Nursing Assessment Exam 1 with Technology and assessments

Terms in this set (77)

drooping of the upper eyelid, resulting from muscle weakness or an inability to move muscles

shortness of sight a common condition in which light entering the eye is focused in front of the retina and distant objects cannot be seen sharply. In high myopia the eyeball is unusually long, whereas in physiological myopia the eyeball length is normal but the power of the cornea is too great for the axial length.

an involuntary rhythmic movement of the eyes, usually from side to side, caused by some illnesses that affect the nerves and muscle behind the eyeball

used to assess disorders, complaints, and injuries of the eyes

an instrument incorporating a light and a magnifying lens, used to examine the external canal of the ear and the eardrum

measures the pressure inside the middle ear.

Cranial nerves III oculomotor, IV trochlear, VI abducens are involved in

moving the eye in all six cardinal fields of vision.

peripheral vascular disease (PVD)is

. affects the peripheral circulation. PVD comprises diseases of both peripheral arteries and peripheral veins, varicose veins and spider veins are examples

occupational therapist provides interventions that help

the client learn to eat and drink

speech therapist provides interventions that help

the client learn to swallow food and liquids safely

physical therapist provides interventions that improve

muscle strength and coordination

Polyneuropathies occur bilaterally in the extremities most commonly as a complication of

a chronic illness. Decreased sensation and reflexes bilaterally in the lower extremities support the diagnosis

Paresthesia is a

numbness, tingling, or prickling sensation. Some clients also describe it as feeling like pins and needles. The condition can result from diabetes, in which nerve or blood vessel damage occurs because of high blood sugar levels

Dendrites deliver data

Axons deliver data

away from the neuron

PNS Sensory afferent

: Sends information from the sensory receptors (e.g., in skin, eyes, nose, tongue, ears) toward the central nervous system

PNS Motor efferent

: Sends information away from the central nervous system to muscles or glands.

Polyneuropathies:

is damage to multiple nerves. Most common form seen in conjunction with diabetes mellitus. Symptoms begin bilaterally in the toes and progressively work upward.

Mononeuropathies:

Isolated neuropathy that is found in a single nerve. Usually results from trauma or overuse such as carpal tunnel syndrome.

Peripheral neuropathies consist of:

Polyneuropathies and Mononeuropathies

Autoimmune responses such as Guillain-Barré syndrome (GBS)is an acute

inflammatory demyelinating disorder of the PNS characterized by an acute onset of motor paralysis that's usually ascending

inherited peripheral neuropathy may include Charcot-Marie-Tooth disease

which results from flaws in genes responsible for manufacturing the myelin sheath, or protective insulation of the nerve.

polyneuropathy symptoms include

Aching, burning, or shooting pain, Distal paresthesias , Cold feet, Impaired sensations of temperature, two-point touch, vibrations, and pain, Weakness in legs or arms that can make it difficult to walk or run or cause stumbling, Tiring easily, Clumsiness or lack of coordination.

Distal paresthesias is a

subjective feeling of a change in sensation, such as numbness or tingling

. Decreased muscle tone and strength that results in floppiness.

Common diagnostic testing for peripheral neuropathy may include:

Electromyography (EMG), Nerve biopsy, Testing for Lyme disease, Testing for HIV, Serum laboratory testing, Complete blood count (CBC), Thyroid function tests, Serum levels for B12 and thiamin, Metabolic panel.

Anticonvulsants secondary use is

to treat nerve pain.

Antidepressants such as Elavil a tricyclic antidepressant and Cymbalta a serotonin-norepinephrine reuptake inhibitor are used to block

the depletion of serotonin and norepinephrine in the CNS.

Romberg test is a motor function test that assesses coordination and equilibrium and would not be included when

assessing sensory perception.

Vygotsky saw cognitive development as

a socially mediated process.

Piaget's theory posits

structured stages of development.

Information processing theory sees the

mind as a computational system that is always evolving

Aricept / donepezil is a reversible inhibitor of the enzyme acetylcholinesterase and is used to slow

the cognitive decline of Alzheimer disease.

Haldol / haloperidol is an

Buspar /buspirone is an

antianxiety agent.

Zoloft / sertraline is an

antidepressant.

obsessive lint-picking

difficulty naming things and people

difficulty swallowing

Carphologia , akathisia , anomia , and dysphagia are

disturbances that may be part of dementia

Dyspnea definition

difficult or labored breathing

Orthopnea definition

is shortness of breath that occurs when lying flat, causing the person to have to sleep propped up in bed of sitting in a chair.

Tachypnea definition

abnormally rapid breathing

retractions definition

when the area between the ribs and in the neck sink in when a person is attempting to inhale but having a difficult time breathing.

Short tern and long term recall

controls the autonomic nervous system and the secretion of hormones by the pituitary gland. Through these nerve and hormone channels, the hypothalamus regulates many vital biological processes, including body temperature, blood pressure, thirst, hunger, and the sleep-wake cycle.

informatics, is

information that is created, stored, and accessed through technology.

clinical information system allows

multiple disciplines to simultaneously access the client's chart and record data that can be viewed by multiple healthcare providers in real time.

administrative information system include:

Human resources, Financial data, Materials management, Risk management, Quality performance

Electronic medical record (EMR) ,

which are similar to electronic charts, help track client data and identify when routine preventive health maintenance most EMRs are designed to stay within a clinical setting

Electronic health records (EHRs) offer

a broader view of the client's health, and are designed to allow simultaneous access by multidisciplinary care providers

Initial baseline assessment

information and problem identification are gathered soon after admission to a healthcare agency.

Problem-focused (or system-specific assessment

Performed as an ongoing process and integrated with nursing care to determine status of a specific problem identified earlier

Emergency assessment

Performed during physical or psychological crisis to identify life-threatening, new, or overlooked problems

Ongoing assessment

Comparison performed several months after initial assessment

Subjective data (also referred to as symptoms or covert data)

can only be described or verified by the client. Examples are sensations like itching; feelings; values; beliefs; attitudes; and perceptions.

Objective data (also called signs or overt data)

are detectable by an observer or can be measured or tested against an accepted standard. Objective data validates subjective data during the physical examination

is obtained directly from the client unless the client is too ill, young, or confused to communicate clearly.

(sometimes referred to as indirect data) is obtained from family members, other healthcare professionals, records & reports, laboratory and diagnostic analyses, and relevant literature.

principle methods used to collect data are

observing, interviewing, and examining.

Interview Times

Whenever possible, choose a time when the client is physically comfortable and free of pain, and when interruptions will be minimal.

Interview Place

A well-lighted, well-ventilated, quiet room where the conversation cannot be overheard will help facilitate client comfort and communication.

Interview Seating Arrangement

Comfortable seating for both the client and the nurse is helpful. In an office environment, placing two chairs at right angles and a few feet from each other will create a more welcoming atmosphere than if the nurse sits across a desk or a table from the client. In a hospital setting, the nurse should be seated at a 45-degree angle to the client's bed

Distance during an interview

Proxemics is the study of use of space. A distance of 2-3 feet apart during an interview is typical in Western cultures. This may need to be adjusted depending on the client's culture and personal needs.

Neutral Questions are

Open-ended questions that are used in nondirective interviews. These can be answered without direction or pressure from the nurse ("How" or "why" types of questions).

A complete physical examination starts at the

head and proceeds in a systematic manner downward (head-to-toe) or by systems (neurological system, etc.) and

complete physical examination must be adapted to:

Client age, Severity of illness, Nurse preferences, Environment, Agency policies and procedures.

Initial physical assessment:

When the client is admitted to the healthcare agency,

System-specific physical assessment(e.g. cardiovascular system)

Focused examination of a body area (e.g. the lungs when difficulty breathing is observed)

Focused physical examination of a body area

such as the lungs

Dorsal Recumbent

Back-lying with knees flexed and hips externally rotated, small pillow under the head, and soles of feet on the surface . Female genitals, reproductive tract and rectum . May be contraindicated in clients with alterations in cardiopulmonary status

Back-lying with legs extended, with or without pillow under the head . Head, neck, axillae, anterior thorax, lungs, breasts, heart, vital signs, upper and lower extremities, reflexes . Not easily tolerated by clients with cardiovascular and respiratory alterations

Seated with back unsupported and legs hanging freely . Head, neck, posterior and anterior thorax, lungs, breasts, axillae, heart, vital signs, upper and lower extremities, reflexes . Older or weaker clients may require support.

Back-lying with feet supported in stirrups, hips in line with the edge of the table. Female genitals and reproductive tract, rectum . Older adults may find this uncomfortable; most clients find this embarrassing.

Side-lying with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow. Vagina, rectum . Older adults and clients with limited joint movement may find this difficult.

Lying on abdomen with head turned to the side, with or without small pillow. Posterior thorax, hip joint movement. Older adults and people with cardiovascular and respiratory problems may not be able to tolerate this position.

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