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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
to the neuron
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.
is damage to multiple nerves. Most common form seen in conjunction with diabetes mellitus. Symptoms begin bilaterally in the toes and progressively work upward.
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
Zoloft / sertraline is an
difficulty naming things and people
Carphologia , akathisia , anomia , and dysphagia are
disturbances that may be part of dementia
difficult or labored breathing
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.
abnormally rapid breathing
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.
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
Performed during physical or psychological crisis to identify life-threatening, new, or overlooked problems
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.
Whenever possible, choose a time when the client is physically comfortable and free of pain, and when interruptions will be minimal.
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
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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