203 Exam #1 Flashcards
What is the primary level of health prevention? Give an example
First round of defense against illness/disease w/ intention of promoting overall health & wellness
Ex. Immunizations, health and safety education
What is the secondary level of health prevention? Give an example
Early screening for disease while patient does not yet display symptoms
Ex. Cancer screening, pap smear, colonoscopy
What is the tertiary level of health prevention? Give an example
Restoration of health after disease/illness symptoms have presented
Ex. Physical therapy after surgery, rehab centers
What is the purpose of the nursing process?
Systemic problem solving to develop a plan of care
What are the five steps of the nursing process?
Assessment, diagnosis, planning/outcome, implementation, evaluation
What is the first step of the nursing process? What does this step entail?
Assessment: collect & analyze data
- involves physiological, psychological, psychosocial, economical, spiritual, and cultural practices & beliefs
What is the second step of the nursing process? What does this step entail?
Diagnosis: analyzing potential/confirmed health problems/needs of the patient using objective & subjective data
What is the third step of the nursing process? What does this step entail?
Planning /outcomes: working w the patient & health care team to determine now to meet both the short & long term goals/needs of the patient (care plan is made during this step)
This stage is time limited
What is the fourth step of the nursing process? What does this step entail?
Implementation (of intervention): medical team collectively acts upon care plan to meet patient goals/needs
This step is not time limited
What is the fifth step of the nursing process? What does this step entail?
Evaluation: ongoing assessment of whether patient’s short & long term goals are being met
Involves clinical judgement to determine if care plan is effective or should be re-evaluated
Which step of the nursing process is specifically time limited? Why?
What are the three primary cognitive skills required for nursing assessment?
Critical thinking
Clinical reasoning & judgement Intuitive thinking
Define the following cognitive skill: critical thinking
Active, purposeful, and organized cognitive process involving creativity, reflection, and problem solving skills
Define the following cognitive skill: clinical reasoning & judgement
Clinical reasoning: Uses patient history, physical signs, & symptoms to formulate a treatment plan
Clinical judgement: interpretation or conclusion about patient needs/concerns or the decision to take action or not
Define the following cognitive skill: intuitive thinking
“Gut feeling” that something is wrong (needs to be done by the nurse despite there potentially not being evidence supporting the concern
What are the four psychomotor skills required for physical assessment?
Inspection, percussion, auscultation, palpitation
Define the following psychomotor skill required for physical assessment: inspection
To look & assess physical aspects of the body
Define the following psychomotor skill required for physical assessment: percussion
Tapping on different areas of the body to assess underlying structures
Define the following psychomotor skill required for physical assessment: auscultation
Listening for sounds, usually done using stethoscope
Define the following psychomotor skill required for physical assessment: palpation
Using hands to assess the body- feel for texture, shape, consistency, pulses, and crepitus
What is the formulla used when converting from Fahrenheit to Celsius?
[(x-32)5] / 9
Subtract 32, multiply by 5, divide by 9
What is the formula used when converting from Celsius to Fahrenheit?
[(x*9)/5] +32
Multiply by 9, divide by 5, add 32
What is the range for “normal” oral and temperature?
97.5°F to 99.5°F
What is the range for “normal” temporal and rectal temperature?
98.7°F to 100.5°F
What is pyrexia?
A fever- at least 100°F
Define blood pressure
Force of circulating blood being exerted on the walls of the large arteries of systemic circulation being pumped out of the heart
Define systolic pressure
Pressure in the arteries as the heart contracts
Define diastolic pressure
Pressure in the arteries as the heart relaxes between beats
Define pulse pressure
Difference between systolic pressure & diastolic pressure
SP - DP = PP
Define mean arterial pressure and explain how it is found
Average blood pressure
MAP = DP + 1/3 (PP)
What are the four possible durations of pain?
Acute pain, chronic pain, intractable pain, intermittent pain
What is acute pain?
Short-term pain that comes on suddenly, does not last long
What is chronic pain?
Long-term pain that lasts a minimum of 6 months
What is intractable pain?
Constant pain
What is intermittent pain?
Pain that comes and goes
What are the eight of types pain?
Cutaneous pair, colicky pain, nociceptive pain, neuropathic pain, Phantom limb syndrome, Psychogenic pain
Radiating pain
Referred pain
What is cutaneous pain?
Originates from the skin & subcutaneous tissues
Sharp pair for a short duration (ex-skin laceration)
What is colicky pain?
Pain that in intensity from mild to severe- usually spasms in the intestines
What is nociceptive pain?
Damage or inflammation to the sensory nerves in soft tissue, may be described as dull, sharp, or achy pain
What are the two types of nociceptive pain?
Somatic pain & visceral pain
What is somatic pain?
Dull, achy, comes from muscles, joints, tissue (ex.arthritis)
What is visceral pain?
Muscle pain thoracic, pelvic, abdominal ex. Menstrual cramps
What is neuropathic pain?
Injury/damage to the nerves in the peripheral or central nervous system (sharps, stings, burns, could experience numbness & tingling)
What is phantom limb syndrome?
Poorly understood type of neuropathic pain that is felt in a body part that has been removed
What is psychogenic pain?
Has no organic or structural cause- described as mental and emotional pain (ex. Social isolation, divorce)
What is radiating pain?
Pain in one part of body moving to another part
What is radiating pain?
Pain felt in part of the body away from the injury site (patient is the best person to ask about their pain)
Which temperature taking technique is most effective for finding core temperature?
What does the OPQRST pain assessment tool stand for?
Onset
Provocation & palliates
Quality
Radiation & region
Severity
Timing & temporal
What does the OLDCARTS pain assessment tool stand for?
Onset
Location/radiation
Duration
Character
Aggravating or alleviating factors
Related symptoms
Treatment
Severity
What age group is the wong-baker face pain rating scale used for?
Three years old and over
What age group is the FLACC assessment scale used for?
Patients younger than 3 years old & patients w/ confusion/dementia
What are the normative characteristics of the following component of the general survey: physical
Overall appearance of health, age, personal hygiene, body structure
What are the normative characteristics of the following component of the general survey: mobility
Gait, posture, range of motion, signs of distress
What are the normative characteristics of the following component of the general survey: behavior
Appropriate, facial expression, mood, speech
What are the 9 main barriers to communication?
Leading the patient
Using medical jargon
Using cliches
Offering false assurance
Asking “why” questions
Changing the subject
Giving opinions
Stereotyping
Using patronizing language
What are the 7 main cultural considerations that may impact the interview?
Comfort level of patient
Physical closeness
Involving significant others
Being addressed by first name
Ask prior to touching
Allow open space for patient to share beliefs
Eye contact (or intentionally avoiding this)
What are the 3 phases of the interview?
Introduction
Working
Termination
Which of the 3 phases of patient interview consists the following:
Identify yourself
Explain your role
Identify patient
Establish trust & rapport
Explain purpose of what you’re doing
Tell patient you will be taking notes
Ask patient if they are comfortable w/ the situation
Introduction phase
Which of the 3 phases of patient interview consists the following:
Collect information
Ask both open-ended & close-ended questions
Observe non-verbal ques
Patient self- medical history
Identify patient problems, needs, & goals
Ask patient if they have questions for you
Working phase
Which of the 3 phases of patient interview consists the following:
Clarify patient’s report & observed findings
Validate patient’s feelings, needs, & concerns
Termination phase
What are the components of health history?
Medical history (past med. treatments, surgical history, immunization records)
Medication
Allergies
Family history
Domestic abuse
Functional assessment (dressing, bathing, eating)
Presenting symptoms
Military
What is a genogram?
Study of hereditary in the individual’s family
Usually focuses on the individual & their immediate family
Genograms are used to ID ______ and ______ ______ problems
genetic and familial health
What is neuropathic pain?
Injury/damage to the nerves in the peripheral or central nervous system ( stabbing, stinging, burning, may experience numbness or tingling)
What is psychogenic pain?
No organic or structural cause-described as mental & emotional pain (ex, social isolation, divorce)
What is phantom limb syndrome?
Poorly understood type of neuropathic pain felt in a body part that has been removed
What is radiating pain?
Pay that moves from one crew of the body to another
What is referred pain?
Pain felt in an area of the body away from the injury site (patient is best person to ask about pain being experienced)
What does the pain assessment pneumonic OLDCARTS stand for?
Onset
Location/radiation
Duration
Character
Aggravating or alleviating factor
Related symptoms
Treatment
Severity
What does the pain assessment pneumonic OPQRST stand for?
Onset
Provocation and palliates
Quality
Radiation and region
Severity
Timing or temporal
McGill pain questionnaire
What does the FLACC pain assessment scale stand for?
Face, legs, activity, cry, consolability
Which patient group should the FLACC pain assessment scale be used with?
Patients younger than 3 years old
Confused patients/patients w/ dementia
Which patient group should the Wong-Baker Faces pain assessment scale be used with?
Patients three years old or above
What are the 3 components of general survey?
Physical appearance, mobility, behavior
What are the characteristics of the physical appearance component of the general survey?
Overall health, age, personal hygiene, body structure
What are the characteristics of the mobility component of the general survey?
Gait, posture, range of motion, signs of distress
What are the characteristics of the behavior component of the general survey?
Appropriate, facial expression, mood, speech
What are the three main techniques used to encourage communication during interview?
Asking close-ended questions
Asking open-ended questions
Active listening/observing
What are the main barriers to communication?
Leading the patient
Using medical jargon
Offering false assurance
Asking “why” questions
Changing the subject
Giving opinions
Stereotyping
Using patronizing language
What are the 7 main cultural considerations that may impact the interview?
Comfort level w/ private issues
Physical closeness
Involving significant others
Being addressed by first name
Asking prior to touching patient
Allowing open space for patient to share beliefs
Maintaining vs. Avoiding eye contact depending on patient’s culture)
What are the 3 phases of the interview process?
- Introduction
- Working
- Termination
Which phase of the interview process consists of the following:
Introducing self & explaining role
Identity patient
Establish trust & rapport
Inform patient that you will be taking notes
Ask patient if they’re comfortable w/ the situation
Introduction phase
Which phase of the interview process consists of the following:
Information collection
Ask both open-ended & close-ended questions
Patient self-reports health history
Identify patient’s problems, needs, & goals
Ask patient if they have questions for you
Working phase
Which phase of the interview process consists of the following:
Clarify patient’s report & findings to validate feelings, needs, & concerns
Termination phase
