate blowing, inspiration is equal to expiration and can be heard over mainstem broncus broncho vesicular sound
soft, low pitch sounds heard over base during inspiration, which is longer than expirations vesicular sound
is a harsh high pitched sound on inspiration when there is a narrowing of the upper airway such as the larynx or trachea stridor
describes as noisy, strtonous respirations stertorous breathing
continous sound that originate in small air passages that are narrowed by secretions, swelling or tumors and may be inspiratory or expiratory and are high pitch sound wheezes
are not normally heard in the lungs, if present, maybe ausculatated along with normal breath sounds adventitious breath sounds
how to palpate respiratory excursion place hand in T9 or T10. normal separation is when thumbs separate 1.5-2 inches or 3.5 cm. instruct to take a deep breath
faintly perceptible vibrations felt through the chestwall when the client speaks commonly ask to say "99" tactile fremitus
2nd intercostal space , left upper sternal border pulmonary valve
2nd intercostal space, right upper sternal border aortic valve
fifth intercostal space, medial to left midclavicular line mitral valve or apical
4th intercostal space, lower left sternal border tricuspid valve
core body temperature well below normal, usually caused by exposure to extreme cold hypothermia
core body temperature well above normal, usually caused by exposure to extreme heat hyperthermia
body temperature above normal, usually caused by infection or response to tissue injury febrile, fever, pyrexia
when assessing moisture, what physiologic changes of aging can worsen existing skin condition dryness
looks like eccymosis except it elevates the skin and looks like a swelling hematoma
balding or loss of hair which can be cause of radiation therapy, cancer treatments, infection, malnutrition or hormone disorder alopecia
excess body hair on the face, chest and abdomen, arm and legs. occurs in females and may be due to endocrine or metabolic dysfunction hisutism
normal rectal and tympanic temp, which are the core temperature 99.5
normal oral temp 98.6
normal axillary temp 97.6
normal heart rate 60-100 beats/minute
pulse higher than 100 tachycardia
pulse lower than 60 bradycardia
normal respiration rate 12-20 breaths/min
respiration higher than 20 tachypnea
respiration lower than 12 bradypnea
normal bp 120/80 mmHg
heat production primarily caused by metabolish
without fever, normal body temp afebrile
body temp is controlled by the thermoregulatory system in the hypothalamus
the patient may sit upright in a chair or in the side of the examining table or bed. Allows visualization of the upper body and facilitate lung expansion. used to take vital signs and assess head, neck,posterior/anterior thorax and lungs, breasts, heart sitting position
the patient is in the dorsal recumbent position with the buttocks at the edge of examining table and feet supported in stirups. this position is used to assess the female rectum and genetalia lithotomy position
the patient kneels, using the knees and chect to bear the weight of the body. the position is used to assess the rectal area knees-chest position
the patient lies on the abdomen, flat on the bed with the head turned to one side. this position is used to assessed the hip joint and posterior thorax prone position
excessive amount and rate of speech composed of fragmented or unrelated ideas flight ideas
a fixed false belief not based in reality delusion
a client eventually answers the questions but only after giving excessive unnecessary detail circumstantial thinking
a delusional belief that others can hear or know what the client is thinking thought broadcasting
stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea thought blocking
rapid fluctuating or changing mood labile
lack of emotional response, lack of change in facial expression and flat voice tones flat affect
usually conducted when a patient first enters a healthcare setting, with information providing a baseline for aomparing later assessment comprehensive assessment
is the act of listening with a stethoscope to sounds produce within the body. It is performed by placing the stethoscope diap\hragm or bell against the body part being assessed auscultation
act of stiking one object aginst another to produce sound. percussion
client's inaccurate interpretation that general events are personally directed to him/her such as hearing a speech on the news and believing the message had personal meaning ideas of reference
showing little or slow to respond facial expression blunted affect
displaying facial expression that is congruent with mood or situation; often silly or giddy regardless of cicumstances inappropriate affect
displaying one type of expression usually serious or somber restricted affect
displaying a full range of emotional expressions broad affect
the gathering of data about a specific problem that has already indentified focused assessement
may result in the skin returning to its normal position slowly. this is when skin turgor is described poor dehydration
is the fullness or elasticity of the skin and is usually assess on the sternum or under the clavicle skin turgor
are small, red blood spots caused by capillary bleeding petechiae
the patient lies flat on the back with legs together but extended and slightly bent at the kneew. this positionis used to assess the head, neck, anterior thorax, and lungs, breasts, heart, abdomen, extremities and peripheral pulses supine position
the patient lies on the back with legs separated, knees bent and the soles of the feet flat on the bed. this position id used to assess the head,neck, anterior thorax and lungs, breasts, heart, extremeties and peripheral pulses dorsal recumbent position
the patient lies on the left or right with the lower arm behind the body and the upper arm bent at the shoulder and elbow. the knees are net with the upper most leg at a more acute angle. sim's position
small, flat change in skin color such as freckle macule
limited cjoices of response may be yes or no. used to gather specific information to focus on a particular area closed ended questions
are small, red blood spots caused by capilllary bleeding petechiaea
planned communication to obtain patient data interview
maybe used by nurses to help patient indentify potential and actual health risks and to explore the habits, behaviors, beliefs, attitudes, and values that influence their health nursing history
compares a patient's current status to baseline data obtained earlier time lapse assessment
is an assessment technique that uses the sense of touch. the hands and fingers are sensitive tools and can assess temperature, turgor, texture, moisture, vibration and shape palpation
is the process of performing deliberate, purposeful observations in a systematic manner. the nurses observes visually, but aloso uses hearing and smell to gather data throught out the assessment inspection
invented words that have meaning only for the client neulogism
maintenance of posture or position over time even when it is awkward or uncomfortable waxy flexibility
overall slowed movements psychomotor retardation
repeated purpisely behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair or tapping the foot automatisms
a type of personality tests that are unstructured and usually conducted by the interview method. stimuli for this tests such as pictures or rorschach's ink blot are standard projective tests
a type of psychological tests that reflects the client's personality in self-concept, impulse control, reality testing and major defenses personality tests
a typr of psychological tests that are designed to evaluate the client's cognitive abilities and intellectual functioning intelligence tests
involves thinking about the overall assessment rather than focusing on isolated bits of information. leads to the formulation of nursing diagnoses as a bases for the client's plan of care data analysis
is the way one views oneself in terms of personal worth and dignity self-concept
wandering off the topic and never providing the information requested tangential thinking
ability to acquire, organize and use information information processing
Created by: fentayo316