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85 terms

skills II exam (1)

STUDY
PLAY
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