NURS 1110 FINAL PT. 2 – Questions With Expert
Solutions
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Terms in this set (570)
subjective data (symptoms) what the pt says; health history
objective data (signs) what you asses; physical assessment and diagnostic
tests
clinical manifestations signs and symptoms
health history -provides subjective data about the health status
-includes past health history, surgeries, medications,
childhood illnesses, family history, psychosocial
history
physical examination -objective data
-gather baseline data about a patient's health status
-supplement, confirm or refute subjective data
health assessment assessment of the physical, mental, spiritual,
socioeconomic and cultural status of an individual
nursing assessment focuses on the client's (pts) functional abilities and
physical responses to illness and stressors
-comprehensive physical what are the types of physical examinations?
examination/assessment
-focused physical assessment
-system-specific assessment
-on going assessment
,-develop a systematic approach and what is the organization of physical assessments?
follow same order each time
-head to toe approach
starts at head and progresses down
the body, feet last
compare sides for symmetry
perform painful procedures LAST
be specifc when documenting
assessments, do not use vague terms
-prepare yourself, the environments,
and pt before you begin
-inspection what are the techniques for physcial exam?
-palpation
-percussion
-auscultation
perform in this order!
inspection -use of sight to gather data
-begins the moment you meet the patient
-look at each area for size, shape, color, symmetry,
position, abnormality
palpation -use of touch to gather data
-used to assess: temp, skin texture, moisture,
anatomical landmarks, edema, masses, tenderness
percussion -tapping your fingers on skin
-tapping produces vibrations that allow you to
determine location, size, density of underlying
structures
-useful for abd and lungs
auscultation -use of hearing to gather data
-direct: listening without equipment
-indirect: listening with help of stethoscope
olfaction use of smell to gather data
,-infants: parents hold what are the age modifications for physical
-toddler: give choices, praise assessment?
-preschoolers: use doll as
demonstration, allow to help
-school age children: allow
independence; teach
-adolescents: privacy;
depresion/suicide risk
-older adults: allow extra time;
provide rest periods if needed, limit
position changes
S: sleep disorders what are common problems with elderly pts?
P: problems with eating or feeding
I: incontinence
C: confusion
E: evidence of falls
S: skin breakdown
general survery -overall impression of a pt
-begins at FIRST contact
-ID signs of distress what are the components of the general survey?
-observe age, gender, race
-assess facial characteristics
-note body position
-observe gait and body type
-listen to client's speech
-assess mental state and affect
-observe hygiene
-measure vital signs
-Ht and Wt
-temp: 97.3-98.6 F oral what are the expected findings regarding VS?
-BP: <120/<80 mm Hg
-pulse: 60-100 bpm, regular 2+
-pulse oximeter: 95-100%
-pain 0 on 0-10 scale
, -inspect skin color, lesions, how to perform skin assessment?
abnormalities, odor
-palpate temp, moisture, skin turgor,
edema, masses
-pink, warm, dry intact what are expected skin assessment findings?
-mucous membranes pink, moist,
intact
-conjunctiva pink, moist
-skin turgor non-tenting
-no lesions or masses
pallor paleness
cyanosis blue-gray color; ashen
jaundice yellow skin color
flushing diffuse redness
erythema reddened area
ecchymosis bruise
petechiae pinpoint red dots (hemorrhages)
mottling bluish marbling
skin turgor -elasticity of the skin
-provides data about hydration status
-expected finding: skin returns when released from
gentle pinch
edema -abnormal finding
-tight skin
-presence of fluid in tissue
-may be discolored, tender
Solutions
Save
Terms in this set (570)
subjective data (symptoms) what the pt says; health history
objective data (signs) what you asses; physical assessment and diagnostic
tests
clinical manifestations signs and symptoms
health history -provides subjective data about the health status
-includes past health history, surgeries, medications,
childhood illnesses, family history, psychosocial
history
physical examination -objective data
-gather baseline data about a patient's health status
-supplement, confirm or refute subjective data
health assessment assessment of the physical, mental, spiritual,
socioeconomic and cultural status of an individual
nursing assessment focuses on the client's (pts) functional abilities and
physical responses to illness and stressors
-comprehensive physical what are the types of physical examinations?
examination/assessment
-focused physical assessment
-system-specific assessment
-on going assessment
,-develop a systematic approach and what is the organization of physical assessments?
follow same order each time
-head to toe approach
starts at head and progresses down
the body, feet last
compare sides for symmetry
perform painful procedures LAST
be specifc when documenting
assessments, do not use vague terms
-prepare yourself, the environments,
and pt before you begin
-inspection what are the techniques for physcial exam?
-palpation
-percussion
-auscultation
perform in this order!
inspection -use of sight to gather data
-begins the moment you meet the patient
-look at each area for size, shape, color, symmetry,
position, abnormality
palpation -use of touch to gather data
-used to assess: temp, skin texture, moisture,
anatomical landmarks, edema, masses, tenderness
percussion -tapping your fingers on skin
-tapping produces vibrations that allow you to
determine location, size, density of underlying
structures
-useful for abd and lungs
auscultation -use of hearing to gather data
-direct: listening without equipment
-indirect: listening with help of stethoscope
olfaction use of smell to gather data
,-infants: parents hold what are the age modifications for physical
-toddler: give choices, praise assessment?
-preschoolers: use doll as
demonstration, allow to help
-school age children: allow
independence; teach
-adolescents: privacy;
depresion/suicide risk
-older adults: allow extra time;
provide rest periods if needed, limit
position changes
S: sleep disorders what are common problems with elderly pts?
P: problems with eating or feeding
I: incontinence
C: confusion
E: evidence of falls
S: skin breakdown
general survery -overall impression of a pt
-begins at FIRST contact
-ID signs of distress what are the components of the general survey?
-observe age, gender, race
-assess facial characteristics
-note body position
-observe gait and body type
-listen to client's speech
-assess mental state and affect
-observe hygiene
-measure vital signs
-Ht and Wt
-temp: 97.3-98.6 F oral what are the expected findings regarding VS?
-BP: <120/<80 mm Hg
-pulse: 60-100 bpm, regular 2+
-pulse oximeter: 95-100%
-pain 0 on 0-10 scale
, -inspect skin color, lesions, how to perform skin assessment?
abnormalities, odor
-palpate temp, moisture, skin turgor,
edema, masses
-pink, warm, dry intact what are expected skin assessment findings?
-mucous membranes pink, moist,
intact
-conjunctiva pink, moist
-skin turgor non-tenting
-no lesions or masses
pallor paleness
cyanosis blue-gray color; ashen
jaundice yellow skin color
flushing diffuse redness
erythema reddened area
ecchymosis bruise
petechiae pinpoint red dots (hemorrhages)
mottling bluish marbling
skin turgor -elasticity of the skin
-provides data about hydration status
-expected finding: skin returns when released from
gentle pinch
edema -abnormal finding
-tight skin
-presence of fluid in tissue
-may be discolored, tender
