skills II exam (1)

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Affect

An emotional response

body system

collecting data according to the functional systems of the body is called?

Data collection

A method for gathering health data in a systematic order

inspection, palpitation, ausculation, percussion

The four data collection techniques are what?

Data collection

To evaluate the client's current condition, to detect early signs of developing health problems, establishing a baseline and to evaluate client's response to interventions are the purposes of what?

head to toe assessment

Gathering data from the top of the head to the bottom of the feet is called?

down & back

to check the ears of a child you pull the ears how?

up and back

To check the ears of an adult, you pull the ears how?

inspection, auscultation, palpitation & percussion

to collect data on bowels sounds you do what 4 things?

5 minutes

How long do you need to listen to the bowel sounds before declaring them absent?

scoliosis, lordosis, kyphosis

What are the three curvatures of the spine?

Scoliosis

A pronounced lateral curvature of the spine (S - shape)

Kyphosis

An increased thoracic curve (hunchback)

Lordosis

An exagerated natural lumbar curve of the spine (swayback)

head to toe & body system

What are two types of data collection?

cerumen

What is normal ear drainage?

PERRLA

Pupils Equal, Round & Reactive to Light Accomodation

privacy

what is the most important thing to consider during data collection?

<3 seconds

What is the normal capillary refill time?

Chest

where do you assess for dehydration on an elderly patient?

Macule

these are flat, round, colored, nonpalpable areas. AKA freckles

Papule

This is elevated, palpable & solid. AKA Wart

Vesicle

this is elevated, round & filled with serum. AKA blister

Wheal

These are elevated, have irregular borders and no free fluid. AKA hives

Pustule

this is elevated, raised border, filled with pus. AKA boil

Nodule

This is an elevated, solid mass, deeper and firmer than papule. AKA enlarged lymph node

Cyst

This is an encapsulated, round fluid-filled or solid mass beneath the skin. AKA tissue growth

RLQ, RUQ, LUQ, LLQ

Order of assessing ab sounds -- 1+, 2+, 3+, 4+

Consensual response

this is a brisk, equal & simultaneous constriction of both pupils when one eye then the other is stimulated with light

extraocular movements

these are eye movements controlled by several pairs of eye muscles. during the assessment, both eyes should move in a coordinated manner. No movement in one may indicate neurologic pathology.

Tracheal sounds

These normal lung sounds are loud & coarse. They are equal in length during inspiration & expiration and are separated by a brief pause

Bronchial sounds

These normal lung sounds are heard over the upper sternum & between the scapulae, are harsh & loud. they are shorter on inspiration than expiration with a pause between them

Bronchovesicular sounds

These sounds are heard on either side of the central chest or back. These medium-range sounds of equal length during inspiration & expiration have no noticeable pause

Vesicular sounds

these sounds are located in the periphery of all the lung fields. Their soft, rustling quality is longer on inspiration than expiration, with no pause between

Adventitious sounds

Abnormal lung sounds are called what?

Crackles

AKA rales. High pitched popping sounds heard in distant areas of the lungs. Sound like Rice Crispies!

Wheezes

Whistling or squeaking sounds, like air moving thru a small opening. If this sound suddenly stops, it may mean the air passage is totally occluded.

Gurgles

AKA rhonchi, low pitched, bubbling heard in larger airways. more prominent during expiration. sounds like wet snoring. May clear with deep breathing or coughing.

rubs

these sounds are grating, leathery sounds caused by two dry pleural surfaces moving over each other.

raised sputum

Whenever adventitious sounds are heard, the nurse also assesses the characteristics of any cough and the appearance of ______ _______.

PERRLA

Abreviation for normal eye and pupil movement is?

1+ Pitting edema

type of edema, slight indentation (2mm), normal contours, associated with interstitial fluid volume 30% above normal is referred to as?

2+ Pitting Edema

type of edema, deeper pit after pressing (4mm), lasts longer with fairly normal contour is referred to as?

3+ Pitting edema

type of edema, deep pit (6mm), remains several seconds after pressing, skin swelling obvious by general inspection, is referred to as?

4+ pitting edema

type of edema, deep pit (8mm), remains for a prolonged time after pressing, possibly minutes, frank swelling, is referred to as?

5+ Brawny edema

type of edema, fluid can no longer be displaced secondary to excessive interstitial fluid accumulation. No pitting, tissue palpates as firm or hard. Skin surface shiny, warm & moist; is referred to as?

inspect

purposeful observation (look)

Percussion

striking or tapping on the body to produce vibratory sounds, TO DETERMINE SIZE AND LOCATION OF UNDERLYING STRUCTURES

Palpate

Lightly touching or applying pressure to the body. USED FOR FEELING SURFACE OF THE SKIN, STRUCTURES THAT LIE JUST BENEATH THE SKIN

Auscultation

Listening to body sounds

1" or 2.5cm

When doing a deep palpitation you should press how deep?

Deep Palpation

This is performed by depressing tissue approximately 1" (2.5cm) with the forefinger of one or both hands, to determine size, shape,consistency and mobility of normal & UNUSUAL masses, SYMMETRY or ASYMMETRY of thyroid gland, skin temp & moisture, TENDERNESS & UNUSUAL vibrations

Wound

This is a break in the skin

Ulcer

this is an open crater-like area

Abrasion

this is an area that has been rubbed away by friction

Laceration

This is a torn, jagged wound

Fissure

this is a crack in the skin, especially in or near mucous membranes

Scar

This is a mark left by healing of a wound or lesion

Pallor

Skin color: pale, regardless of race

Flush

skin color: Pink; from fever and or hypertension

Ecchymosis

Skin color: Purple; from trauma to soft tissue

Cyanosis

Skin color: Blue; from low tissue oxygenation

Jaundice

Skin color: Yellow; from liver or kidney disease, destruction of red blood cells

turgor

Resiliency of the skin (hydration). A combination of elastic quality of the skin & pressure exerted on it by fluid within. Older adult: chest. Younger: arm

Tenting

This is produced when nurse releases tissue and it does not go back to normal quickly, it indicates dehydration.

S3

this heart sound is normal in children but abnormal in adults

Once a month

Self-examination of breast, > 20 years, should be done how often?

Edema

this is excessive fluid within tissue and signifies abnormal fluid distribution. Clients with cardiovascular, liver & kidney disfuction are prone to this. Signs include, weight gain, tight rings, patterns in skin after removing socks or shoes

Skin Perception

You use a cotton ball, safety pin, warm water, ice water & tuning fork to test:

5-34

How many times a minute do normal bowel sounds (resembling clicks or gurgles) occur

bowel sounds

HYPERACTIVE (if frequent), HYPOACTIVE (occur after long intervals of silence) and ABSENT (if no sound for 2-5 minutes) are used to describe what?

External Hemorrhoids

Saccular protrusions filled with the blood, at the anus

mobility, shape, consistency, size, tenderness

Characteristics of palpated masses are:

Fixed

does not move when palpated

Mobile

Can be moved with palpation

round

Resembles a ball when palpated

Tubular

is elongated and felt when palpated

Ovoid

Remembles an egg when palpated

Irregular

has no definite shape when palpated

Edematous

Leaves indentation when palpated

Nodular

Feels bumpy to touch when palpated

Granular

Feels gritty to touch when palpated

Spongy

Feels soft to touch when palpated

Hard

Feels firm to touch when palpated

Tenderness

Amount of discomfort when palpated - none, slight, moderate or severe

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