lOMoARcPSD|52939654
Fundamentals EXAM 2 review
Fundamentals of Nursing (Galen College of Nursing)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Downloaded by Maria Rivera ()
, lOMoARcPSD|52939654
EXAM 2-REVIEW
CHAPTER 22: Assessing Health Status
1. Assessment-always done first at the beginning of the shift
detailed data collection-history, current problems, ADL's, psychosocial/ cultural, physical
assessment, height/ weight/ VS
subjective data-symptom i.e. pain, from pt. POV
objective data-sign i.e. B/P, can be measured
2. Physical assessment
Comprehensive -complete on admission/detailed
Focused-specific i.e. abdominal problems
Patient is the primary source of information
INSPECTION
Observation-look without touching(appearance, behavior, contours of the body,
characteristics of movements, respirations.
SKIN
Macule- Circumscribed, flat area, change in skin color, < 0.5cm, if larger it is a
patch( freckles, petechiae, flat moles, vitiligo )
Papule-Elevated, solid lesion, < 0.5 cm, if larger it is a nodule(wart, elevated mole,
lipoma, basal cell carcinoma)
Vesicle-Circumscribed, superficial collection of serous fluid, <0.5cm (varicella/chicken
pops , herpes zoster/shingles, second-degree burn
Plaque-circumscribed, elevated, superficial, solid lesions, >0.5cm (psoriasis)
Wheal-Firm, Edematous, irregularly shaped area, diameter varies( insect bite,
urticaria/hives)
Pustule-elevated, superficial lesion filled with purulent fluid (acne, impetigo)
PERRLA-pupils
equal
round
reactive to
light
accommodating
Consensual reflex-when the pupils react the same, R constricts = L constricts
Downloaded by Maria Rivera ()
Fundamentals EXAM 2 review
Fundamentals of Nursing (Galen College of Nursing)
Scan to open on Studocu
Studocu is not sponsored or endorsed by any college or university
Downloaded by Maria Rivera ()
, lOMoARcPSD|52939654
EXAM 2-REVIEW
CHAPTER 22: Assessing Health Status
1. Assessment-always done first at the beginning of the shift
detailed data collection-history, current problems, ADL's, psychosocial/ cultural, physical
assessment, height/ weight/ VS
subjective data-symptom i.e. pain, from pt. POV
objective data-sign i.e. B/P, can be measured
2. Physical assessment
Comprehensive -complete on admission/detailed
Focused-specific i.e. abdominal problems
Patient is the primary source of information
INSPECTION
Observation-look without touching(appearance, behavior, contours of the body,
characteristics of movements, respirations.
SKIN
Macule- Circumscribed, flat area, change in skin color, < 0.5cm, if larger it is a
patch( freckles, petechiae, flat moles, vitiligo )
Papule-Elevated, solid lesion, < 0.5 cm, if larger it is a nodule(wart, elevated mole,
lipoma, basal cell carcinoma)
Vesicle-Circumscribed, superficial collection of serous fluid, <0.5cm (varicella/chicken
pops , herpes zoster/shingles, second-degree burn
Plaque-circumscribed, elevated, superficial, solid lesions, >0.5cm (psoriasis)
Wheal-Firm, Edematous, irregularly shaped area, diameter varies( insect bite,
urticaria/hives)
Pustule-elevated, superficial lesion filled with purulent fluid (acne, impetigo)
PERRLA-pupils
equal
round
reactive to
light
accommodating
Consensual reflex-when the pupils react the same, R constricts = L constricts
Downloaded by Maria Rivera ()
