Studied by 1 personWhat side do you listen to a bruit with your stethoscope?
bell
what does aerobic exercise benefit
cardiac
Complications of immobility?
osteoporosis, DVT
rule of nurses with holisitic care
mind, body, spirit
ebp
outlines the process of nursing
what do we use to use evidence based skills?
clinical expertise, patients values, patients preferences, research based articles, subjective objective data
what is masslows hierarchy of needs
meeting patient where they are based off of needs
masslows hirearchy of needs
physiological, safety, love/belonging, esteem, self-actualization
what is I's and O's
hydration status
primary prevention
immunizations
secondary preventions
blood pressure, screening
2 ways of communication
verbal and nonverbal
verbal communication
spoken or written words
nonverbal communication
five senses and everything that does not involve spoken or written word
how to deliver cultural competent care
based off how to patient wants to be treated if safe
client confidentiality
only people who are involved in direct care
what should we use when charting about a patient?
initials
what do we do with charts/ computers when we walk away?
close/ log out
subjective data
patient tells you
objective data
observe
negligence
falls below standard of care
first priority with patients
safety
what do we worry about with hygiene?
skin integrity
Assessment order
inspection, aussultaion, percussion, palpation
where does sound travel better?
in solids
how do we do palpation?
light to deep
normal percussion over lungs?
residence
bronchial vesicular
in the middle of the chest anterior
largest part of lung
vesicular
crepitis
crackling air under skin
tactile fermitis
palpable vibration of the chest wall that results from the transmission of sound vibrations through the lung tissue to the chest wall
what are adventitious sounds
abnormal sounds
most common adventitious sounds
strider, wheezing
what does wheezing sound like?
high pitched whistle sound
what does strider sound like?
snoring sound
most common O2 delivery
nasal canula
Diaphoretic breathing
breathing deep into the stomach and fully engaging the diaphragm
tripod
hands on knees to breathe
what does standing straight do to the lungs
compress the lungs
active vs passive ROM
active is doing it themselves. passive is you helping
allens test
tests arterial blood flow in hand. hold wrist for a second and watch
rhomberg test
balence test cerebellar function
how to access bowel habits
how often, consistency
where to listen to bowel sounds?
right lower quadrent
signs of hydration?
skin turger doesnt tent
signs of dehydration
skin truger tents, dizziness, headaches dryness
urniary retention
inability to empty the bladder
pulses
radial, brachial, carotid, popliteal, dorsalis pedis
cranial nerves
olfactory, optic, oculomotor, abducens, trigeminal, facial, acoustic, glossopharyngeal, vagus, spinal accessory, hypoglossal
how to grade reflexes?
0-4, 2+ is normal
mucous membranes
pink
tongue
ventral is rough, dorsal is smooth
vision chart 20/40
they can see at 20 feet when normal can see at 40
corneal light reflex
should appear symmetric and center
RUQ
liver, gallbladder, duedenum, head of pancreas, right kidney & adrenal, part of ascending & transverse colon
RLQ
Cecum, appendix, right ovary, right ureter, right spermatic cord
LUQ
Stomach, spleen, left lobe of liver, body of pancreas, left kidney & adrenal, part of transverse & descending colon
LLQ
part of descending colon, sigmoid colon, left ovary, left ureter, left spermatic cord
typany
hollow, high, drum like sounds, excessive air in chest
over liver and spleen sounds like?
dull
how often should they do breast exams
once a months
occult blood
not visible
head control in babys
by 6 months
roaches 6 C's
compassion, competence, confidence, conscience, commitment, and comportment
what are you looking for in inspection
any visible abnormalities
what is the technique for auscultation
light to deep
what is the normal pattern for listening for ausultation
counter clockwise
what can a skin assessment indicate
skin abnormalities
what is the anatomy of the lungs, shape, configuration of chest
apex at top, base at bottom, left is bigger
what are normal percussion sounds
Resonant sounds are low pitched, hollow sounds
bronchial
expiratory sounds last longer than inspiratory ones
bronchovesicular
inspiratory and expiratory sounds are about equal
vesicular
inspiratory sounds last longer than expiratory sounds
where is the apical impulse the loudest
apex of heart
where does blood flow start and end
right atrium , right ventricle, pulmonary arteries in the lungs, back to the heart through the pulmonary veins, left atrium, left ventricle and the aorta
what does it mean when peripheral pulses are weak
blood flow is reduced to vital organs
if the peripheral pulse is weak what do we check next
apical pulse
what exercise is helpful for cardiovascular system
aerobic exercise
passive ROM technique
2 times a day and 2-5 times each exercise
flexion
flex in
abduction
arms up
adduction
arms in
inversion
turn foot in
supination
hand palm up
circumduction
turn in circle
protraction
shoulders forward
how long for bowel sounds
2 minutes if normal
what is urinary retention
how much urine is left in the bladder after the bladder is emptied spontaneously
how is cerebellar functioning tested
assessment of gait and balance, the finger-to-nose test, heel-to-shin test
what is the frontal lobe for
thinking, memory, behavior and movement
what is the parietal lobe for
language and touch
what is the occipital lobe for
sight
what is the temporal lobe for
hearing, learning and feelings
what is the grading scale for deep tendon reflexes
0-4, 2+ normal
what are mental exams used for
evaluate mental and memory status
how to examine a child ear
down and forward
how to examine ear of adult
up and back
where are lymph nodes accessible on the body
sides of face and neck
describe mucous membrane
moist inner lining of most organs
describe tongue
pink rough on top shiny on bottom
Note
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