Exam 1 Flashcards
What is subjective data?
What a patient says about himself or herself during history taking.
What is objective data?
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
What is database?
Formed from objective data, subjective data, and the patient’s record and laboratory studies.
Name the steps of the nursing process in order:
- Assessment
- Diagnosis
- Outcome identification
- Planning
- Implementation
- Evaluation
What takes place during the assessment phase of the nursing process?
- Collect data
- Use evidence based assessment techniques
- Document relevant data
What happens during the diagnosis phase of the nursing process?
- Compare clinical findings with normal and abnormal variations
- Interpret data:
- identify clusters of clues
- make hypothesis
- test hypothesis
- derive diagnosis
- Validate inferences based on findings
- Document the diagnosis
What is a cue?
A piece of information, a sign or symptom, laboratory result or imaging result
What is a hypothesis?
A possible explanation for the cue or set of cues
What is the outcome identification part of the nursing process?
- Identify expected outcomes that are for that individual person
- Establish realistic and measurable outcomes
- Develop a time line
What is the planning part of the nursing process?
- Establish priorities
- Set time lines
- Document plan of care
What is the implementation step of the nursing process?
- Implement in a safe and timely manner
- Use evidence based interventions
- Collaborate with colleagues
- Coordinate care delivery
- Provide health teaching
What is the evaluation step of the nursing process?
- Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation
- Use ongoing assessment to revise diagnoses, outcomes, plan
- Disseminate results to patient and family
What are the priority problems levels?
1 - First-level priority
2- Second-level priority
3- Third-level priority
4- Collaborative problems
What are first-level priorities?
Emergent, life threatening, and immediate
What are Second-level priorities?
Next in urgency, requiring attention so as to avoid further deterioration
What are third-level priorities?
Important but can be addressed after more urgent problems
Current and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs)
Evidence-based assessment
What is RCTs?
Randomized clinical trials
What is EBP?
Evidenced-based practice (Research into practice)
What should evidence-based assessment be used in conjunction with?
Should be used in conjunction with provider experience to lead to better health outcomes for patients
What are the four types of databases that can be collected from patient?
1 - Complete total health database
2 - Episodic / problem-centered database
3 - Follow-up database
4 - Emergency database
When would a complete total health database be used?
When a patient is a new admission to a hospital
What is a complete total health database?
- complete health history and full physical examination
- describes current and past health state and forms baseline to measure all future changes
What is an episodic or problem-centered database?
- Used for limited or short-term problems
- Collect “mini” database, more focused than a complete database
- Concerns mainly one problem
- History and examination follow direction of presenting concern
What is a follow-up database?
- Status of all identified problems should be evaluated at regulate and appropriate intervals
- Note changes that have occurred
- Evaluate whether problem is getting worse or better
What is an emergency data base?
- Rapid collection of data, often compiled concurrently with lifesaving measures
What is a biomedical model?
Looking at only biological factors when diagnosing and treating a condition
What is clustering?
Interpreting data by identifying clusters of cues
What does EBP stand for?
Evidence based practice
What does NANDA stand for?
North American Nursing Diagnosis Association
How far should you sit from your patient during the interview?
You should social distance (sit 6 feet away)
What is the point of the interview?
- Subjective data collection
- Patient perception of health
- First step in the therapeutic relationship
What is the goal of the interview?
Identify health strengths and problems as a bridge to the physical examination
What type of data does the interview collect?
Subjective data (what the person says about his or her health)
Why is collecting subjective data so important?
Because the patient knows everything about their health and the nurse knows nothing
What are characteristics of a successful interview?
- Gather complete and accurate data, including description and chronology of any symptoms of illness
- Establish rapport and trust so person feels free to share all relevant data
- Patient teaching (health promotion/prevention)
- Building a relationship of open communication and trust
What expectations should be set before the interview?
- Time and place of interview and physical exam
- Introduction and role
- Purpose of interview
- How long it will take
- Expectation of participation
- Presence of others (family, etc.)
- Confidentiality and to what extent it may be limited
- Any costs that the patient must pay
What are the external factors to keep in mind during communication during the interview?
- Ensure privacy
- Refuse interruptions
- Physical environment (no music, lights up, med temp room)
- Dress is appropriate for setting
- Note-taking may be unavoidable
- Tape and video recording
What are some things to keep in mind when introducing yourself to a patient?
- Always introduce yourself, even if you have taken care of them before
- Call them by Mr. Mrs. or Ms. and their last name
What are open-ended questions?
- Questions that ask for narrative responses
- Questions that state the topic only in general terms
What type of question should be mostly used during the interview?
Open-ended questions
When should open-ended questions be used?
- To begin the interview
- To introduce a new section of questions
- Whenever the patient introduces a new topic
What are closed or direct questions?
- Questions that ask for specific information
- Questions that elicit a short one or two word answer, a yes or no answer, or a forced choice
When should direct questions be used during the interview?
- After opening narrative to fill in details person may have left out
- When you need many specific facts about past health problems or during review of systems
- To move the interview along
What is a reflection?
- Restating back what the client said
- Is a statement, not a question
When should a reflection be used with a client?
Can be used to encourage or keep exploring an issue without additional questions
How do you use a reflection with a client?
- Start with “You feel…”, “You’re wondering…” , “It sounds like…”
- May use new words, but much of the reflection should be the same as what the client said
- Voice inflection should go down. Should not be said as a question.
What is a summary statement?
- Summaries are longer reflections
- Collection of main themes from the section just completed
When should a summary statement be used?
- Can be used to consolidate several pieces of information
- When transitioning to a new topic
- To finish a conversation
How do you make a summary statement to your client?
Repeat back the important parts of what the client told you. Always end with asking “What did I miss?”
What should the interview always end with?
A positive comment:
- Affirmation
- Acknowledgement
What is an affirmation?
Find a positive attribute about that person
What is an acknowledgement?
State your appreciation for that person
What are the 10 traps of interviewing?
1- Providing false assurance or reassurance 2- Giving unwanted advice 3- Using authority 4- Using avoidance language 5- Engaging in distancing 6- Using professional jargon 7- Using leading or biased questions 8- Talking too much or too fast 9- Interrupting 10- Using too many “why” questions
What are some things to remember when considering gender during the interview?
- Beware of maintaining cultural norms during interview and examination process
- Maintaining privacy and modesty
What are some things to keep in mind about sexual orientation during the interview process?
- Maintaining neutrality related to patient’s presentation by being mindful of communication patterns
- Being aware of your own personal bias and baggage
Biographical Data to be collected from patient:
1- Name 2- Address and phone number 3- Age and birth date 4- Birthplace 5- Sex 6- Marital status 7- Race 8- Ethnic origin 9- Primary language and if interpreter is needed 10- Occupation: usual and present
What considerations need to be taken about the source of patient’s history?
- Record who furnishes information
- Judge reliability of informant and how willing he or she is to communicate
- Note any special circumstances, such as use of interpreter
What is one way to gauge whether an informant is reliable?
- A reliable person always gives the same answers when questions are rephrased or are repeated later in interview
What should be asked after taking the patient’s demographics?
Reason for seeking care
What is Reason for Seeking Care and how should it be written?
Why is the patient there?
Should be enclosed in quotation marks to indicate patient’s exact words
What is another name for “Reason for seeking care”
Chief complaint
What information goes in Present Health or History of Present Illness section?
- Location of pain
- Character or quality
- Quantity or severity
- Timing
- Setting
- Aggravating or relieving factors
- Associated factors (does this happen every time you…?)
- Patient’s perception (ask pt what they feel like is happening)
Which section does the subjective data collected from patient go?
In the “present health” or “history of present illness” section
What is included in past medical history?
- childhood illnesses
- accidents or injuries
- serious or chronic illnesses
- hospitalizations
- operations
- obstetric history
- immunizations
- last examination date
- allergies
- current medications
What needs to be documented for the patient’s medications?
- drug name
- dose
- route
- times per day
- last does taken
(Can also ask what they take it for if unsure)
What information is needed when asking about family history?
- Age and health or cause of death of relatives
- Health of close family members (immediate family members and grandparents)
- Family history of various conditions
What are some examples of conditions in the family history that would be good to know?
- heart disease
- high blood pressure
- stroke
- diabetes
- cancer
What systems do we need to ask the patient about?
general overall health state, skin, hair, head, eyes, ears, nose and sinuses, mouth and throat, neck, breast, axilla, respiratory system, cardiovascular, peripheral vascular, gastrointestinal, urinary system, male genital system, female genital system, sexual health, musculoskeletal system, neurologic system, hematologic system, endocrine system
What are the five steps to evidence-based practice?
1- Ask the clinical question 2- Acquire sources of evidence 3- Appraise and synthesize evidence 4- Apply relevant evidence in practice 5- Assess the outcomes
What is facilitation as an examiners verbal response while talking with a patient?
A response that encourages the client to say more and shows them that you are interested
Ex: “go on”, nodding yes, maintaining eye contact
Why would an examiner use silence when talking with a patient?
- lets the client know they have time to think
- gives you a chance to observe client
- give client a chance to not be interrupted and not lose train of thought
What is empathy and why would it be used when talking with a client?
- Names a feeling and allows its expression
- Allows person to feel accepted and strengthens rapport
- Useful when client hasn’t identified the feeling or isn’t ready to discuss it yet
When is clarification useful when talking with a patient?
- Useful when the patient’s word choice isn’t clear
- summarizes the person’s word and simplifies the statement to ensure you are on the right track
What is confrontation when talking with a client?
- Clarifying inconsistent information
- Focusing client’s attention on an observed behavior, action, or feeling
What is interpretation when talking with a client?
- Links events, makes associations, and implies cause
- Not based on direct observations but instead on inference or conclusion
- Your interpretation may be incorrect but helps prompt further discussion
What is an explanation when talking with a client?
- Informing the person
- Sharing factual and objective information
What are the different types of nonverbal behaviors we should keep in mind toward our patient during an interview?
- appearance, whether you’re standing or sitting, where you are in relation to the patient, your posture, how you are leaning, if you’re distracted vs engaged, facial expression, eye contact, tone of voice, rate of speech, touch
What are the four different distance zones? And how far is each zone from the patient?
1- Intimate zone (0 to 1.5ft)
2- Personal distance (1.5 to 4ft)
3- Social distance (4 to 12ft)
4- Public distance (12+ft)
Remarks about the intimate zone, what is it used for?
- Visual distortion occurs
- Best for assessing breath and body
Remarks about personal distance
- Perceived as an extension of the self, similar to a bubble
- Voice moderate
- Body odors apparent
- No visual distortion
- Much of physical assessment occurs at this distance
Remarks about social distance
- Used for impersonal business transactions
- Perceptual information much less detailed
- Much of interview occurs at this distance
Remarks about public distance
- Interaction with others is impersonal
- Speaker’s voice must be projected
- Subtle facial expressions imperceptible
What age is a patient in the sensorimotor stage?
Birth to 2 years
What age is a patient in the preoperational stage?
2-6 years
What age is a patient in the concrete operations stage?
7-11 years
What age is a patient in the formal operations stage?
12+ years
Characteristics of the sensorimotor phase
- Infant learns by manipulating objects
- At birth reflexive communication, then moves though 6 stages to reach actual thinking
Characteristics of preoperational stage
- Beginning use of symbolic thinking
- Imaginative play
- Masters reversibility
Characteristics of concrete operations stage
- Logical thinking
- Masters use of numbers and other concrete ideas such as classification and conservation
Characteristics of the formal operations stage
- Abstract thinking. Futuristic; takes broader, more theoretical perspective
Language development during sensorimotor stage
- Communication largely nonverbal
- Vocab of more than 4 words by 12 mo.
- Increases to over 200 and use of short sentences before 2 yrs
Which senses does a nurse use?
- Sight
- Smell
- Touch
- Hearing
Skills performed during assessment, in order:
- Inspection
- Palpation
- Percussion
- Auscultation
What is inspection?
Close, careful scrutiny, first of the whole person and then of each body system
When does inspection start?
Begins when you first meet the patient
What should the assessment of each body system start with?
Inspection
What is the first step of assessment?
Inspection
What does inspection require?
- Good lighting
- Adequate exposure
- Occasional use of instruments
What is the second step of assessment?
Palpation
What are we feeling when we palpate?
- Texture
- Temperature
- Moisture
- Organ location and size
- Swelling, vibration, or pulsation
- Rigidity or spasticity
- Crepitation
- Presence of lumps or masses
- Presence of tenderness or pain
What are the types of palpation techniques?
- Fingertips
- Fingers and thumb
- Dorsa of hands and fingers
- Base of fingers or ulnar surface of hands
What do we use our fingertips to palpate?
Best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps
What are the fingers and thumb used for during palpation?
Detection of position, shape, and consistency of organ or mass
What are the dorsa of hands and fingers used for during palpation?
Best for determinng temperature because skin here is thinner than on palms
What are the base of fingers or ulnar surface of hand used for during palpation?
Best for vibration
Explain the sequence of events used during palpation?
- Light palpation first
- Deeper palpation when needed (use intermittent pressure)
- Bimanual palpation
When should deeper palpation not be used?
In there is a situation in which deep palpation could cause internal injury or pain
What is bimanual palpation?
Requires use of both hands to envelop or capture certain body parts or organs for more precise delimitation
What is the third step of the assessment process?
Percussion
What is percussion?
Tapping person’s skin with short, sharp strokes to assess underlying structures
What is percussion used for?
- Mapping location and size of organs
- Signaling density of a structure by a characteristic sound
- Detecting a superficial abnormal mass
- Eliciting pain if underlying structure is inflamed
What are the characteristics of sound we listen for during percussion?
- Amplitude
- Pitch
- Quality
- Duration
What is amplitude?
Is the sound loud or quiet?
What are we listening to pitch for?
To determine if it’s high pitch or low pitch
What are we listening to when determining the quality of the sound while doing percussion?
A subjective difference caused by the distinctive overtones of a sound (clear or hollow, booming, muffled thud, a dead stop, etc.)
What are we listening to when determining the duration of a sound during percussion?
The length of time the note lingers
What is the fourth step in assessment?
Auscultation
What is auscultation?
Listening with a stethoscope
How does a stethoscope work?
It does not magnify sound, but it blocks out extraneous sounds
What is the diaphragm of a stethoscope used for?
Listening to high pitched sounds
What is an example of sounds the diaphragm used to listen to?
Lung sounds, some heart sounds, bowel sounds
What type of pressure should be used when using the diaphragm of a stethoscope?
Firm pressure
What type of pressure should be used when using the bell part of the stethoscope?
Light pressure
What type of sounds is the bell of a stethoscope used to listen to?
Lower pitched sounds
What are some examples of sounds the bell of the stethoscope would be used to listen to?
Some heart sounds Vascular sounds (blood flow sounds)
Describe correct placement of the diaphragm?
Applied tightly and firmly to the skin
Describe the correct placement of the bell?
Applied lightly to the skin
The single most important step to decrease infection
Wash your hands
When should you wash your hands (or use hand sanitizer)?
- Before and after physical contact with each patient
- After contact with blood, body fluids, secretions, and excretions
- After removing gloves
When should you wear gloves?
- When potential exists for contact with any body fluids
If there is potential for blood or body fluid spattering, what should you do?
Wear a gown, mask, protective eyewear, and gloves
List the different types of percussion notes that can be heard
- resonant
- hyperresonant
- tympany
- dull
- flat
What are characteristics of a resonant percussion note?
- Medium-loud amplitude
- Low pitch
- Clear, hollow quality
- Moderate duration
Example of where a resonant percussion note can be heard?
Over normal lung tissue
What are the characteristics of a hyperresonant percussion note?
- Louder amplitude
- Lower pitch
- Booming quality
- Longer duration
What is an example of where a hyperresonant percussion note can be heard?
- Normal over child’s lung
- Abnormal in the adult, over lungs with increased amount of air as in emphysema
What are the characteristics of a tympany percussion note?
- Loud amplitude
- High pitch
- Musical and drumlike quality
- Longest duration
What is an example of where a tympany percussion note can be found?
Over air-filled viscus (e.g. the stomach, the intestine)
What are the characteristics of a dull percussion note?
- Soft amplitude
- High pitch
- Muffled thud quality
- Short duration
What is an example of where a dull percussion note can be found?
Relatively dense organ as liver or spleen
What are the characteristics of a flat percussion note?
- Very soft amplitude
- High pitch
- A dead stop of a sound, absolute dullness quality
- Very short duration
What is an example of where a flat percussion note can be heard?
When no air is present, over thigh muscles or bone, or over a tumor
What does the term Standard Precautions mean?
It is the principle that all fluids, etc. could contain transmissible infectious agents.
So, precautions apply to all patients:
- hand hygiene
- use of PPEs
- respiratory hygiene/cough ettiquite
What is a nosocomial infection?
A health care-associated infection
What are considered vital signs?
- Temperature
- Pulse
- Respirations
- Blood pressure
- Blood oxygen
How does the body maintain a steady temperature?
- Through a feedback mechanism which is regulated in the hypothalamus of the brain
How can the body’s temperature become unbalanced?
Due to outside temperatures or infection
Routes of measuring a patient’s temperature
- Oral sublingual
- Rectal
- Axillary
- Tympanic membrane
- Temporal artery
What is a normal oral temperature of a resting person?
37 degrees celcius
What is a normal oral temperature range?
35.8 - 37.3 degrees Celcius
What is the most used route to take a patient’s temperature, and why?
Oral sublingual site
Because it’s accurate and convenient
What is a reason someone’s oral temperature my not be accurate?
If they just drank something cold
What is the most accurate route of tempature measurement?
Rectal
When would a patient’s temperature be taken rectally?
If they are:
- comatose
- confused
- in shock
- cannot open or close mouth
What bodily temperature indicates hyperthermia?
Greater than 38 degrees Celsius
Greater than 100.4 degrees F
What temperature indicates hypothermia?
Less than 36 degrees Celsius
Less than 96.8 degrees F
A patient has a temperature of 39 degrees Celsius. They have? Spelling?
Hyperthermia
A patient has a temperature of 35 degrees Celsius. They have? Spelling?
Hypothermia
What is normal temperature influenced by?
- Diurnal cycle
- Menstruation cycle in women
- Exercise
- Age
What is the diurnal cycle?
Temperature raises 1 - 1.5 degrees F in the late afternoon / evening
What happens to someone’s temperature during their menstruation cycle?
- Progesterone secretion during ovulation at midcycle
- Causes a 0.5 - 1 degree F rise in temperature that continues until menses
How can exercise affect body temperature?
Moderate to hard exercise increases body temperature
How does age affect body temperature?
- Wider normal variations occur in infant and young children (they have less effective heat control mechanisms)
- In older adults, temperature is usually lower with a mean of 36.2 degrees C
What is the mean body temperature of older adults?
- 2 degrees C
97. 2 degrees F
What is pulse a measurement of?
Stroke volume
What is stroke volume?
Amount of blood every heart beat pumps into aorta
How does stroke volume cause pulse?
Force flares arterial walls and generates pressure wave, felt in periphery as pulse
What information is gained from palpating a peripherial pulse?
- Gives rate and rhythm of heartbeat
- Gives local data on condition of artery
Pulse point usually palpated while measuring vital signs
Radial pulse
How would you palpate the radial pulse?
- Use pads of first three fingers
- Radial pulse is at flexor aspect of wrist, laterally along radius bone
- Push until strongest pulsation is felt
What is documented after taking someone’s pulse?
- Rate
- Rhythm
- Force
If rhythm of pulse is regular, how should you count?
Count number of beats in 30 seconds and multiply by 2
Start counting after 1st beat is heard
If rhythm of pulse is irregular, how should you count?
Count number of beats in one full minute
Why is the 30 second interval used when measuring pulse?
It is the most accurate and efficient method when heart rates are normal or rapid and when rhythms are regular
When assessing pulse, what should you pay attention to?
- Rate
- Rhythm
- Force
- Elasticity
Which patients may not have a pulse with good elasticity?
Patients with heart disease, smokers
Normal heart rate range in a resting adult
60 to 100 bpm
What bpm indicates a patient has tachycardia?
Greater than 100 bpm
What bpm indicates a patient has bradycardia?
Less than 50 bpm
If a patient has a bpm of 45 bpm, what do they have?
Bradycardia
If a patient has a bpm of 115, what do they have?
Tachycardia
What is the rhythm of a normal pulse?
Normally has an even tempo
What are some examples of patients who would not have a pulse with an even tempo?
If they have sinus arrhythmia
Or atrial fibrillation
How is pulse force recorded?
Using a three-point scale
Explain the three-point scale when documenting pulse
3+ : Full, bounding
2+ : Normal
1+ : Weak, thready
0 : Absent
When would someone have a 3+ pulse force?
When they have increased stroke volume
- Exercise
- Anxiety
When would someone have a 1+ pulse force?
When they have decreased stroke volume
- hemorragic shock
- old and dehydrated
What does a 2+ pulse force indicate?
Normal (most healthy people)
How should respirations be?
Breathing should be relaxed, regular, and silent
How should you measure respirations?
- Do not mention that you will be counting them
- Count for 30 seconds (or a full minute if you suspect an abnormality)
What is a normal rate of respirations?
10-20 breaths per minute
Why should we write out breaths per minute instead of abbreviating to bpm
Can get confused with beats per minute
In general, what is blood pressure measuring?
The force of blood pushing against the side of vessel wall
What is systolic pressure?
Maximum pressure felt on artery during left ventricular contraction, or systole
What is diastolic pressure?
Elastic recoil, or resting, pressure that blood exerts constantly between each contraction
If you were explaining the difference between systolic and diastolic pressure to your patient, how would you explain it?
Systolic is when the heart is squeezing the blood, and diastolic is when the heart relaxes
What is the average blood pressure in young adults?
120/80 mm Hg
What biological factors cause blood pressure to vary?
- Age
- Gender
- Race
How does age affect blood pressure?
A gradual rise occurs from childhood to adult
How does gender affect blood pressure?
BP is lower in females than in males
How does race affect blood pressure?
BP is usually higher in African Americans
Factors the level of blood pressure are determined by:
1- Cardiac output 2- Peripheral vascular resistance 3- Volume of circulating blood 4- Viscosity 5- Elasticity of vessel walls
How does cardiac output affect blood pressure?
More blood pumped = increased pressure
How does peripheral vascular resistance affect blood pressure?
When vessels become smaller or constricted, pressure needed to push becomes greater (think big straw vs. skinny straw)
How does the volume of circulating blood affect blood pressure?
This refers to how tightly blood is packed into arteries
So, increasing contents in vessels (ex: blood transfusion) increases pressure
What is viscosity?
The thickness of blood
How does elasticity of vessel walls affect blood pressure?
Stiff walls = increased pressure
How does the viscosity of blood affect blood pressure?
When blood is thicker, pressure increases
Example of increased cardiac output:
What happens to blood pressure?
Heavy exercise
BP goes up
Example of decreased cardiac output:
What happens to blood pressure?
Pump failure (weak pumping action after myocardial infarction, or in shock) BP goes down
Example of a decrease in circulating blood:
Hemorrhage
Example of an increase in volume of circulating blood:
- Increased sodium and water retention
- Intravenous fluid overload
What causes an increase in the viscosity of blood?
Increased hematocrit in polythemia
What can cause increased rigidity in arterial walls?
What would happen to blood pressure?
Hardening as in arteriosclerosis
Heart is pumping against greater resistance, so BP would go up
In which situations should you take serial measurements of pulse and blood pressure?
- You suspect volume depletion
- Person is known to have hypertension or taking antihypertensive medications
- Person reports fainting or syncope
How should you detect orthostatic or postural vital signs?
1- Have person rest supine for at least 3 mins, then take baseline BP and pulse readings
2- Have person sit up and assess BP and pulse
3- Have person stand up and assess BP and pulse
4- After person has been standing for 3 minutes, assess BP and pulse
It is normal for blood pressure to drop by how much when a person stands up?
1 mm Hg
If a patient reports fainting upon standing, what are you going to try to detect?
Orthostatic hypotension
What is orthostatic hypotension?
When a patient has a drop in BP greater than 20mm Hg systolic
OR a drop in BP greater than 10mm Hg diastolic when they change position from lying to standing
When can orthostatic changes typically occur in patients?
- prolonged bed rest
- older age
- hypervolemia
- with some medications
Symptom of high blood pressure that is often overlooked
Headache
Measurements of NORMAL blood pressure
Systolic LESS THAN 120
AND
Diastolic LESS THAN 80
Measurements of ELEVATED blood pressure
Systolic between 120-129
AND
Diastolic LESS THAN 80
Measurements of STAGE 1 HYPERTENSION
Systolic between 130-139
OR
Diastolic between 80-89
Measurements of STAGE 2 HYPERTENSION
Systolic 140 or higher
OR
Diastolic 90 or higher
Measurements for a HYPERTENSIVE CRISIS
Systolic higher than 180
AND/OR
Diastolic higher than 120
If a patient has a BP of 120/80 mm Hg, what is their blood pressure category?
Stage 1 hypertension
If patient has a BP of 120/78 mm Hg, what is their blood pressure diagnosis?
Elevated
If a patient has a BP of 118/76 mm Hg, what is their blood pressure category?
Normal
If a patient has a BP of 210/89 mm Hg, what is their blood pressure category?
Hypertensive crisis
If a patient has a BP of 131/78 mm Hg, what is their blood pressure category?
Stage 1 hypertension
If a patient has a BP of 160/89 mm Hg, what is their blood pressure category?
Stage 2 Hypertension
If a patient has a BP of 135/91 mm HG, what is their blood pressure category?
Stage 2 Hypertension
How is oxygen saturation measured?
Which a pulse oximeter
What is a pulse oximeter?
A noninvasive method to assess arterial oxygen saturation
What unit is blood oxygen measured in?
SpO2
SpO2 of a healthy person with no lung disease and no anemia?
97% to 98%
What level of blood oxygen is worrisome?
Less than 97% SpO2
What is primary hypertension?
There is no known cause responsible for it
This makes up 95% of cases
What is an auscultatory gap?
- Period when Korotkoff sounds disappear during auscultation
- Maximum inflation pressure helps avoid this
- Does occur in about 5% of people, most often in hypertension caused by a noncompliant arterial system
What are Korotkoff sounds?
- Sounds heard during BP reading
- Consist of phases I, IV, & V
Name of a blood pressure cuff
Sphygmomanometer
What does TPR BP stand for?
Temperature, pulse, respiration, blood pressure
What does SpO2 stand for?
Oxygen saturation
Abbreviation for oxygen saturation
SpO2
If a patient has nail polish and the pulse oximeter can’t read through it, what should you do?
Put it on the side of their finger, side of hand, or ear
What is the 2-step blood pressure method used for?
- To prevent injury to patient from inflating cuff too far
- To give a smaller window on sphigmomanometer to listen to
Steps of the 2-step blood pressure method:
- Put cuff on
- Palpate brachial pulse
- Inflate cuff
- Look at # of mmHg when you can no longer feel pulse
- Deflate cuff, wait for a few minutes
- Put stethoscope on brachial pulse
- Inflate to 20-30mm Hg above # you just found
- Deflate cuff
- 1st sound is systolic, no more sound is diastolic
What are the phases of Korotkoff sounds?
Phase I Ausulatory gap (abnormal) Phase II Phase III Phase IV Phase V
What does plase I of Korotkoff sounds sound like?
Tapping: Soft, clear tapping, increasing in intensity
Why can you hear sound during phase I of Korotkoff sounds?
The cuff pressure decreases and blood spurts at high velocity into brachial artery. The turbulent blood flow is audible
What does phase II of Korotkoff sounds sound like?
Swooshing: softer murmer follows tapping
Why does phase II Korotkoff sounds sound like swooshing?
You can hear the turbulent blood flow through still partially occluded artery
What does phase III of Korotkoff sounds sound like?
Knocking: crisp, high-pitched sounds
Why does phase III of the Korotkoff sounds sound like tapping?
There has been a longer duration of blood flow through the artery. Artery closes just briefly during diastole
What does phase IV of Korotkoff sounds sound like?
Abrupt muffling: Sound mutes to low-pitched, cushioned murmer; blowing quality
Why does phase IV of the Kortokoff sounds sound like abrupt muffling?
- Artery no longer closes in any part of the cardiac cycle
- Change in quality, not intensity
What does phase V of the Kortokoff sounds sound like?
Silence
Why is there silence during phase V of the Kortokoff sounds?
There is a decreased velocity of blood flow
Which Kortokoff phase determines systolic blood pressure?
Phase I
Which Korotkoff sound determines diastolic pressure?
Phase V
If pt’s BP is taken while angry or upset:
Falsely high
If pt’s BP is taken while arm is above level of heart:
Falsely low
If pt’s BP is taken with arm below level of heart:
Falsely high
If pt supports their own arm during BP reading:
Falsely high diastolic
If pt’s legs are crossed during BP reading:
Falsely high systolic and diastolic
If the BP cuff is too narrow during reading:
Falsely high BP
If cuff is wrapped too loosely or undevenly during BP reading:
Falsely high BP
If the cuff is inflated too low during BP reading:
Falsely low systolic
If the cuff is inflated too high during BP reading:
Pain for the pt
If you push stethoscope too hard on bracial artery during BP reading:
Falsely low diastolic
If you deflate the BP cuff too quickly:
Falsely low systolic or falsely high diastolic
If you deflate the BP cuff too slowly:
Falsely high diastolic
Halting during descent and reinflating cuff to recheck systolic:
Falsely high diastolic
Failure to wait 1-2 minutes before repeating entire BP reading:
Falsely high diastolic
List hypertension risk factors:
- Smoking
- Dyslipidemia
- Diabetes mellitus
- Age >60 years
- Gender (men & postmenopausal women)
- Family history of cardiovascular disease
Lifestyle modifications to control blood pressure:
- lose weight
- limit alcohol
- increase aerobic physical activity
- reduce sodium
- maintain adequate potassium intake
- maintain adequate calcium and magnesium intake
- stop smoking
- reduce saturated fat and cholesterol
When is general survey done?
During first step, (Assessment) while introducing yourself to patient
What are we assessing during general survey?
- Physical appearance
- Body structure
- Mobility
- Behavior
When do we assess mental status?
At the same time as general survey (during Assessment while introducing yourself)
What are we assessing during mental status assessment?
- Appearance
- Behavior
- Cognition
- Thought process
In more detail, what factors are we noting during general survey?
- Age: appears stated age
- Sex: appears stated sex
- Skin color: ethnicity, pink, even skin tone, tattoos, body piercings, etc.
- Facial features: symmetrical? Abnormalities?
- Stature/posture: extremely tall or short? Erect?
- Mobility: gait, range of motion, able to ambulate independently
What is mental status?
A person’s emotional and cognitive functioning
What are optimal functioning aims for mental status?
- Life satisfaction
- Work satisfaction
- Caring relationships
- Self satisfaction
A balance between good and bad days
- Social function
- Occupational function
How is mental status assessed?
It is inferred through assessment of behaviors.
It is not 100% objective
Which behaviors are we assessing during mental status assessment?
- Consciousness
- Language
- Mood and affect
- Orientation
- Attention
- Memory
- Abstract reasoning
- Thought process
- Thought content
- Perceptions
What is a patient’s mood, in relation to mental status?
A more prolonged display of feelings
What is affect in relation to a patient’s mental status?
Temporary expression of feelings
What does orientation mean in relation to mental status?
Does the person know person, place, time:
- Who they are
- Where they are
- What time it is
What does perceptions mean in relation to mental status?
Patient’s awareness through all of their senses
List the levels of consciousness:
- Alert
- Lethargic (somnolent)
- Obtunded
- Stupor or semi-coma
- Coma
What does it mean if a patient is alert?
Awake
Oriented
Meaningful interactions
What does it mean if a patient is lethargic (somnolent)?
Not fully alert
Drifts to sleep
Aroused when name called
What does it mean if a patient is obtunded?
Sleepy
Difficult to arouse (need to shout or sternal rub)
What does it mean if a patient is stupor (or semi-coma)?
Unconscious
Responds only to vigorous sternal rub
What does it mean if a patient is in a coma?
Completely unconscious
No response to pain or stimuli
Examples of a patient being in coma:
- Right after surgery and still sedated
- Sometimes a trauma patient
What is a mental status examination (MSE)?
A systemic check of emotional and cognitave functioning
When do we perform the MSE?
Assessed while asking health history interview questions
What are the four main headings of the mental status examination?
Appearance
Behavior
Cognition
Thought process
(ABCT)
When is it necessary to perform a full mental status exam?
When integrating the MSE in HH, you notice or learn:
- Behavior changes
- Memory changes
- Brain lesions (trauma, tumor, stroke)
- Aphasia (secondary to brain damage)
- Symptoms of phychiatric mental illness
- Family concerns about patient
When observing a patient’s appearance during a MHE, what are we looking at?
Dress
Grooming and hygiene
What do we pay attention to about how a patient is dressed during a MHE?
Appropriate for:
- Setting
- Season
- Age
- Gender
- Social group
What do we pay attention to about a patient’s grooming and hygiene during a MHE?
Clean and well groomed?
Disheveled appearance in previously well-groomed person is significant
Factors we observe when assessing a patient’s behavior during a MHE?
Level of consciousness
Facial expression
Speech
Mood and affect
What are we noting about a person’s level of consciousness during a MHE?
Person is awake, alert, aware
Responds appropriately
What are we noting when assessing a patient’s facial expression during a MHE?
Appropriate to situation
Changes appropriately with topic
What are we noting about a patient’s speech during a MHE?
Shares conversation appropriately
Pace is moderate
Articulation is clear and understandable
Word choice is effortless
What are some ways a patient’s speech may not be moderate?
If they’re anxious and speaking fast Pressured speech (won’t let you get a word in)
What are some examples of what would make a person’s speech not be articulate?
Dentures
Stroke
What does it mean for a patient’s word choice to be effortless? What would be the opposite of effortless?
Appropriate to educational level
Completes sentences
Pauses to think
How do we judge a patient’s mood and affect?
Body language
Facial expression
Asking “how do you feel today?”
When assessing a patient’s orientation, what main questions should we ask them? And examples of how to ask them
Time
- Day of week, date, year, season
Place
- where they live, address, phone number, present location, name of city and state
Person
- name, age, type of work they do
How do you document orientation if patient is completely orientated?
Awake, alert, and oriented to person, place, and time.
How do you document orientation if a patient only knows who they are?
Awake, alret, oriented to person, not time or place
How do you document if a patient doesn’t know date/month/year/season?
Awake, alert, oriented to person and place, not to time
What does a patient’s attention span referr to when doing MHE?
Completes a thought without wandering
How can you assess a patient’s recent memory?
Assess 24 hour diet recall or by asking time person arrived at agency
How can you assess a patient’s remote memory?
Verify historical events, birthdays or anniversary dates
What is a patient’s judgement when doing a MHE?
Ability to compare and evaluate alternatives and reach an appropriate course of action
How can we assess whether a patient has good judgement during a MHE?
- Test on daily or long-term goals
- Note what person says about job plans, social or family obligations, and plans for the future.
- Ask for rationale for their health care (compliance/decision making)
What would make us determine that a patient has good judgement during a MHE?
All thoughts and plans are logical and realistic
List of factors that can cause impared judgement:
- long history of drug use
- developmental disability
- emotional dysfunction
- schizophrenia
- organic brain disease (Altzhimer’s/dimensia)
How can you test a patient’s new learning abilities in a MHE?
The four unrelated words test
What is the four unrelated words test?
A highly sensitive and valid memory test
How do you perform the four unrelated words test on a patient?
- Pick four words with different sounds
- Ask person to remember four words
- Ask patient to repeat (be certain of understanding)
- Ask for recall in 5, 10, & 30 minutes
Normal response is accurate recall
Loss of ability to speak (spelling)
Aphasia
What is aphasia?
Loss of ability to speak, write coherently, or understand speech
If you suspect a patient has aphasia, how can you test their word comprehension?
Point to articles and have patient name them
If you suspect a patient has aphasia, how can you test their reading?
Ask person to read available print (can they read?)
If you suspect a patient has aphasia, how can you test their writing ability?
Ask person to write a sentence; note coherence and spelling
What is a mandatory regulatory requirement when assessing patients?
Screening for suicidal thoughts
How do you go about asking a patient about suicidal thoughts?
Begin with more general questions - probe if needed
Examples of questions you’d ask a patient to determine if they have suicidal thoughts?
- Have you ever felt so blue you thought of hurting yourself or do you feel like hurting yourself now?
If yes, - Do you have a plan to hurt yourself?
If yes, - How would other people react if you were dead?
What is PHQ-9?
A patient health questionare to assess for depression
What is GAD-7?
Patient health questionare to assess for generalized anxiety disorder
When do you ask patient all 9 questions of the PHQ-9?
If answer is yes to first 2 questions
Most abused phychoactive drug
Alcohol
What does it mean if a medication is additive to alcohol?
Makes patient very drowsy when mixed with alcohol
What does it mean if a patient’s medication interacts with alcohol?
Doesn’t blend - makes them very sick
Comorbidities of alcohol:
- up to 1 drink/day = increased breast cancer risk
- chronic alcohol use = liver disease
- heavy/binge drinking = increased risk of cardiac issues
- hypertension
Fastest growing drug problem in US
Prescription drug use
How many adolescents use illicit drugs?
1 out of 10
How many Americans over 12 use illicit drugs?
9.5%
3 most frequently abused prescription opoid pain relievers:
- oxycodone
- hydrocodone
- methadone
What should you ask if you find out a patient is taking opoid pain relievers?
How much they take
How long they have been taking them
What is CAGE?
A questionare to determine alcohol dependence
Why is accurate diagnosis of alcoholism needed?
For:
- advice
- intervention
- appropriate treatment
- and follow up
Which trimester during pregnancy, do women drink the most? When do they drink the least?
Most = 1st trimester Least = 3rd trimester
Which age range does alcohol use decrease?
Age 65 or older
Why does alcohol use decrease with age?
Effects of alcohol become increased with smaller amounts because body’s ability to filter out alcohol decreases
Characteristics of older adults that increase risk with alcohol use:
- Liver metabolism and kidney function decrease = alcohol in blood for longer
- Less tissue mass = increased alcohol concentration in blood
- Medications = interact with alcohol
- Increases risks of falls, depression, and GI problems
If patient is currently intoxicated or going through substance withdrawl, how should you collect subject data?
Collect what you can, maybe ask a family member
And record the rest later
How should you ask a patient about alcohol use?
“Do you sometimes drink beer, wine, or other alcoholic beverages?”
If yes - “How many times in the past year have you had:
- Five or more drinks a day (for men)
- Four or more drinks a day (for women)?”
How many drinks is it ok for women to drink?
How many drinks is it ok for men to drink?
Women: 1 drink or less per day
Men: 2 drinks or less per day
What is nutritional status?
The degree of balance between nutrient intake and nutrient requirements
Factors that affect nutritional status:
- Physiologic
- Psychological
- Developmental
- Cultural
- Economic
What are the purposes of nutritional assessment?
- Identify individuals who are malnorished (or at risk)
- Provide data for providing nutrition plan of care
- Establish baseline data for evaluating effacacy of nutritional care
Underweight BMI measurement:
<18.5
Overweight BMI measurement:
25-29.9
Obese BMI measurement:
> 30
Nutrition screening is a quick and easy way to identify the following:
- nutritional risk
- weight loss
- inadequate food intake
- recent illness
Parameters of nutrition screening:
- weight and weight history
- diet information
- anthropometric measures
Methods for collecting current dietrary intake information:
- 24 hour recall
- food frequency questionnaire
- food diary
Easiest and most popular nutrition screening method
24 hour recall
What does a 24 hour nutrition recall entail?
- questionnaire or pt is interviewed and asked to recall everything eaten in past 24 hours
Possible errors during a 24 hour nutrition recall
- Pt unable to remember everything
- Pt may alter truth
- Snack items/sauces/condiments often underreported
What is a food frequency questionnaire?
Documents times per day, week or month individual eats particular foods
Drawbacks of a food frequency questionnaire?
Does not quantify amount of intake
Relies on pt’s memory for how often a food was eaten
What is the most accurate method of screening a patient’s nutrition?
Food diary
What does a food diary entail?
Documents everything consumed for a certain period of time
What is the recommended period of time recommended to document for a food diary?
Three days
2 week days, 1 weekend day
Potential problems with a food diary?
- noncompliance
- inaccurate recording
- atypical intake on recording days
- conscious alteration of diet during recording period
Height and weight, triceps skinfold thickness, and circumferences are examples of what type of measurements?
Anthropometric measures
Most commonly used anthropometric measures:
- height and weight
- triceps skinfold thickness
- circumferences
What are derive weight measurements used for?
3 derived weight measures are used to depict changes in body weight
What are the three derived weight measures?
- body weight as a percentage of ideal body weight
- percent of usual body weight
- body mass index
What measurement is a marker of optimal weight for height and an indicator of obesity?
BMI
How do you collect a patient’s serial weight?
Weigh pt at the same time every day (most accurate in AM, after patient sleeps)
Measurement that assesses body fat distribution as an indicator of health risk
Waist-to-hip ratio
Define android obesity
Apple shape
Persons with greater proportion of fat in upper body, especially abdomen
Define gynecoid obesity
Pear shape
Persons with most of fat in hips and thighs
Waist circumference measurements that indicate an increased risk of CV and metabolic disease:
Women: > 35 inches
Men: > 40 inches
How should you measure a patient’s waist circumference?
Measure smallest part of waist, right above hip bones
Factors that determine if pt has metabolic syndrome:
- elevated BP
- impaired fasting glucose
- increased triglycerides
- decreased healthy cholesterol
- increased waist circumference
Number that determines a patient has impaired fasting glucose
Blood sugar >100 when fasting
When should you measure a patient’s fasting glucose?
At LEAST 2 hours after eating
Is most accurate when they first wake up, before eating
How do you determine if a patient has metabolic syndrome?
If pt has 3 out of 5 factors
Measurements provide an estimate of body fat stores or extent of obesity or undernutrition
Skinfold thickness
Most commonly selected area for skinfold thickness measurement
Triceps skinfold (TSF)
When comparing measurements of skinfold thickness, which factors should you take into consideration?
Age
Sex
Body frame
Define pain
A highly complex and subjective experience that origionates from the CNS, the PNS, or both
Detect painful sensations from periphery and transmit them to the CNS
Nociceptors
Where are nociceptors located?
Skin Joints Connective tissue Muscle Thoracic, abdominal, and pelvic viscera
How are nociceptors stimulated?
Mechanical or thermal trauma
Or by chemical mediators from site of tissue damage
4 phases of nociception:
1- Transduction
2- Transmission
3- Perception of pain
4- Modulation
Explain the transduction phase of nociception
- injured tissue releases chemicals that propagate pain message
- action potential moves along an afferent fiber to the spinal cord
Explain the transmission phase of nociception
The pain impulse moves from the spinal cord to the brain
Explain the perception of pain phase of nociception
Signifies the conscious awareness of a painful sensation
Explain the modulation phase of nociception
Neurons from brainstem release neurotransmitters that block the pain impulse
What ensures that the process of nociception can happen?
Must have intact and functioning nerve fibers in the periphery
Indicates type of pain that does not adhere to typical phases
Neuropathic pain
What does neuropathic pain imply?
An abnormal processing of pain message
Examples of neuropathic pain
- pt with diabetes hurts to walk, but doesnt have sores on feet
- amputee has a phantom limb
Most difficult type of pain to assess and treat
Neuropathic pain
Why is neuropathic pain so difficult to assess and treat?
- pain is often perceived long after site of injury heals
- pain can not be identified by diagnostic testing
List pain sources based on origin
- Visceral pain
- Referred pain
- Deep somatic pain
- Cutaneous pain
Pain that originates from larger interior organs
Visceral pain
What can visceral pain stem from?
Direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction
Along with pain, what does visceral pain present with?
Autonomic responses such as vomiting, nausea, pallor, and diaphoresis
Pain that is felt at a particular site but originates from another location
Referred pain
Where may referred pain originate from?
Visceral or somatic structures
Sources of deep somatic pain
Blood vessels Joints Tendons Muscles Bone
What can an injury with deep somatic pain result from?
Pressure
Trauma
Ischemia
Pain derived from skin surface and subcutaneous tissues
Cutaneous pain
Characteristics of cutaneous pain
Injury is superficial with a sharp, burning sensation
Something to keep in mind about cutaneous pain
A clinician’s lack of awareness and understanding of neuropathic pain may contribute to this mislabeling
Categories of pain
Acute pain
Chronic pain
What is acute pain?
Short term and self-limiting pain that provides a protective purpose (warns of injury)
Examples of acute pain
Surgery
Trauma
Kidney stones
Child birth
Time frame for acute pain
Less than 6 months
What is chronic pain?
Diagnosed when pain continues for 6 months or longer
Time frame for chronic pain
At least 6 months and greater
Examples of chronic pain
Arthritis
Cancer
Broken bones can lead to chronic pain
Pain is always…?
Subjective
Most reliable indicator of pain?
Patient’s subjective report
How to perform a brief pain inventory:
- ask patient to rate pain (0-10) scale
- pediatric patient - use faces scale
Initial pain assessment questions
P, Q, R, S, T, 3As:
Pain location Quality Radiating Severity Timing Aleviating Aggrivating Associated
