Physical Assessment & Phlebotomy Skills
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| Objective data | Data perceived by the examiner , can be seen, heard, and measured, and can be verified by more than one person
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| Subjective data | Data perceived by the patient; examiner is unaware of symptoms unless patient describes senstion
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| Chronic | Develops slowly & persist over a long period, often for a persons lifetime
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| Remission | Partial or complete disappearance of clinical & subjective characteristics of a disease
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| Acute | Begins abruptly with marked intensity of severe signs & symptoms and then often subsides after a period of treatment
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| Anorexia | Lack of appetite that results in the ability to eat. Can occur in many disease conditions
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| Asthenia | A condition of debility, loss of strength & energy depleted vitality
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| Cyanosis | Bluish discoloration of the skin & mucous membranes caused by an increase of de-oxygenated hemoglobin in the blood
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| Diaphoresis | Secretion of sweat, especially the profuse secretions associated with elevated body temp, physical exertion, exposure to heat, mental/emotional stress
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| Dyspnea | SOB or difficulty in breathing that is sometimes caused by certain heart & lung conditions, strenuous activity, or anxiety
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| 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)
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| Edema | Abnormal accumulation of fluid in the interstitial spaces
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| Erythema | Redness or inflammation of the skin or mucous membranes that result in dilation & congestion of superficial capillaries
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| Fetid | Pertaining to something that has a foul, putrid, or offensive odor (aka malodorous)
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| Orthopnea | Abnormal condition in which a person has to sit or stand to breathe deeply or comfortably; occurs in many respiratory & cardiac symptoms
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| Pallor | Unnatural paleness or absence of color in the skin; often results from decreases in hemoglobin & RBC
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| Pruritis | Symptom of itching & an uncomfortable sensation that leads to urge to scratch (allergy, infection, jaundice, increased serum urea, skin irritation)
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| Purulent drainage | creamy, viscous, pale yellow/yellow green fluid exudate; result of fluid remain of liquefied necrosis tissue
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| Sallow | Pertaining to an unhealthy, yellow color, usually said of a complexion or skin
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| 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
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| When a patient is in supine, what areas are assessed? | Head & neck, anterior thorax & lungs, breast, axillae, heart, abdomen, extremities, pulses
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| When a patient is in dorsal recumbent position, what areas are assessed? | Head & neck, anterior thorax & lungs, breast, axillae, heart & abdoment
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| When a patient is in lithotomy position, what areas are assessed? | Female genitalia & genital tract
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| When a patient is in sims position, what areas are assessed? | Rectum & vagina
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| When a patient is in prone position, what areas are assessed? | Musculoskelatal system
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| What a patient is in lateral recumbent position, what areas are assessed? | Heart
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| When a patient is in knee-chest position, what areas are assessed? | Rectum
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| Inspection | Visually inspect the patients body & observe moods, including all responses and nonverbal behaviors
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| 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
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| Auscultation | Process of listening to sounds produced by the body. Nurse will listen to cardiovascular system, respiratory system, and digestive system
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| 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
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| 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
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| 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
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| 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
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| 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
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| What is the review of systems (ROS)? | Systematic method for collecting data on all body systems
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| 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)
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| What is the LPN's role in patient assessment? | Ongoing assessment with RN
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| 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
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| 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
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| Cognition | Ability to think
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| What does the acronym PERRLA stand for? | Pupils equal, round, reactive to light, and accomodation
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| 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
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| 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)
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| What is skin turgor? | Refers to elasticity of skin
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| Describe crackles | Produced by fluid in bronchioles & alveoli; are short, discrete, interrupted, crackling, or bubbling sounds that are most commonly heard during inspiration
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| Describe wheezes | Sounds produced by the movement of air through narrowed passages in the tracheo-bronchial tree
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| Describe sonorous wheezes | Have a lower pitched, coarser, gurgling, snoring quality, and usually indicates the presence of mucus in trachea and the large airways
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| What causes the "lubb-dubb" sound of the heart? | Closure of the atrioventricular and the semilunar valves, respectively
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| How is the strength of the pulse measured? | 0 - absent, 1+ - thready, 2+ - weak, 3+ -normal, 4+ - bounding
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| 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
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| What does physical assessment of the abdomen include? | Listening to bowel sounds, assessment of the abdomen, and percussion of the abdomen
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| What causes decreased bowel sounds? | NPO, inactive bowel sounds - peristalsis is not present
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| What is borborygmus? | Hyperactive bowel sounds
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| What do you always do before palpation? | Auscultate
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| Carotid bruit | Abnormal "swishing" sounds heard of organs, glands, arteries
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| How long do you auscultate heart sounds, noting rate & rhythm? | 1 full minute
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| What is the normal adult heart rate? | 60-100bpm
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| Adventitious | Abnormal breath sounds
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| 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
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| What is a result of dehydration? | Decreased skin turgor or "tenting"
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| What do you palpate for in the feet? | Strength & equality of pedal pulses
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| What do you assess for in the feet? | Pedal pulses, edema, capillary refill
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| How are pedal pulses compared & how do you chart them? | Compared bilaterally; charted as present, equal, strong/weak bilaterally
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| What does 1+ mean in edema? | Barely perceptible; pitting is 2mm
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| What does 2+ mean in edema? | Mild; pitting 4mm; rebounds 10-15 seconds
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| What does 3+ mean in edema? | Moderate; pitting 6mm, last for 30 seconds to less than 1 minute
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| What does 4+ mean in edema? | Severe; deep pitting 8mm, last as long as 2 to 5 minutes
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| Compression from external devices may occur; when performing neurovascular assessment, what is important to remember? | Pulselessness, Paresthesia, Paralysis, Polar temperature, Pallor, Puffiness (edema), Pain
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| Arteries | Blood vessels that carry blood away from the heart
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| Veins | Blood vessels that return blood to the heart
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| Capillaries | Microscopic vessels that link arterioles to venules; site where nutrients, waste, and hormones are exchanged blood & tissue
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| What is the function of the capillaries? | To release chemicals, including O2, glucose, hormones, and nutrients that will be used by the surrounding tissues
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| Venipuncture | Most common method, involves inserting a hollow-bore needle into the lumen of a large vein to obtain a specimen
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| 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
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| 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
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| The nurse should never ___________ needles and must always discard them in ______________________ close to the patient. | Recap / puncture resistant container
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| When are blood samples drawn? | When there are symptoms of fever & chills that often accompany bacterium are present
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| Where are the specimens are drawn from? | Two different sites
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| How is the diagnosis confirmed? | When both cultures grow an infecting agent
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| Can you draw from an IV? | No, unless sepsis in the catheter is suspected
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| What should be held until cultures are drawn? | Antibiotic therapy
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| When it comes to safety, what position must you never draw blood from? | Standing
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| 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
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| How long can a tourniquet stay in place? | 1 to 2 minutes
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| 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
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| What do you label collections tubes with & when? | Patients identifying information, before being sent to the lab
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| To prevent hemolysis, how do you rotate tubes when additives are present? | Gently roll back and forth 8 to 10 times
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| What are the most common veins for venipuncture? | Cephalic vein, basilica vein, and median cubital vein
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