Assessment broken down by system Flashcards

1
Q

complex intergration of mental processes and intellectual function for the purposes of reasoning, learning, memory and personality.

  • reasoning is a high level thinking process that allows an individual to make decision and judgments
  • memory is the ability of an individual to retain and recall information for learning or recall of past experiences.
  • personality is the way of individual feels and behaves, often based on how he or she thinks
A

cognition

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2
Q

disoriented to surrounding, may have impaired judgement, may need cues to respond to commands.

A

confused

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3
Q

drowsy, needs gentle verbal or touch simulation to initiate response

A

lethargic

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4
Q

responds slowly to external stimulation and needs repeated stimulation to maintain attention and response.

A

obtunded

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5
Q

responds only minimally with vigorous stimulation and may only moan as a verbal response.

A

stuporous

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6
Q

no observable response to any external stimuli

A

comatose

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7
Q

responds readily, but may be confused

A

alert

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8
Q

anxiety, confusion, and restlessness can be signs of ______ .

A

hypoxia

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9
Q

A blood pressure above baseline can indicate what?

A

intracranial pressure

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10
Q

commonly used set of questions for screening cognitive function. may indicate presence of cognitive impairment.

A

mini mental state examination (MMSE)

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11
Q

is a standardized evidence based tool that enables non-psychiatrially trained clinicians to identify and recognize delirium quickly.

A

confusion assessment method (CAM)

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12
Q
  • acute, fluctuating with sudden onset
  • multiple possible causes, may be reversible
  • Tx based on cause
  • reorient and provide safe environment
A

delirium

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13
Q
  • chronic progression with slow onset
  • irreversible, unknown cause
  • last months to years
  • tx symptoms
  • use validation, do not argue
  • safe environment
  • observe for hallucinations and delusions
  • can’t be oriented
A

dementia

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14
Q
  • understand the difference b/t delirium and dementia
  • prevent client from experiencing hypoxia
  • prevent fluid and electrolytes imbalances
  • be exact with medication dosage of opioids, steroids, psychoactive drugs, and general anesthesia.
  • teach clients to avoid substance use
  • promote positive lifestyle behaviors
  • teach older adults to stimulate the intellectual portion of their brain with new learning activities.
A

interventions to promote cognition

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15
Q
  • predictable routines
  • simple instructions
  • familiar people and objects
  • appropriate environmental stimuli
  • focus on safety
  • foster communication
  • delirium and mild dementia reorient to person, place, time
  • collaborate with interdisciplinary team to determine the cause.
A

interventions with abnormal assessment of cognition

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16
Q

clients with moderate to severe dementia _____ be oriented because of the chronic confusion.

A

cannot

17
Q

the intactness of the structure and function of the integument and mucous membranes.

A

tissue integrity

18
Q
  • assess for changes in skin color, moles/lesions, excessive skin dryness, bruising, and hair loss or brittle nails.
  • document existing tissue impairment in detail.
  • stage pressure areas
  • monitor serum albumin and prealbumin levels.
A

assessment of tissue integrity

19
Q
  • SBAR
  • use specific language
  • report last time observed well
  • report any medication given
  • report recent lab values or diagnostic test completed
A

reporting your observation

20
Q

a chronic health condition is one that has existed for at least 3 months.

A

chronically ill

21
Q
  • be patient, relaxed, and unhurried
  • allow plenty of time for response.
  • be alert for signs of fatigue.
  • take advantage of natural opportunities to assess
  • ensure assistive devices are in place and functioning
  • proceed in a manner to keep position changes to a minimum
  • proceed from lesser invasive areas to more especially for older adults with confusion
A

examiner considerations when assessing older adults

22
Q
  • physical assessment begins immediately upon entering the room
  • note skin color and gait as well as the caregiver response and caregiver/child interaction
  • perform assessment as opportunity presents.
  • if infant is sleeping, listen to lungs and heart sounds
  • use play therapy, offer choices
  • save invasive or pain assessment until end
A

considerations for children

23
Q

unequal pupils are indicative of what?

A

brain swelling, hemorrhage or head injury

24
Q

what is a decrease in pupillary reaction indicative of ?

A

Intracranial pressure or sedation

25
Q

what medication can causes the pupils to dilate ?

A

atropine

26
Q

what medications can cause the pupils to shrink in size?

A

opioids