Unit test 4
About this set
Created by:
rseraphine on November 4, 2010
Subjects:
physical assessment, family, domestic violence (dv), documentation and reporting, home health, elimination
Classes:
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99 terms
Terms | Definitions |
|---|---|
 purpose of physical assessment | ID care needs Prioritize care Care plan Report |
| Bell of stethoscope | detects low-pitched sounds press lightly on skin picks up abnormal heart sounds |
| Diaphragm of stethoscope | detects high-pitched sounds press firmly on skin |
| Edema | excess interstitial fluid |
| normal heart sounds | S1 and S2 S1 "lub" is low pitched & dull S2 "dub" is higher pitched & shorter |
| Cardiac Rub | high-pitched "rub" pericardium is inflamed and rubbing against heart |
| S3 | abnormal extra heart sound normal in children heard in CHF galloping sound |
| S4 | abnormal heart sound always abnormal left side is weak HTN |
| Murmur | abnormal blood flow in heart valve doesn't close all the way |
| murmur sound | "lubshhh" "lubshhh" "shhhdub" "shhhdub" |
| pansystolic murmur | characterized by a swooshing sound abnormal blood flow in heart |
| murmur grade | 0-6 3 being moderately loud 4 being loud 6 don't need stethoscope |
| bruit | blowing or swishing sound can be auscultated in carotid turbulent blood flow due to arterial obstruction |
| thrill | vibrating sensation sounds like water running trough hose or cat purring could be palpated in carotid if bruit detected |
| JVD | If seen in pt: may indicate rt-sided heart failure or advanced cardiopulmonary disease Pt. is in fluid overload outline of vein or pulsation detected |
| normal bowel sounds | 5-15 seconds between each sound |
| pigeon chest | permanent deformity may be caused by rickets |
| funnel chest | congenital defect sternum is depressed and points posteriorly puts pressure on heart |
| barrel chest | seen in pts with emphysema broad deep chest |
| adventitious breath sounds | abnormal breath sounds (in general) narrowed airways airways filled with fluid or mucus pleural linings are inflamed |
| vesicular breath sounds | best heard at base of lungs and on inspiration soft-intensity, low-pitched, "gentle sighing" air moving through bronchioles and alveoli |
| broncho-vesicular breath sounds | best heard bw scapulae and lateral to sternum at 1st and 2nd ICS moderate-intensity and moderate-pitched "blowing" sounds air moving through bronchi |
| bronchial (tubular) breath sounds | best heard anteriorly over trachea have short inspiratory phase, longer expiratory phase high-pitched, loud, "harsh" sound air moving through trachea |
| crepitus | air trapped in SQ tissue possible trauma, incision, chest tube feels mooshy SQ emphysema |
| Rhonchi | gurgles secretions Dx ineffective airway clearance |
| Rales | Crackles fluid in alveoli Dx impaired gas exchange |
| friction rub | rubbing together of inflamed pleural spaces have pt hold breath to make sure it is not cardiac rub |
| wheeze | high pitched narrowing of bronchi and bronchus asthma, COPD best heard on expiration |
| family according Kozier | basic unit of society |
| family according to Neuman | primary system responsible for the transmission of social values, psychological growth, and spiritual strength |
| nuclear family | family structure of parents and their offspring |
| extended family | relatives of nuclear family; grandparents or aunts and uncles |
| traditional family | autonomous unit with both parents in home with children mother- nurturer father- bread winner |
| two-career family | both partners employed may or may not have children |
| systems theory | any change in one part of the system requires a change in the other parts each family member plays a part input-throughput-output food-digestion-energy |
| Approaches to understanding family | Systems theory Structural-functional theory Developmental Communication Role theory Family strengths |
| Diagnosis Related Groups | establish specific time lines and costs for ea. medical Dx established to curb the increasing cost of health care |
| anuria | lack of urine production < 100 mL/day |
| dysuria | painful or difficult voiding |
| frequency | voiding at frequent intervals > 4-6 x/day |
| nocturia | voiding 2 or more x/night |
| polyuria | diuresis production of abnormally large amount of urine by kidneys |
| oliguria | low urine output usually < 500 mL/day |
| urgency | sudden or strong desire to void |
| urinary incontinence | involuntary urination |
| urinary retention | bladder over distended with urine and inability of bladder to empty itself |
| impaired urinary elimination | dysfunction in urine elimination |
| functional urinary incontinence | inability of usually continent person to reach toilet in time to avoid unintentional loss of urine |
| overflow urinary incontinence | involuntary loss of urine associated with over distention of the bladder |
| reflex urinary incontinence | involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached |
| stress incontinence | sudden leakage of urine with activities that increase intra-abdominal pressure |
| total urinary incontinence | continuous and unpredictable loss of urine |
| urge urinary incontinence | involuntary passage of urine occurring soon after a strong sense of urgency to void |
| intragenerational family | more than 2 generations living together |
| bladder training | client postpones voiding, resists or inhibits the sensation of urgency, and voids according to a timetable rather than according to the urge to void |
| blood urea nitrogen (BUN) | a measure of blood level of urea, the end product of protein metabolism |
| creatinine clearance | a test that uses 24-hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function |
| Crede's maneuver | manual exertion of pressure on the bladder to force urine out |
| detrusor muscle | smooth muscle layers of the bladder |
| diuretics | agents that increase urine secretion |
| enuresis | bedwetting |
| meatus | an opening, passage or channel |
| micturition | process of emptying the bladder |
| neurogenic bladder | result of impaired neurologic function; clt does not perceive bladder fullness and is unable to control urinary sphincters |
| nocturnal frequency | the need for older adults to arise during the night to urinate |
| polydipsia | excessive thirst |
| prompted voiding | supplements habit training by encouraging clt to try to use toilet and reminding them when to void |
| reflux | an automatic response of the body to a stimulus |
| residual urine | the amount of urine remaining in the bladder after a person voids |
| suprapubic catheter | catheter inserted through the abdominal wall above the symphysis pubis into the urinary bladder |
| urinary hesitancy | a delay and difficulty in initiating voiding; often associated with dysuria |
| return flow enema | enema to facilitate expulsion of flatus |
| cleansing enema | enema to prepare intestine for some diagnostic tests and surgeries |
| oil retention enema | enema that lubricates rectum and anal canal to facilitate stool passage |
| left lateral Sims | position with low cleansing enema |
| low volume cleansing enema | draws fluid into the colon by osmosis and stimulates peristalsis |
| nursing Dxs for clt with diarrhea | risk for impaired skin integrity acute pain risk for fluid volume deficit |
| amount of fluid an individual needs/day | 2000 - 3000 mL |
| amount of fiber an individual needs/day | 20 - 35 grams |
| degrees of reaction for "fecal impaction" | no BM for several days loss of appetite nausea abdominal distention small amt of loose stool |
| hemoccult test | determines if there are any microscopic amts of blood in stool |
| upper gastrointestinal bleeding | Bleeding of the upper digestive structures , sometimes evidenced by blood in the vomit and/or black or tarry stools |
| large intestine | 50 to 60 inches long, includes the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum and anus |
| fxn of colon | absorption of water & nutrients, mucoid protection of intestinal wall and fecal elimination |
| constipation | decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard stool |
| source-oriented record | Record in which each person or department makes notations in a separate section of pt's chart |
| narrative charting | Record of client data and nursing interventions, written in sentences and paragraphs. consists of written notes that include routine care, normal findings, and pt problems. |
| problem-oriented medical record (POMR) or problem-oriented record (POR) | Record that includes data arranged according to the problems the pt has. members of health care team contribute to the problem list. main components: database, problem list, plan of care, progress notes |
| charting by exception (CBE) | Record in which only significant findings or exceptions to norms are recorded |
| focus charting | a method of charting that uses key words to describe what is happening to the client |
| critical pathways | forms that identify the outcomes that certain groups of clients are expected to achieve on each day of care. also includes the interventions for each day. |
| variance | goal that is not met. unexpected occurrences that affect the planned care or the client's responses to care. works best for clients with one or two Dx |
| case management model | emphasizes quality, cost-effective care given within an established length of stay. promotes collaboration and teamwork among caregivers. |
| kardex | concise method of organizing and recording data. quick guide to keep info current. includes specific data such as: name, room number, allergies, IV fluids, meds, etc... |
| graphic record | record that includes T,P,R,BP and weight, height |
| intake and output record | record that includes all routes of fluid intake and all routes of fluid loss |
| medication administration record (MAR) | record that includes date of med order, exp date, med name, dose, frequency and route, and nurse's signature. |
| skin assessment record | record that includes stage of skin injury, drainage, odor, culture information and treatment |
| flow sheets | quick and concise method of recording info. graphic record I&O record MAR skin assessment record |
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