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N1109 - Physical Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

a process to systematically collect info about a pt

creates a comprehensive database for use in planning care

A

health assessment

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2
Q

Data collected during a health assessment includes:

A 
physical
social
cultural
environmental
emotional
wellness behavior
illness s/sx
pt strength/weaknesses
risk factors
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3
Q

An interview includes which 2 sources?

A

primary

secondary

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4
Q

A focused interview is used to:

A

clarify points
missing info
clarity of info

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5
Q

HIPAA

A

Health Insurance Portability and Accountability Act

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6
Q

Who set the tone for nursing theory?

A

Florence Nightingale

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7
Q

Government agencies that oversee health, wellness, and health promotion

A

US Preventative Service Task Force
Healthy People 2020
Office of Disease Prevent and Health Promotion (ODPHP)

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8
Q

Leavell and Clark set up what model?

A

levels of preventative healthcare

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9
Q

Theses actions are taken to maintain health, prevent illness, provide early detection of a disease, and restore the individual to the highest level fo optimum functioning

A

levels of prevention

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10
Q

What are the 3 levels of prevention?

A

Primary
Secondary
Tertiary

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11
Q

Primary level of prevention focuses on:

A

health promotion and specific protection

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12
Q

Secondary level of prevention focuses on:

A

early dx
promote treatment
disability limitation

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13
Q

Tertiary prevention focuses on:

A

restoration and rehabillitation

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14
Q

What occurs during primary prevention?

A

education
protection measures
-immunizations, exercise, clean water, reducing exposure to carcinogens/occupational hazards

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15
Q

What occurs during secondary prevention?

A

treating early stages of disease

BP screenings, breast examinations

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16
Q

What occurs during tertiary prevention?

A

individuals effected by disease

surveillance
maintenance
rehabillitation

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17
Q

___ ___ refers to those actions used to increase health or well-being and improvement of the health of individuals, families, and communities

A

health promotion

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18
Q

Health promotion is ___ motiviated

A

behavior

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19
Q

According to the Health Belief Model, what effects individual perceptions and beliefs influence the decision to act to prevent illness:

A

vulnerability to illness
if the illness effects are serious
behavior prevents the illness
benefit of reducing a risk is greater than the cost of preventative behavior

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20
Q

Biological factors that effect health promotion model

A 
age
gender
BMI
strength
agility
balance
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21
Q

Psychological factors that effect health promotion model

A

self-esteem
motivation
perception of one’s heath status

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22
Q

Sociological factors that effect health promotion

A

socioeconomic status
education
race
ethnicity

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23
Q

Racial and ethnic minorities often experience what?

A

poor access to healthcare

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24
Q

the state of being different

A

diversity

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25
Q

shared biologic characteristics and physical features

A

race

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26
Q

learned, shared, and transmitted values, beliefs, normals, and lifeway practices of a particular group

A

culture

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27
Q

represents various ethic, religious, and other groups with distinct characteristics from the dominant culture

A

subculture

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28
Q

a consciousness of belonging to a group differentiated by symbolic markers

A

ethnicity

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29
Q

people of a minority group gradually assumes attitudes, values, beliefs of dominant group

ex: move to a new country, starts eating their food, etc.

A

assimilation

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30
Q

belief that one’s own culture is superior

A

ethnocentrism

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31
Q

insiders perspective

A

emic worldview

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32
Q

outsiders perspective

A

etic worldview

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33
Q

socializing into one’s primary culture

*must know

A

enculturation

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34
Q

process of adapting to and adopting a new culture

*must know

A

acculturation

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35
Q

assuming all members of a culture are alike

A

sterotyping

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36
Q

being disoriented bc of sudden strangeness of new culture

A

culture shock

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37
Q

conscious recognition of differences and similarities between cultures

A

culture awareness

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38
Q

respect for cultural behaviors based on understanding of other perspective

A

cultural sensitivity

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39
Q

knowing and utilizing cultural knowledge to solve problems

ability of a nurse to bridge cultural gaps in caring, work with cultural differences and enable client’s and families to achieve meaningful and supportive care

*must know

A

cultural competence

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40
Q

This occurs when people have a cultural ignorance or cultural blindness about others; when people use their own values and lifestyles as the absolute guide in dealing with pts and interpreting their behavior

A

cultural imposition

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41
Q

supernatural controls your health

ex: if you sin, you may be sick as a “punishment from God”; roots/spiritual intervention to get well

A

Magico-religious belief

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42
Q

life controlled by physical and biomedical process

ex: pills, txment, sx

A

biomedical

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43
Q

take into account all aspects of a person, spiritual, emotional, phyisical, etc.

ex: Yin Yang

A

holistic

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44
Q

passed down remedies

A

folk medicine

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45
Q

DC instructions should be provided in which language?

A

pts native tongue

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46
Q

give life to a person, as it signifies whatever at the center of all aspects of a persons life

A

spirit

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47
Q

an awareness of one’s inner self an sense of a connection to a higher being, to nature, or to some purpose greater than ones self

part of the healing process; balance needed to maintain health and well-being to cope with illness

complex; unique to individuals

A

spirituality

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48
Q

nurses must be aware of their own ___ to provide spiritual care to others

A

spirituality

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49
Q

spiritual well-being qualities

A 
experience joy
able to forgive self and others
accept hardship and mortality
express enhanced quality of life
positive sense of physical and emotional well-being
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50
Q

the 2 dimensions of spiritual well-being

A

supports the relationship btw a person and God or some higher power

positive relationship and connections people have with others

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51
Q

give purpose and meaning to a person’s life, allowing for action

A

faith

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52
Q

a specific system of practices associated with a denomination, sect or form of worship

A

religion

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53
Q

product of spirituality and fath

A

hope

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54
Q

doubts the existence of God

discover meaning in what they do or how they live bc they find not ultimate meaning for the way things are

A

agonistic

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55
Q

denies the existence of God

search for meaning in life through their work and their relationships with others

A

Atheist

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56
Q

Spiritual development beings in ___

A

childhood

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57
Q

___ and ___ are closely linked to a person’s spiritual well-being, providing an inner strength for dealing with illness and disability.

A

faith and hope

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58
Q

hope provides ___

A

comfort

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59
Q

pts who may experience spiritual distress

A

lonely, few visitors
express fear, anxiety
about to have sx
illness r/t emotions or have religious or social implications
require a lifestyle change
preoccupied with religion and their health
pastor is unable to visit

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60
Q

symptoms of spiritual distress

A

disturbance in personal beliefs
questioning meaning of life, death, suffering
questioning credibility of one’s belief system
demonstrating discouragement or despair
choosing not to practice usual religious rituals
having doubts about beliefs
expressing not having a reason to live
feeling spiritually empty
emotional detachment from self and others
expressing concern over meaning of life
requesting assistance for a disturbance in belief system

calling in to work

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61
Q

Buddhism

A 
spiritual peace and liberation from anxiety to help healing
txment to prolong life encouaraged
no intoxicants
moderation eating and drinking
discourage use of drugs
assess carefully for pain
accepts modern medical science
sometimes refuse txment on Holy days
often will not take off from work d/t illness
does not always accept meds
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62
Q

Buddhism diet

A

some are vegetarians
no alcohol
many will fast on Holy days

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63
Q

Christian science

A

healing through prayer and spiritual regeneration
no dietary restriction
discourage alcohol use
medications not used but immunizations allowed if required by law
blood products avoided
transplants are rare

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64
Q

Hinduism

A 
believe illness is result of sin
faith healing
meat is forbidden
death as rebirth, reincarnation
medical is last resort
assess carefully for pain
prolonging life is discouraged
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65
Q

Islam

A

any attempt to terminate life is prohibited
ritual cleansing and preparation of the deal for burial
pork, alcohol forbidden
prescriptions containing alcohol allowed as medicine

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66
Q

Islam women prefer ___ health care providers

A

women

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67
Q

During the month of Ramadan, Islam ____ will not eat until after ___

A

women; sunset

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68
Q

Judaism

A 
circumcision on 8th day of birth
medical care by physician expected
all body parts must be buried
abortion is permitted if mother is in danger
no drugs, alcohol
discourages life support
some refuse tx on the Sabbath
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69
Q

Judaism diet

A

Kosher (avoid pork, shellfish)
Milk and meat are not mixed
Fish with fins, scales allowed

Orthodox Jews restrict pork, predatory fowl, and shellfish

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70
Q

Protestant

A

Over 50 denominations; practices differ
may prohibit alcohol
may believe in “laying on of hands” and “anointing with oil”

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71
Q

Roman Catholic

A 
may request sacrament of the sick
nurse may baptize a critically ill newborn if priest not available
Fasting = discipline
meds allowed if good for whole person
abortion, sterilization are forbidden
only natural birth allowed
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72
Q

Jehovah’s Witnesses

A

avoid food to which blood is added
No last rites or infant baptism
Opposed blood transfusions

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73
Q

Seventh-Day Adventists

A

Vegetarian
health = important
avoid narcotics, stimulants
may refuse medical txment on Sabbath (Friday sundown until Saturday sundown)

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74
Q

preventable differences in the burden of disease, injury, violence, r opportunities to achieve optimal health that are experienced by socially disadvantaged populations

A

health disparities

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75
Q

vulnerable populations for health disparities

A 
age
gender/gender identity
income
race
ethnicity and language
nativity
sexual orientation
disability
geographic location
uninsured/underinsured
maternal/infant health
immigrants, refuges
incarcerated men, women
veterans
homelessness
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76
Q

the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically

A

health equality

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77
Q

detailed record of the pts past and current health, as well as a record of perceptions about their state of health

A

health record

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78
Q

when/how does the health history begin

A

collection of information through an interview

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79
Q

purpose of the health history

A

to document the responses of the pt regarding actual and potential health concerns

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80
Q

information covered in the health history

A

past, present illnesses
family, genetic info
wellness assessment

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81
Q

most common secondary sources

A

medical records

significant others

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82
Q

actions that are used during the encoding and decoding processes to obtain info, develop relationships, and promote understanding of self and others

A

interactional skills

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83
Q

types of interactional skills

A 
attending
paraphrasing/clarification
direct leading
focusing
questioning
reflecting
summarizing
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84
Q

what is the most important interactional skill?

A

listening

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85
Q

___ ___ involves taking the pts whole message by hearing the words as well as interpreting body language.

A

successful listening

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86
Q

involves giving full attention to verbal and nonverbal messages

maintaining eye contact, proper body positioning

A

attending

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87
Q

repeating the pts verbal or nonverbal message for the pts benefit

A

reflecting

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88
Q

process of gathering ideas, feelings, and themes that pts have discussed throughout the interview and restating them in several general statements

A

summarizing

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89
Q

professional characteristics to enhance the nurse-pt interaction

A

positive regard
empathy
genuineness
concreteness

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90
Q

barriers to effective pt-interaction

A 
false reassurance
interrupting, changing subject
passing judgement
cross-examination
euphemisms
unwanted advice
technical terms
sensitive issues
cultural influence, bias
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91
Q

the initial interview begins with…

A

the nurse describing the interview process, explaining its importance, and telling the pt what to expect

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92
Q

purpose of a focused interview

A

clarification of previously obtained data
gather missing info
guide the direction of the physical assessment
identify, validate probable nursing dx

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93
Q

OLDCART

A 
onset
location
duration
characteristics
aggravating factors
relieving factors
treatment
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94
Q

ICE

A

impact on ADLs
coping strategies
emotional response

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95
Q

information the health history includes

A 
name, age, DOB
demographics
birth place
marital status
sex/gender/sexual orientation
race
religion
occupation
health insurance
source of info, reliability
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96
Q

what does psychosocial hx include?

A 
occupational hx
education
financial background
roles, relationships
family (NOT FAMILY HX)
social structure/emotional concerns
self-concept
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97
Q

what are the 4 key criteria for documentation

A

factual information
timeliness
legibility
approved abbreviations

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98
Q

factual information should be

A

objective

what you can see, hear, feel, touch, etc)

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99
Q

information given is brief but comprehensive

A

concise

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100
Q

exact and accurate details

A

precise

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101
Q

brief, clearly expressed

A

succinct

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102
Q

expressed using accepted professional medical terminology, symbols, abbreviations, and acronyms

A

professional

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103
Q

information included in present health/illness

A 
reason for seeking care
height/weight
VS
health beliefs, practices
health patterns
meds
health goals
pain
104
Q

information in past medical hx

A 
childhood illnesses
immunizations
medical illnesses
hospitalization
sx
injury
blood transfusions
emotional/psychiatric problems
allergies
use of alcohol, tobacco, drugs
105
Q

who is included in the family hx

A

parents
siblings
grandparents

106
Q

this type of charting is used for a specific purpose such as VS, meds administration, I&O, preop or postop care, wound assessments

A

flow sheets

107
Q

exam findings that require immediate assistance

A 
SBP >160 or DBP >90
temp <97 or >100
HR <60 or >90
RR <12 or >28
O2 SAT <92%
Urine output <30mL/hr or <240 mL/8 hours
dark amber, bloody urine
postop N/V
uncontrolled pain, chest pain
bleeding
altered LOC, confusion, difficulty arousing
sudden restlessness/anxiety
108
Q

What are the 4 basic techniques of a physical assessment?

A

inspection
palpation
percussion
auscultation

109
Q

the skill of observing the pt in a systematic manner to obtain data r/t health status

A

inspection

110
Q

assessment for each body system includes…

A 
color
shape
contour
symmetry
movement
drainage
111
Q

assessing the pt through the sense of touch to determine specific characteristics of the body

A

palpation

112
Q

characteristics obtain through palpation include…

A 
size
shape
location
mobility of a part
position
vibrations
temperature
texture
moisture
tenderness
edema
113
Q

how should your hand move during palpation?

A

gentle, move slowly and intentionally, apply the correct amount of pressure

114
Q

how far to press for abdominal palpation

A

1cm

115
Q

safest, least uncomfortable method of palpation

A

light palpation

116
Q

when is deep palpation used?

A

palpate the abdomen and organs that lie deep within a body cavity or when overlying musculature is thick, tense, or rigid

ex: obesity, abdominal guarding

117
Q

the nurse strikes through a body part with an object, fingers, or reflex hammer, ultimately producing a measurable sound is known as…

A

percuession

118
Q

what are the 3 types of percussion?

A

direct
blunt
indirect

119
Q

technique of tapping the body with the fingertips of the dominate hand

A

direct percussion

120
Q

placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the dominant hand with a closed fist to deliver a blow

A

blunt percussion

121
Q

technique most commonly used because is produces sounds that are clearer and more easily interpreted

A

indirect percussion

122
Q

high pitch, drum like sound

ex: fluid over organs

A

tympany

123
Q

low pitch, hollow tone

ex: over lungs

A

resonance

124
Q

heard with COPD

A

hyperresonance

125
Q

high pitch, heard over organs

ex: liver

A

dullness

126
Q

what to avoid when auscultating

A

over clothes, gowns
over sheets
rubbing against pt clothes or drapes
touching the stethoscope tubing

127
Q

what are the 3 parts to a stethoscope?

A

binaural
flexible tubing
end piece (diaphragm; bell)

128
Q

which part of the stethoscope end piece is used to assess low pitch sounds; best for lungs and normal heart sounds

A

diaphragm

129
Q

which part of the stethoscope end piece is used to assess low frequency sounds; can pick up a heart murmur

A

bell

130
Q

bits of information that hint at the possibility of health problem

ex: grimacing, guarding, odors

A

cues

131
Q

what should a pt see you do before performing a physical assessment?

A

wash your hand

132
Q

hands should be scrubbed and rinsed with soap for how long?

A

40-60 seconds

133
Q

what should you do with the end piece of a stethoscope between pts?

A

clean it

134
Q

when does a general survey begin?

A

at first sight

overview of the WHOLE person

135
Q

what is the first thing you should observe for when you see your patient?

A

are there any signs of distress?

136
Q

general survey is based on which 4 things?

A

physical appearance
body structure
mobility
behavior

137
Q

what does the physical appearance include?

A 
age
sex
LOC
skin color
facial movement
138
Q

when eyelids are drooping

A

ptosis

139
Q

what does body structure include?

A 
stature/position
nutritional status
symmetry of structures
posture
position
obvious deformities
140
Q

when the body is wasting away (can see bones)

A

cachectic

141
Q

what does mobility include?

A

gait

ROM

142
Q

what does behavior include?

A 
facial expression
mood and affect
speech
dress
personal hygiene
143
Q

what are some things that can cause chronic or acute weight gain or loss

A 
dieting
starvation
overeating
fever
cancer
CHF
hypo, hyperthyroidism
diuretic abuse
alcoholism, drug abuse
anabolic steriod abuse
144
Q

what is considered a normal BMI?

A

18.5-25

145
Q

what is considered an overweight BMI

A

25.1-29.9

146
Q

what is considered an obese BMI

A

> 30

147
Q

a weight circumference should be less than what?

A

40

148
Q

what will decrease as a person ages

A

height, weight

occurs more in males

149
Q

posterior curvature of the spine (humpback)

A

kyphosis

150
Q

VS are what kind of data?

A

objective

151
Q

what are the 5 VS?

A 
temp
RR
HR
BP
pain
152
Q

normal temp range for an adult

A

96.8-100.4 F (36-38C)

153
Q

normal HR

A

60-100

154
Q

normal RR

A

12-16

155
Q

normal BP

A

120/80

156
Q

normal pulse pressure

A

30-50

157
Q

what controls body temperature?

A

hypothalamus

anterior: heat loss
posterior: heat production

158
Q

compensatory heat production is stimulated through ___ ___ ___ and ___

A

voluntary muscle contraction

shivering

159
Q

heat production includes which 4 things?

A

basal metabolic rate (ex: hypo, hyperthyroid)
voluntary muscle movement
shivering
non-shivering thermogenesis

160
Q

heat loss includes which 4 things?

A

radiation
conduction
convection
evaporation

161
Q

transfer heat from one object to another without contact made between the 2

A

radiation

162
Q

transfer heat from one object to another with direct contact

A

conduction

163
Q

transfer heat away by air movement

A

convection

164
Q

transfer of heat when liquid made into gas

A

evaporation

165
Q

factors that affect body temperature

A 
age
exercise
hormones
circadian rhythm
environment
medications
stress
166
Q

which age group is unable to control body temperature?

A

newborns

keep away from vents, fans; keep a light blanket over them

167
Q

what is pyrexia?

A

fever

168
Q

how far to insert temperature probe for rectal temps on adults?

A

1.5 inches

169
Q

how to assess tympanic temp on adults

A

up, out

170
Q

how to assess tympanic temp in peds

A

down, out

171
Q

where to assess pulse for adult CPR, child

A

carotid artery

172
Q

where to assess pulse for CPR, infant

A

brachial

173
Q

when is the femoral artery assessed?

A

CPR, shock

174
Q

where is pulse assess for infants, neonates?

A

dorsalis pedis

175
Q

pulse that can be felt, goes away, then felt again

A

thready

176
Q

point of maximum impulse is AKA

A

apical pulse

177
Q

where is the point of maximum impulse/apical pulse found?

A

angle of louis

178
Q

factors that influence HR

A 
exercise
temperature
emotions
drugs, medications (ex: digoxin)
hemorrhage
postural changes
pulmonary changes
179
Q

s/sx of low cardiac output

A

chest pain
dyspnea
dizziness

180
Q

how to assess a pulse deficit

A

peripheral pulse MINUS apical pulse

181
Q

pulse strength ratings

A

0: absent
1: pulse difficult to feel, weak, thready
2: strong
3: bounding

182
Q

movement of gas in and out of lungs

A

ventilation

183
Q

movement of oxygen and CO2 between alveoli and RBC

A

diffusion

184
Q

distribution of RBC to and from pulmonary capillaries

A

perfusion

185
Q

amount of air a person inhales

A

tidal volume

186
Q

breathing is a ___ process

A

passive

187
Q

where is respiratory centered?

A

medulla oblongata
pons
chemoreceptors

188
Q

ventilation is regulated by

A

CO2
O2
pH in arterial blood

189
Q

factors influencing respirations

A 
exercise
acute pain
anxiety
smoking
body position
meds
neuro injury
Hgb
190
Q

< 12 breaths/minute

A

bradypnea

nonlabored

191
Q

> 20 breaths/minute

A

tachypnea

nonlabored

192
Q

labored breathing; high rate and depth

A

hypernea

193
Q

increased depth, rate

A

hyperventilation

194
Q

decreased amount of CO in the blood

A

hypocapnia

195
Q

decreased rate and possibly depth

A

hypoventilation

196
Q

increased amount of OC2 in the blood

A

hypercapnia

197
Q

irregular periods of breathing with apnea

A

Cheyne-Stokes

198
Q

abnormally deep, regular with high rate

A

Kussmal’s

199
Q

abnormally shallow, 2-3 breaths, then irregular period of apnea

A

Brot’s

200
Q

peak of maximum pressure when ejection occurs

contraction

A

SBP

201
Q

minimal pressure exerted against arterial walls at all times

relaxation

A

DBP

202
Q

how to find the pulse pressure

A

SBP minus DBP

203
Q

factors that affect BP

A

biological
–age, ethnicity
psychological
–stress, anxiety

204
Q

when is BP generally the lowest?

A

AM; peaks in late afternoon or evening

205
Q

BP with INCREASE with __ where as HR will decrease

A

age

206
Q

HTN

A

> 140/90

207
Q

hypotension is usually associated with ___

A

illness

208
Q

s/sx of hypotension

A 
pallor
mottling
clamminess
confusion
^ HR
209
Q

SBP drop of 20 and DBP drop of 10

A

orthostatic hypotension

210
Q

pts at risk for orthostatic hypotension

A

dehydrated
anemic
prolonged bedrest
recent blood loss

211
Q

how to obtain orthostatic VS

A

assess BP, HR when pt is lying, then sitting, then standing

take BP, HR 1-3 minutes between position changes

212
Q

s/sx high BP

A

HA
flushing of face
nosebleed

213
Q

s/sx of high BP

A

dizziness
mental confusion
cool skin

214
Q

what should be avoided 30 minutes prior to assessing BP?

A

caffeine

smoking

215
Q

positioning when assess BP on thigh

A

prone

216
Q

how to measure BP cuff size

A

2/3 of arm length from shoulder or 2/3 length from hip to knee

217
Q

how to assess BP using palpation method

A 
place cuff correctly
place 2 fingers over brachial artery
inflate cuff 30 above point where palpated
slowly release bulb valve
1st palpable pulse = SBP
218
Q

T or F. palpable BP only measures SBP.

A

True

219
Q

sound sequence for SBP and DBP

A

SBP: 1st
DBP: 5th

220
Q

an unpleasant sensory and emotional experience associated with actual or potential tissue damage or describe in terms of such damage

A

pain

221
Q

what are 3 theories of pain?

A

specificity
pattern
gate control

222
Q

gate control pain is either ___ or ___

A

open; closed

223
Q

receptors that transmit pain sensation

A

nociceptors

224
Q

transmission of pain occurs in how many phases?

A

3

225
Q

what occurs during the 1st phase of pain transmission?

A

pain impulse is transmitted from the peripheral nerve fibers to the spinal cord

226
Q

what occurs during the 2nd phase of pain transmission?

A

pain impulses travel to the spinal cord, ascend the spinothalamac tract to the brainstem and thalamus

227
Q

what occurs during the 3rd phase of pain transmission?

A

signals are transmitted between the thalamus and the somatic sensory cortex which is the site of pain perception

228
Q

which type of dx causes a reduce pain receptions?

A

DM

those with back injuries

229
Q

pain that does not last longer than 6 months

A

acute pain

230
Q

prolonged, usually recurring or persistant pain last 6 months or longer

A

chronic

231
Q

when is it considered malignant pain?

A

associated with cancer or other life threatening conditions

232
Q

pain that occurs in the skin or subcutaneous tissue

A

cutaneous pain

ex: paper cut

233
Q

pain that arises from ligaments, tendons, bones, blood vessels, and nerves

A

deep somatic pain

ex: sprained ankle

234
Q

pain that occurs in the abdominal cavity, cranium, and thorax

burning, aching, or feeling of pressure

A

visceral pain

ex: bowel obstruction

235
Q

pain that is felt in a part of the body that is considered removed

ex: abdominal pain after organ removal

A

referred pain

236
Q

perceived at the source of pain and extends to nearby tissue

ex: cardiac pain

A

radiating pain

237
Q

long last, unpleasant, and can be described as burning, dull, and aching. Episodes of sharp, shooting pain can be experienced

A

neuropathic pain

238
Q

Dx associated with neuropathic pain

A

trigeminal neuralgia
peripheral neuropathy
shingles

239
Q

pain perceived in a body part that is missing or paralyzed

A

phantom limb pain

240
Q

factors that influence pain

A

race
ethnicity
sex
culture

241
Q

behavior responses to pain

A 
facial grimacing
moaning
crying
screaming
guarding
immobilizing body part
tossing, turning
rhythmic body movements such as rubbing
242
Q

which body system is stimulated during early stages of acute pain?

A

sympathetic nervous system

elevated BP, HR, RR
pallor
diaphoresis

243
Q

which body system is stimulated during visceral pain?

A

parasympathetic nervous system

low BP, HR
warm, dry skin

244
Q

factors that affect nutrition

A

physical
psychosocial
cultural
economic

245
Q

examples of pts who may have under nutritional status

A 
dysphagia
myasthenia gravis
MS
stroke
ALS
246
Q

what is included in a diet recall (24 hour recall)

A

meals
snacks
liquids, including alcohol
herbs, supplements, vitamins

247
Q

this questionnaire assesses intake of a variety of food groups on a daily, weekly, or longer basis

A

food frequency questionnaire

248
Q

how long do pts record their dietary habits for a food record?

A

3 days

249
Q

where to measure waist circumference

A

bony landmark on the lateral border of the ilium

250
Q

areas where skin folds can be measured

A 
triceps
chest
subscapular
midaxillary
suprailiac regions
abdomen
upper thigh
251
Q

noninvasive tool for assessing body composition employing principles of electroconduction through water, muscle, and fat

A

bioelectrical impedance analysis (BIA)

252
Q

minimum body fat standard for men

A

3%

suggested 12-20%

253
Q

minimum body fat standard for women

A

12%

suggested 20-30%

254
Q

protein-calorie malnutrition

A

maramus

255
Q

protein malnutrition

A

kwashiorkor

256
Q

inorder to be Dx with metabolic syndrome (MetS) 3/5 of these biomarkers must be met

A 
waist circumference
glucose level
high-density lipoprotein (HDL)
triglyceride level >150
HTN

N1109 - Physical Assessment (14 decks)

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