Comprehensive Flashcards
What does MDS stand for and when is it utilized?
Minimum Data Set used in medicare
1.What are the five steps in hand rubbing *hand hygiene with alcohol based hand sanitizer 2.Duration? Flat Bed Pickups interweave through firetrucks
Flat Palms Back of hands interlaced Palms interlaced Interlocked hands *finger pads* Thumbs Fingertips 20 seconds until dry
What is the purpose of a basic complete physical? 2
- To obtain objective data and interpret it 2. To determine patients status
What is a baseline assessment. When is one taken.
A baseline assessment is taken upon the initial meeting with a patient. Whether a new patient at a doctors office or a patient in an emergency situation. The purpose of the baseline assessment is to obtain an initial record of patients status to be compared with later assessments to determine any change in status/condition.
Health assessment data is either ____ or ____
Healthy and within defined limits or not (equates to a health problem)
What do continuous, ongoing, and follow-up assessments determine? How?
Determine the effects of time and/or nursing care by comparing the most recent assessments with previous ones
What are the possible outcomes of continuous, ongoing, and follow-up assessments
- patient Condition is stable or stabilizing 2. patient condition is changing or changed
What are the two outcomes if the continuous assessment shows a patients condition is changing or has changed?
- patient is improving and progressing towards optimum health 2. Patient is worsening
What is the nurses responsibility upon discovering any abnormal finding or change in patient status?
To immediately report change to MD or NP
The RN should do what action every-time they interact with the patient
- Complete a quick assessment at minimum 2. Follow AIDET
Aprox. how many people die in hospitals each year due to medical errors that could have been prevented?
44,000 - 98,000
What example did the joint commission used when discussing the importance of constant ongoing assessment?
Patients deteriorate 8-12 hours before a cardiac event in clinical settings. Interventions are possible if deterioration is recognized and reported
What are the two main focuses of a physical assessment?
1.Subjective data 2. Objective data
Of the two main focuses of physical assessments, which one will be the focus of nurse 144?
Objective Data
What is the main difference between a nursing assessment and a Medical Assessment?
Nursing assessments have a holistic approach
What are the 5 aspects of holistic patient centered care? PPDSS *for each aspect tell if it is subjective or objective*
- Psychological-Sub 2. Physiological-Ob 3. Developmental-Ob 4. Sociocultural-Sub 5. Spiritual-Sub
What are the 5 components of a basic complete physical exam. Ruby Has Visits Post Sex
- Reason for Visit 2. Health history (subjective) 3. Vitals 4. Physical assessment 5. Systematic assessment
What four things must a systematic assessment be? SAS-E
Safe, accurate, systematic and efficient
What is the number one consideration above all else in any assessment or procedure?
Safety
What 3 things does the RN need to ensure they are respectful of during assessments? Carefully Recognize Emergency’s
- Culture 2. Ethnicity 3. Religion
The RN should always use what type of communication?
Therapeutic Communication
How can the RN become more culturally aware?
Through Self-reflection and Elimination of personal biases
What must the RN do when faced with a patient that is expressing values from a different culture that affect the process of assessment?
Modify the plan of care and environment to accommodate the patients values and wishes.
Treat others religions with_____ and ____
dignity and respect
What are the 4 main types of developmental differences that the RN may need to accommodate for during physical assessments? AIR-I
- Age (growth and development of children) 2. Impaired or delayed development 3. Regression-trauma 4 impaired cognitive status
What are two main types of impaired cognitive status?
1 dementia 2. Brain injury or dysfunction
What 4 things should all assessments be? SAC-E
Safe, Accurate, Systematic, Efficient
What are the 4 types of physical assessments? EPCF
- Emergency ALWAYS NUMBER ONE 2. Pain or primary concern 3. Comprehensive 4. Focused or Targeted
What are the 5 methods of assessment? IPP-AO
- Inspection 2. Palpation 3. percussion 4. Auscultation 5. Olfaction
Describe supine position
lying on the back with the face up.
Describe Prone position
lying on the chest with the face down (“lying down” or “going prone”)
Describe Dorsal Recumbent position
patient lies on the back with the lower extremities moderately flexed and rotated outward.
Describe lateral recumbent position
Patient lies on side with lower extremities moderately flexed
Describe lithotomy position
a supine position of the body with the legs separated, flexed, and supported in raised stirrups
Describe sims position
It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. Can also be called lateral recumbent
What is the precordium?
Front side of the heart against chest wall
What is the pericardium?
The double layered membrane that surrounds the heart
What is the mediastinum?
The portion of the thoracic cavity that contains the heart and is between the lungs
What is a sinus arrhythmia/dysrhtrhmia?
Heart rates that change with breathing
What is a thrombus?
A blood clot
What is an embolus
A traveling blood clot
What is the carotid sinus?
Site of baroregulators in the carotid artery. Do not massage the area or you could drop the heart rate/pressure
What are the three normal breath sounds?
Bronchial, Bronchovesicular, vescular
What are adventitious sounds?
Abnormal breath sounds
What is stridor, rhonchi?
High pitched whistling breath sounds caused by secretions
What is dyspnea?
Labored breathing
what are fremitus?
Tremors felt during chest palpation-99 mickey mouse
What is a atelectasis
full or partial collapsed lung
What is bronchiectasis?
Damaged airway
Where do you listen for aortic heart sounds What heart sound is most prevalent?
the second ICS at the right sternal border S2
Where do you listen for pulmonic heart sounds What heart sound is most prevalent?
1-3 ICS on left sternal border S2
Where do you listen for Erb’s point What heart sound is most prevalent?
Third ICS Left sternal border equal S1/S2
Where do you listen for murmurs
Erbs point
Where do you listen for tricuspid heart sounds What heart sound is most prevalent?
4th or 5th ICS left lower sternal border S1
Where do you listen for Mitral(apical) heart sounds What heart sound is most prevalent?
5th ICS on the left MCL S1 Can be palpated
What is the main cause for hair loss in older populations lower extremities?
Poor circulation
What is the duodenum what quadrant?
First part of small intestine after the stomach RUQ
What is the ileum
The third portion of the small intestine between the jejunum and cecum
What is the jejunum?
The second part of the stomach between duodenum and ileum
What is the cecum
Pouch connected to the junction of the small and large intestines.
What us the ileo-cecal junction?
a sphincter valve that connects the ileum and the cecum
Where is the suprapubic area?
the area above the bladder
What is the umbilicus?
the belly button
What is scaphoid?
Concave abdomen
What is Ascites?
Distended belly caused by edema related to liver disease
What are the adenoids?
Small glands on roof of mouth behind soft palate
What is a facies?
A facial expression typical for a specific disease
What are some age variations for visual acuity?
-Weakened focusing power -senile hyaline plaque -cataracts
What are some age variations in the sclera?
Yellowing
What are some racial variations in the sclera
Darker skin can lead to a darker more yellow sclera
What are some normal variations in hearing due to age?
Reduced hearing due to age- presbycusis
What are some age related variations in the ear canal?
hard, thick, dry ear wax course hair
What are the 3 supplies you will need to assess HEENT?
Pen light Gloves Tongue Blade
What are two major safety precautions when assessing the GI system
-If the is pain don’t palpate -if there is pulsations don’t palpate
WHat is a bursa(e)
Sac filled with synovial fluid at the synovial joint
What is the periosteum?
Layer of fibrous connective tissue covering the outside of the bone
What is synovial fluid?
Lubricating fluid in the synovial joints
What is a ligament?
Band of collagen rich connective tissues that binds bone to bone
What is a tendon?
Band of collagen rich connective tissue connecting bone to muscle
What is osteoporosis?
a degenerative bone disease characterized by loss of bone mass
What is Kyphosis?
Exaggerated rounding of the back
What is lordosis
excessive inward curve of the spine
What is scoliosis?
Lateral curve of the spine
What is the romberg test?
Test used to examine balance
What are DTR’s?
Deep tendon reflexes
What is the subarachnoid space?
Gap between arachnoid space and pia mater filled with cerebral spinal fluid
What is paresthesia?
Pins and needles
What is the function of the frontal lobe?
Cognitive function, voluntary muscles, personality
What is the function of the parietal lobe?
Processes sensory information
What is the function of the occipital lobe?
Visual processing
What is the function of the temporal lobe?
Auditory processing
What is the somatic nervous systems function?
Voluntary muscle movments
What is the autonomic nervous systems function?
involuntary control and regulation
What is CN 1 and its function? Sensory or motor?
Olfactory nerve conveys the sense of smell Sensory
What is CN 2 and its function?Sensory or motor?
Optic nerve Conveys vision Sensory
What is CN 3 and its function? Sensory or motor?
Ocularmotor nerve -EOM’s Motor
What is CN 4 and its function Sensory or motor?
Trochelar nerve EOM’s Motor
What is CN 5 and its function? Sensory or motor?
Trigeminal nerve provide sensation to the skin of the face and also controls the muscles of mastication Both
What is CN 6 and its function? Sensory or motor?
Abducens nerve EOM Motor
What is CN 7 and its function? Sensory or motor?
Facial Nerve Facial expressions both
What is CN 8 and its function? Sensory or motor?
Vestibulocochlear nerve Hearing and Balance sensory
What is CN 9 and its function? Sensory or motor?
glossopharyngeal nerve Oral sensation, taste, and salivation both
What is CN 10 and its function? Sensory or motor?
Vagas lots of functions both
What is CN 11 and its function? Sensory or motor?
Accessory nerve Shoulder elevation and head-turning motor
What is CN 12 and its function Sensory or motor?
Hypoglossial Nerve Tongue movement motor
How would you test CN 2?
Visual acuity
How would you test CN 3, 4, 6?
EOM and Blink response
How would you test CN 8?
Whisper test and romburg test
How would you test CN 10
soft palate rise on phonation
What is Pain?
Unwanted or unpleasant sensation
Pain is always _______
What the patient says it is
Is pain the same as suffering?
No
IN 1994 the joint commission coined what phrase as a part of their campaign to _____ that is no longer accepted but that directly contributed to current opioid epidemic
Improve pain relief Pain is the fifth vital sign
What are the two numeric pain assessment tools?
-1-10 scale -Visual Analog scale — 1-100 mm line that the patient marks and is measured
When a patient uses verbal descriptions of pain how should they be documented?
By direct quote in patient chart
What does COLDSPA stand for?
-Characteristic -Onset -Location -Duration -Severity -Pattern -Aggravating or Alleviating factors
What does OLDCARTS stand for?
-Onset -Location -Duration -Character -Aggravating or alleviating factors -Related Symptoms -Treatments -Severity
What does PQRSTU stand for?
-Provocative or Palliative factors -Quality -Region/Radiation -Severity -Timing -How is the pain affecting U
What are two other pain assessment tools?
-NIPS-Neonatal and infant pain scale -The wong-baker faces pain scale
Pain assessment is always _____ data
Subjective but objective data is used as clues
