316 exam 1 Flashcards
what is one important element of a general survey and health assessment?
A) Everyone’s treatment is the same
B) Treat the whole person
C) Focus on one body system
B) Treat the whole person
address four areas: physical appearance, body structure, mobility, behavior
T or F
Comprehensive assessment includes a complete health history and full physical examination
true
what is a comprehensive assessment (or complete/total)?
includes a complete health history and full physical examination, describes a current and past state, forms a baseline against all future changes that can be measured, —first diagnosis
A focused assessment- (or problem-centered or episodic)
collects a mini database, smaller in scope and more targeted than a complete assessment, concerns mainly one problem, one body system. It is used in all settings (hospital, primary care, or long-term)
T or F
Subjective data: obtained as the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination
false
what is subjective data?
what the person says about themselves during history
taking, what the client or caregiver shares with the nurse
what is objective data?
what we as health professionals observe by inspecting,
percussing, palpating, and auscultating during the physical examination or assessment
a privacy best practice when conducting a health assessment is?
HIPAA- Health Insurance Portability and Accountability Act (1996) any written, verbal, or electronic communications = medical records, accounting
information, patient information, and conversations between or among healthcare professionals about patients are confidential under the law and this agreement
a good practice during an interview may include:
pick all that apply
A) Giving advice on how to handle a problem
B) Building a rapport
C) Teaching about health promotion
Answer B & C
The first and most important part of data collection, is collecting subjective data, individual knows everything about their health.
Gather complete and accurate data about a person’s health state, including a description and chronology of any symptoms of illness
Establish rapport and trust so the person feels accepted and free to share all relevant data
Teach people about the health state so they may participate in identifying problems
Build rapport to continue the therapeutic relationship and to facilitate diagnoses, planning,
and treatment
Begin teaching for health promotion and disease
The mutual goal is optimal health for the patient
T or F
Inspection: applies to the sense of touch to assess these factors: texture, temp, moisture, organ location, size, swelling, vibration/pulsation, rigidity/spasticity, crepitation, lumps or masses, tenderness or pain
false
what is inspection?
concentrated watching, close scrutiny, first as a whole individual, then each body system, how you start each assessment, requires good lighting might need instruments like penlight, otoscope
what is palpitation?
applies your sense of touch to assess these factors: texture, temp, moisture, organ location, and size, swelling, vibration/pulsation, rigidity/spasticity, crepitation, lumps or masses, tenderness or pain
what is percussion?
tapping the person’s skin with short, sharp strokes to assess underlying structures, sound depicts the location, size and density of the underlying organ
(avoid over bony prominences)
what is auscultation?
listening to sounds produced by the body (BEST PRACTICE : skin to skin)
what is pain?
Pain is what the patient says it is, and they cannot rely on a physical exam to “see” it
PQRST, numeric rating scales, verbal descriptor scales, visual analog scales
what is the priority for a patient in pain?
establishing a diagnosis
what are acute vs chronic pain behavioral cues?
acute will change vitals, chronic will have bracing, rubbing, sighing
is pain different in dementia?
yes
what does PQRST stand for?
P- Provocation/Palliation
Q- Quality/Quantity
R-Region/Radiation
S- Severity Scale
T- Timing
what is the ABCDE rule?
Teach skin self-examination using ABCDE rule to detect suspicious lesions
* A: asymmetry
* B: border
* C: color
* D: diameter
* E: elevation and enlargement
what is +1 edema?
mild, slight indentation, no swelling
what is +2 edema?
moderate, indentation subsides rapidly
what is +3 edema?
deep, indentation remains for a short time, appears swollen
what is +4 edema?
very deep, indentation lasts a long time, appears very swollen
what are normal nail findings?
smooth surface, convex curvature, pink nail bed, angle between nail and bed (nail angle) ~160 degrees
what are abnormal nail findings?
clubbing (nail angle >180 degrees), spoon-shaped nails (koilonychia), pitting, discoloration
what is a stage I pressure injury?
intact skin, red, unbroken, localized redness, lighter skin-does not blanch, darker
skin remains darker-does not blanch
what is a stage II pressure injury?
partial thickness erosion, loss of epidermis, shallow abrasion or open blister
looking, red-pink wound bed
what is a stage III pressure injury?
full thickness extending into SQ, crater-like, fat may be visible
what is a stage IV pressure injury?
full-thickness, all layers to supporting structures, muscle, tendon, bone, slough (cream/yellow) and eschar (black)
what are palpation assessment techniques?
*Fingertips: skin texture, swelling, pulsation and presence of lumps
*Grasping action of the fingers and thumb –detect the position, shape, and consistency of an organ or mass
*Back of the hands: best for determining the temp of skin
*Base of fingers or ulnar surface of the hand – best for vibration
Keep in mind that the person needs to be relaxed/ Palpate tender areas last
when is it good to use the diaphragm of the stethoscope for auscultation?
good for high pitched –breath, bowel, and normal breath sounds
hold the diaphragm firmly against skin (not the gown)
when is it good to use the bell of the stethoscope for auscultation?
good for soft, low-pitched sounds such as extra sounds (murmurs)
hold the bell very lightly on the skin (not the gown)
where are sources of visceral pain?
larger internal organs
where are sources of cutaneous pain?
skin surface and subcutaneous tissue
where are sources of deep somatic pain?
blood vessels, tendons, joints, muscles, bones
where are sources of referred pain?
felt at one site, but originated from another location
both sites are innervated by same spinal nerve, and it is difficult for brain to differentiate point of origin
referred pain may originate from visceral or somatic structures
example: an inflamed appendix in right lower quadrant of abdomen may have referred pain in periumbilical area
what is the impact of poorly controlled pain on the cardiac system?
tachycardia (fast HR), elevated BP, increased myocardial oxygen demand, increased cardiac output
what is the impact of poorly controlled pain on the pulmonary system?
hypoventilation, hypoxia (low oxygen), decreased cough, atelectasis (complete or partial collapse of lung)
what is the impact of poorly controlled pain on the CNS?
fear and anxiety
what is the impact of poorly controlled pain on the immune system?
impaired cellular immunity, impaired wound healing
what are the overall impacts of poorly controlled chronic pain?
depression, isolation, confusion, diminished quality of life, limited mobility and function
what are nociceptors?
- specialized nerve endings designed to detect painful sensations, they transmit sensations to the central nervous system
- can be stimulated directly by trauma or injury or secondarily by chemical mediators released from the site of tissue damage
- carry pain signals to CNS by two primary sensory (afferent) fibers: Aδ and C fibers
what is Transduction?
noxious stimuli, pain is converted to action potential in neuron, like nail piercing the foot
what is transmission?
pain impulse moves from level of spinal cord to brain
what is perception?
conscious awareness of painful sensation
what is modulation?
when the pain message is inhibited (brain)
what is the purpose of acute pain?
self-protective purpose; acute pain warns individual of
actual or potential tissue damage
ex: surgery, trauma, kidney stones
what are causes of nonmalignant chronic pain?
often caused by musculoskeletal conditions such as
arthritis, low back pain, or fibromyalgia
what is nonmalignant chronic pain?
- long lasting, pain does not stop when injury heals and outlast protective purpose (from peripheral or central sites)
- pain intensity does not correspond with physical findings
- originates from abnormal processing of pain fibers
- pain is client’s self report
what does neuropathic pain imply?
implies an abnormal processing of pain message
what is the proposed mechanism of neuropathic pain?
spontaneous and repetitive firing of nerve fibers, almost seizure like in activity
is there evidence that older adults perceive pain to a lesser degree or that their sensitivity is diminished?
no, pain is common among older individuals and should not be accepted or tolerated
- leads to under-reporting and less aggressive treatment
what changes in the functional status of older adults may indicate acute pain?
acute confusion, slowness, fatigue, rigidity, ADLs
- need to rule out other causes of pain like infection or med interactions
what is affected by Alzheimers?
Somatosensory cortex is generally unaffected by dementia of Alzheimer type- but verbal expression is affected
what are common pain-producing conditions in the aging adult?
arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, peripheral neuropathies, angina, chronic constipation, cancer
what is PAINAD?
used to assess pain in advanced dementia
what are initial pain assessment questions?
Do you have pain
Where is it
When did it start
What does it feel like
How much pain do you have now
What makes it better or worse
How does the pain limit your function or activities
How do you react when you are in pain
What does this pain mean to you
what is objective data for joints?
- not size and contour
- check active or passive ROM
- measure circumference of involved joint, compare with baseline
- joint motion does not normally cause tenderness or pain
what are nonverbal behaviors of acute pain?
Guarding
Grimacing
Vocalizations
Moaning, agitation, restlessness,
stillness, diaphoresis
Changes in vital signs – why?
what are nonverbal behaviors of chronic pain?
Gives little indication they are in pain
Under-detected –ask client how they act or behave when in pain
Bracing, rubbing, diminished activity,
Sighing, change in appetite
what is objective data for muscles and skin?
- inspect skin and tissues for color, swelling, masses, or deformities
Assess changes in sensation with eyes closed:
-test ability to perceive sensation with tongue blade
(sharp or dull)
-helps identify location and extent of altered sensation
what is objective data for the abdomen?
- Observe for contour and symmetry
- Palpate for muscle guarding and organ size
- Not any areas of referred pain
what is the elasticity of the skin of older adults?
less elasticity, skin folds and sags
what is the conditions of the sweat and sebaceous glands of older adults?
decreased in number and function, leaving skin dry
what is senile purpura in older adults?
discoloration due to increasing capillary fragility
what is the most important environmental risk factor for skin cancer?
exposure to ultraviolet (UV) radiation both from sun and tanning sources
what are examples of subjective data health history questions for the skin/hair/nails?
Past history of skin disease, allergies, hives, psoriasis, or eczema?
Change in pigmentation or color, size, shape, tenderness?
Excessive dryness or moisture?
Pruritus or skin itching?
Excessive bruising?
Rash or lesions?
Medications: prescription and over-the-counter?
Hair loss?
Change in nails’ shape, color, or brittleness?
Environmental or occupational hazards?
Self-care behaviors?
what are health history questions for hair skin and nails for older adults?
What changes have you noticed in your skin in past few years?
Any delay in wound healing?
Any change in feet: toenails, bunions, wearing shoes?
Falling: bruises, trauma?
History of diabetes or peripheral vascular disease?
what are the steps of a complete physical examination?
- Skin assessment integrated throughout examination
- Scrutinize the outer skin surface first before you concentrate on underlying structures
- Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly (areas are dark, warm, moist, providing perfect conditions for irritation or infection)
- always inspect feet, toenails, between toes
how do you assess skin?
as one entity, getting overall impression helps reveal distribution patterns
what is assessment technique I & P?
inspection and palpation-may have accompanying signs that can be felt
how do you inspect the color of the skin?
- General pigmentation, freckles, moles, birthmarks
- Widespread color change
Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow)
Note if color change transient or due to pathology
how do you inspect temperature of the skin?
Use backs of hands to palpate person
Normal-warm, and temperature equal bilaterally; warmth suggests normal circulatory status
Hands and feet may be slightly cooler in a cool environment
Hypothermia-generalized or localized
Hyperthermia-generalized or localized
what is diaphoresis?
sweating to an unusual degree
what areas do you assess with inspection and palpation of the skin?
Moisture
Texture
Thickness
Edema
Mobility and tugor
Vascularity or bruising
what is a normal nail degree?
160
what is a curved nail degree?
160 or less
what is an early clubbing nail degree?
180
what are confluent skin lesions?
Lesions that merge or run together, creating a larger, irregular area (circles spread out)
what are discrete skin lesions?
Individual lesions that remain separate and distinct.
what are grouped skin lesions?
lesions closely clustered together
what are gyrate skin lesions?
lesions with twisted or coiled appearance
what are target or iris lesions?
Lesions with concentric rings of color, resembling a target or iris.
what are polycyclic lesions?
Lesions with multiple circles or rings that intersect.
what are zosteriform lesions?
Linear arrangement along a nerve route, resembling herpes zoster (shingles).
what is the skin assessment of Skin Tugor?
Definition: The skin’s elasticity and ability to return to its normal state after being pinched or pulled.
Assessment: Pinch a small amount of skin on the back of the hand or forearm; normal turgor results in immediate return to its original position.
what is the skin assessment of Erythema?
Definition: Redness or inflammation of the skin, often due to increased blood flow.
Assessment: Observing for red patches or areas on the skin; the severity can range from mild to severe.
what is the skin assessment of Urticaria?
Definition: Hives; raised, itchy welts on the skin that result from an allergic reaction.
Assessment: Presence of raised, red, and often itchy welts that may vary in size and shape.
what is the skin assessment of Seborrhea?
Definition: A skin condition characterized by excessive oiliness, often affecting the scalp (dandruff) or other areas.
Assessment: Presence of oily or greasy skin, flaking, and redness, commonly observed in areas with a high concentration of sebaceous glands.
what is the skin assessment of xerosis?
Definition: Dry skin, often characterized by roughness, scaling, and itching.
Assessment: Feeling for dry and rough skin, observing for flakiness or peeling.
what is the skin assessment of a nodule?
Definition: A solid, raised, and palpable lesion or mass in the skin or subcutaneous tissue. solid elevation 0.5 to 1cm in diameter, extends deeper than papule
Assessment: Feeling for a firm, rounded elevation that may extend deeper into the skin.
what is the skin assessment of a papule?
Definition: A small, raised, solid lesion on the skin, typically less than 1 centimeter in diameter.
Assessment: Observing for small, elevated bumps with defined borders.
what is the skin assessment of a macule?
Definition: Flat, colored lesions that are less than 1 centimeter in diameter.
Assessment: Observing for flat areas of discoloration on the skin.
what is the skin assessment of Senile Purpura?
Definition: Bruising that occurs in older adults due to thinning and fragility of blood vessels.
Assessment: Observing for purple or red discoloration resulting from minor trauma.
what is the skin assessment of Jaundice?
Definition: Yellowing of the skin and eyes due to elevated levels of bilirubin in the blood.
Assessment: Observing for a yellow tint to the skin, sclera (white part of the eyes), and mucous membranes.
what is the skin assessment of scales?
secondary lesion
flakes on skin layer ex: psoriasis
what is the skin assessment of crust?
secondary lesion
dried exudate on skin ex: impetigo
what is the skin assessment of fissure?
secondary lesion
cracks in skin ex: athletes foot
what is the skin assessment of an ulcer?
secondary lesion
area of destruction of entire epidermis ex: pressure sore
what is the skin assessment of a scar?
secondary lesion
excess collagen production after injury ex: surgical healing
what is the skin assessment of atrophy?
secondary lesion
loss of some portion of the skin
what are Lichenifications?
secondary skin lesions where the skin thickens, hyperpigmentation and exaggerated skin lines are noted
what are atrophic scars?
pitted or indented scars that occur when the skin heals below the normal layer, due to lack of regenerative tissue, stretch marks
what is excoriation of the skin?
where skin is scraped or abraded, well defined injury with sharp or linear edges
what is petechiae?
Tiny, pinpoint, red or purple spots on the skin. Result from small hemorrhages under the skin, often due to platelet disorders or capillary fragility.
what is purpura?
Definition: Confluent areas of petechiae or ecchymosis, presenting as larger areas of skin discoloration.
Causes: Various, including blood clotting disorders, vasculitis, or certain infections.
senile:due to capillary fragility
what is ecchymosis?
bruise, Larger, irregularly shaped area of purplish discoloration resulting from blood extravasation into the skin.
Causes: Trauma or injury that damages blood vessels beneath the skin.
what is an angioma?
Benign tumor consisting of small blood vessels. Causes: Typically a result of blood vessel proliferation, common types include cherry angiomas and spider angiomas.
what classification are Pigmented nevi (moles)?
Macule (flat, pigmented spot on the skin)
what classification are freckles?
Macule (small, flat, colored spot on the skin)
what classification is a xanthoma?
Nodule (solid, raised lesion larger than 0.5 cm in diameter)
what classification is a mosquito bite?
Wheal (raised, edematous, irregularly shaped area on the skin)
what classification is chicken pox?
Vesicle (small fluid-filled blister)
what is a wheal?
type of plaque, result is transient edema in dermis
ex: intradermal skin test
what is plaque on skin? primary lesion
flat elevated surface found on skin or mucous membrane ex: thrush
what is a bulla?
Bulla: large blister greater than 0.5cm ex: burn
what is ADOPIE? what does it stand for?
the steps of the nursing process
Assessment- recognize cues
Diagnosis- generate hypothesis
Outcome identification
Planning- judge hypothesis
Implementation (take action)
Evaluation- evaluate status
what is a complete database?
often collected in the provider’s office or clinic. It includes a complete health history, past and current health problems, and a head-to-toe physical assessment.
what is a focused or problem-centered database?
this is used for a limited or acute problem focused on
one complaint or body system. An example would be a fever and sore throat. It is used in all client settings.
what is a follow-up database?
This is used in all settings to assess if the identified problem has gotten better, chronic conditions are not getting worse, and are there any recent changes in health status.
what is an emergency database?
rapid collection of data in an emergency, life threatening situation. An example would be an allergic reaction or drug overdose. Once the client is stable, then a more thorough database can be collected
what is a level one priority?
Airway
Breathing
Circulation
what is a level two priority?
acute pain, mental status changes, abnormal lab values,
infections
what is a level three priority?
knowledge deficit, family coping issues, changes in mobility
what is a general survey?
study of the whole person, covers general health state and any obvious physical characteristics
is an introduction for physical examination that will follow:
- should give oral impression
- objective parameters are used to form gen survey
- apply to whole system not just one body system
what does the encounter of a general survey look like?
immediate impression? Are your finding what you expect? Note any unexpected or abnormal findings. Height and weight in the normal range, vital signs in normal range for age
what are 4 areas to consider in a general survey?
Physical appearance
Body structure
Mobility
Behavior
what is the Physical Appearance part of collecting objective data?
Age: person appears his or her stated age
Sex: sexual development appropriate for gender and age
Level of consciousness: person alert and oriented, attends to your questions and responds appropriately
Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions
Facial features: symmetric with movement
*No signs of acute distress present?
what is the Body Structure part of collecting objective data?
Stature: height appears within normal range for age, genetic heritage
Nutrition: weight appears within normal range for height and body build; body fat distribution even
Symmetry: body parts look equal bilaterally and are in relative proportion
Posture: person stands comfortably erect as appropriate for age
Exceptions-Aging person who may be stooped with kyphosis
Position: person sits comfortably in chair or on bed or examining table, arms relaxed at sides, head turned to examiner
Body build, contour: proportions are correct
Arm span (fingertip to fingertip) equals height
Body length from crown to pubis roughly equal to length from pubis to sole
Obvious physical deformities: note any congenital or acquired defects
what is the Mobility part of collecting objective data?
Gait: normally, base is as wide as shoulder width
Foot placement: accurate; walk smooth, even, and well-balanced; and associated movements, such as symmetric arm swing, are present
Range of motion: note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated
No involuntary movements
what is the Behavior part of collecting objective data?
Facial expression: person maintains eye contact (unless a cultural taboo exists), expressions appropriate to situation (e.g., thoughtful, serious, or smiling)
Note expressions both while face is at rest and while person is talking
Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly
Speech: articulation (ability to form words) clear and understandable
Dress
Personal hygiene
what does HIPAA cover?
written, verbal or electronic communications
basically anything that can be linked back to patient
what is health promotion?
is a set of positive acts we can take. For ex :
teaching and helping your patient to choose a healthier lifestyle.
what is disease prevention?
can be achieved through counseling from PCP/
designed to change unhealthy behaviors ( poor nutrition, lack of exercise, smoking, excessive ETOH use.
what is the most appropriate position when interviewing your patient?
equal status seating
at eye level with them, if bedridden arrange a face to face position to avoid standing over
what is Provocation/Palliation asking
What provokes or alleviates the pain? What makes it better or worse?
what is Quality asking
What is the nature or quality of the pain? (e.g., sharp, dull, stabbing, burning)
what is region/radiation asking
Where is the pain located? Does it radiate to other areas?
what is severity asking
How intense is the pain? This can often be assessed using a numerical scale.
what is timing asking
When did the pain start? Is it constant or does it come and go?
what are the fingertips used to palpate
fine tactile discrimination of skin texture, swelling, pulsation, presence of lumps
what are fingers and thumbs used to palpate
detection of position, shape, and consistency of an organ or mass
what is the dorsa of the hands and fingers used to palpate
best for temperature
what is the base of fingers or ulnar surface of hand used to palpate
vibration
what is the order of activities for an assessment?
- inspection
- palpation
- percussion
- auscultation
