Exam 1 Flashcards
a process to systematically collect info about a pt
creates a comprehensive database for use in planning care
health assessment
Data collected during a health assessment includes:
physical social cultural environmental emotional wellness behavior illness s/sx pt strength/weaknesses risk factors
An interview includes which 2 sources?
primary
secondary
A focused interview is used to:
clarify points
missing info
clarity of info
HIPAA
Health Insurance Portability and Accountability Act
Who set the tone for nursing theory?
Florence Nightingale
Government agencies that oversee health, wellness, and health promotion
US Preventative Service Task Force
Healthy People 2020
Office of Disease Prevent and Health Promotion (ODPHP)
Leavell and Clark set up what model?
levels of preventative healthcare
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
levels of prevention
What are the 3 levels of prevention?
Primary
Secondary
Tertiary
Primary level of prevention focuses on:
health promotion and specific protection
Secondary level of prevention focuses on:
early dx
promote treatment
disability limitation
Tertiary prevention focuses on:
restoration and rehabillitation
What occurs during primary prevention?
education
protection measures
-immunizations, exercise, clean water, reducing exposure to carcinogens/occupational hazards
What occurs during secondary prevention?
treating early stages of disease
BP screenings, breast examinations
What occurs during tertiary prevention?
individuals effected by disease
surveillance
maintenance
rehabillitation
___ ___ refers to those actions used to increase health or well-being and improvement of the health of individuals, families, and communities
health promotion
Health promotion is ___ motiviated
behavior
According to the Health Belief Model, what effects individual perceptions and beliefs influence the decision to act to prevent illness:
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
Biological factors that effect health promotion model
age gender BMI strength agility balance
Psychological factors that effect health promotion model
self-esteem
motivation
perception of one’s heath status
Sociological factors that effect health promotion
socioeconomic status
education
race
ethnicity
Racial and ethnic minorities often experience what?
poor access to healthcare
the state of being different
diversity
shared biologic characteristics and physical features
race
learned, shared, and transmitted values, beliefs, normals, and lifeway practices of a particular group
culture
represents various ethic, religious, and other groups with distinct characteristics from the dominant culture
subculture
a consciousness of belonging to a group differentiated by symbolic markers
ethnicity
people of a minority group gradually assumes attitudes, values, beliefs of dominant group
ex: move to a new country, starts eating their food, etc.
assimilation
belief that one’s own culture is superior
ethnocentrism
insiders perspective
emic worldview
outsiders perspective
etic worldview
socializing into one’s primary culture
*must know
enculturation
process of adapting to and adopting a new culture
*must know
acculturation
assuming all members of a culture are alike
sterotyping
being disoriented bc of sudden strangeness of new culture
culture shock
conscious recognition of differences and similarities between cultures
culture awareness
respect for cultural behaviors based on understanding of other perspective
cultural sensitivity
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
cultural competence
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
cultural imposition
supernatural controls your health
ex: if you sin, you may be sick as a “punishment from God”; roots/spiritual intervention to get well
Magico-religious belief
life controlled by physical and biomedical process
ex: pills, txment, sx
biomedical
take into account all aspects of a person, spiritual, emotional, phyisical, etc.
ex: Yin Yang
holistic
passed down remedies
folk medicine
DC instructions should be provided in which language?
pts native tongue
give life to a person, as it signifies whatever at the center of all aspects of a persons life
spirit
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
spirituality
nurses must be aware of their own ___ to provide spiritual care to others
spirituality
spiritual well-being qualities
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
the 2 dimensions of spiritual well-being
supports the relationship btw a person and God or some higher power
positive relationship and connections people have with others
give purpose and meaning to a person’s life, allowing for action
faith
a specific system of practices associated with a denomination, sect or form of worship
religion
product of spirituality and fath
hope
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
agonistic
denies the existence of God
search for meaning in life through their work and their relationships with others
Atheist
Spiritual development beings in ___
childhood
___ and ___ are closely linked to a person’s spiritual well-being, providing an inner strength for dealing with illness and disability.
faith and hope
hope provides ___
comfort
pts who may experience spiritual distress
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
symptoms of spiritual distress
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
Buddhism
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
Buddhism diet
some are vegetarians
no alcohol
many will fast on Holy days
Christian science
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
Hinduism
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
Islam
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
Islam women prefer ___ health care providers
women
During the month of Ramadan, Islam ____ will not eat until after ___
women; sunset
Judaism
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
Judaism diet
Kosher (avoid pork, shellfish)
Milk and meat are not mixed
Fish with fins, scales allowed
Orthodox Jews restrict pork, predatory fowl, and shellfish
Protestant
Over 50 denominations; practices differ
may prohibit alcohol
may believe in “laying on of hands” and “anointing with oil”
Roman Catholic
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
Jehovah’s Witnesses
avoid food to which blood is added
No last rites or infant baptism
Opposed blood transfusions
Seventh-Day Adventists
Vegetarian
health = important
avoid narcotics, stimulants
may refuse medical txment on Sabbath (Friday sundown until Saturday sundown)
preventable differences in the burden of disease, injury, violence, r opportunities to achieve optimal health that are experienced by socially disadvantaged populations
health disparities
vulnerable populations for health disparities
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
the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically
health equality
detailed record of the pts past and current health, as well as a record of perceptions about their state of health
health record
when/how does the health history begin
collection of information through an interview
purpose of the health history
to document the responses of the pt regarding actual and potential health concerns
information covered in the health history
past, present illnesses
family, genetic info
wellness assessment
most common secondary sources
medical records
significant others
actions that are used during the encoding and decoding processes to obtain info, develop relationships, and promote understanding of self and others
interactional skills
types of interactional skills
attending paraphrasing/clarification direct leading focusing questioning reflecting summarizing
what is the most important interactional skill?
listening
___ ___ involves taking the pts whole message by hearing the words as well as interpreting body language.
successful listening
involves giving full attention to verbal and nonverbal messages
maintaining eye contact, proper body positioning
attending
repeating the pts verbal or nonverbal message for the pts benefit
reflecting
process of gathering ideas, feelings, and themes that pts have discussed throughout the interview and restating them in several general statements
summarizing
professional characteristics to enhance the nurse-pt interaction
positive regard
empathy
genuineness
concreteness
barriers to effective pt-interaction
false reassurance interrupting, changing subject passing judgement cross-examination euphemisms unwanted advice technical terms sensitive issues cultural influence, bias
the initial interview begins with…
the nurse describing the interview process, explaining its importance, and telling the pt what to expect
purpose of a focused interview
clarification of previously obtained data
gather missing info
guide the direction of the physical assessment
identify, validate probable nursing dx
OLDCART
onset location duration characteristics aggravating factors relieving factors treatment
ICE
impact on ADLs
coping strategies
emotional response
information the health history includes
name, age, DOB demographics birth place marital status sex/gender/sexual orientation race religion occupation health insurance source of info, reliability
what does psychosocial hx include?
occupational hx education financial background roles, relationships family (NOT FAMILY HX) social structure/emotional concerns self-concept
what are the 4 key criteria for documentation
factual information
timeliness
legibility
approved abbreviations
factual information should be
objective
what you can see, hear, feel, touch, etc)
information given is brief but comprehensive
concise
exact and accurate details
precise
brief, clearly expressed
succinct
expressed using accepted professional medical terminology, symbols, abbreviations, and acronyms
professional
information included in present health/illness
reason for seeking care height/weight VS health beliefs, practices health patterns meds health goals pain
information in past medical hx
childhood illnesses immunizations medical illnesses hospitalization sx injury blood transfusions emotional/psychiatric problems allergies use of alcohol, tobacco, drugs
who is included in the family hx
parents
siblings
grandparents
this type of charting is used for a specific purpose such as VS, meds administration, I&O, preop or postop care, wound assessments
flow sheets
exam findings that require immediate assistance
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
What are the 4 basic techniques of a physical assessment?
inspection
palpation
percussion
auscultation
the skill of observing the pt in a systematic manner to obtain data r/t health status
inspection
assessment for each body system includes…
color shape contour symmetry movement drainage
assessing the pt through the sense of touch to determine specific characteristics of the body
palpation
characteristics obtain through palpation include…
size shape location mobility of a part position vibrations temperature texture moisture tenderness edema
how should your hand move during palpation?
gentle, move slowly and intentionally, apply the correct amount of pressure
how far to press for abdominal palpation
1cm
safest, least uncomfortable method of palpation
light palpation
when is deep palpation used?
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
the nurse strikes through a body part with an object, fingers, or reflex hammer, ultimately producing a measurable sound is known as…
percuession
what are the 3 types of percussion?
direct
blunt
indirect
technique of tapping the body with the fingertips of the dominate hand
direct percussion
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
blunt percussion
technique most commonly used because is produces sounds that are clearer and more easily interpreted
indirect percussion
high pitch, drum like sound
ex: fluid over organs
tympany
low pitch, hollow tone
ex: over lungs
resonance
heard with COPD
hyperresonance
high pitch, heard over organs
ex: liver
dullness
what to avoid when auscultating
over clothes, gowns
over sheets
rubbing against pt clothes or drapes
touching the stethoscope tubing
what are the 3 parts to a stethoscope?
binaural
flexible tubing
end piece (diaphragm; bell)
which part of the stethoscope end piece is used to assess low pitch sounds; best for lungs and normal heart sounds
diaphragm
which part of the stethoscope end piece is used to assess low frequency sounds; can pick up a heart murmur
bell
bits of information that hint at the possibility of health problem
ex: grimacing, guarding, odors
cues
what should a pt see you do before performing a physical assessment?
wash your hand
hands should be scrubbed and rinsed with soap for how long?
40-60 seconds
what should you do with the end piece of a stethoscope between pts?
clean it
when does a general survey begin?
at first sight
overview of the WHOLE person
what is the first thing you should observe for when you see your patient?
are there any signs of distress?
general survey is based on which 4 things?
physical appearance
body structure
mobility
behavior
what does the physical appearance include?
age sex LOC skin color facial movement
when eyelids are drooping
ptosis
what does body structure include?
stature/position nutritional status symmetry of structures posture position obvious deformities
when the body is wasting away (can see bones)
cachectic
what does mobility include?
gait
ROM
what does behavior include?
facial expression mood and affect speech dress personal hygiene
what are some things that can cause chronic or acute weight gain or loss
dieting starvation overeating fever cancer CHF hypo, hyperthyroidism diuretic abuse alcoholism, drug abuse anabolic steriod abuse
what is considered a normal BMI?
18.5-25
what is considered an overweight BMI
25.1-29.9
what is considered an obese BMI
> 30
a weight circumference should be less than what?
40
what will decrease as a person ages
height, weight
occurs more in males
posterior curvature of the spine (humpback)
kyphosis
VS are what kind of data?
objective
what are the 5 VS?
temp RR HR BP pain
normal temp range for an adult
96.8-100.4 F (36-38C)
normal HR
60-100
normal RR
12-16
normal BP
120/80
normal pulse pressure
30-50
what controls body temperature?
hypothalamus
anterior: heat loss
posterior: heat production
compensatory heat production is stimulated through ___ ___ ___ and ___
voluntary muscle contraction
shivering
heat production includes which 4 things?
basal metabolic rate (ex: hypo, hyperthyroid)
voluntary muscle movement
shivering
non-shivering thermogenesis
heat loss includes which 4 things?
radiation
conduction
convection
evaporation
transfer heat from one object to another without contact made between the 2
radiation
transfer heat from one object to another with direct contact
conduction
transfer heat away by air movement
convection
transfer of heat when liquid made into gas
evaporation
factors that affect body temperature
age exercise hormones circadian rhythm environment medications stress
which age group is unable to control body temperature?
newborns
keep away from vents, fans; keep a light blanket over them
what is pyrexia?
fever
how far to insert temperature probe for rectal temps on adults?
1.5 inches
how to assess tympanic temp on adults
up, out
how to assess tympanic temp in peds
down, out
where to assess pulse for adult CPR, child
carotid artery
where to assess pulse for CPR, infant
brachial
when is the femoral artery assessed?
CPR, shock
where is pulse assess for infants, neonates?
dorsalis pedis
pulse that can be felt, goes away, then felt again
thready
point of maximum impulse is AKA
apical pulse
where is the point of maximum impulse/apical pulse found?
angle of louis
factors that influence HR
exercise temperature emotions drugs, medications (ex: digoxin) hemorrhage postural changes pulmonary changes
s/sx of low cardiac output
chest pain
dyspnea
dizziness
how to assess a pulse deficit
peripheral pulse MINUS apical pulse
pulse strength ratings
0: absent
1: pulse difficult to feel, weak, thready
2: strong
3: bounding
movement of gas in and out of lungs
ventilation
movement of oxygen and CO2 between alveoli and RBC
diffusion
distribution of RBC to and from pulmonary capillaries
perfusion
amount of air a person inhales
tidal volume
breathing is a ___ process
passive
where is respiratory centered?
medulla oblongata
pons
chemoreceptors
ventilation is regulated by
CO2
O2
pH in arterial blood
factors influencing respirations
exercise acute pain anxiety smoking body position meds neuro injury Hgb
< 12 breaths/minute
bradypnea
nonlabored
> 20 breaths/minute
tachypnea
nonlabored
labored breathing; high rate and depth
hypernea
increased depth, rate
hyperventilation
decreased amount of CO in the blood
hypocapnia
decreased rate and possibly depth
hypoventilation
increased amount of OC2 in the blood
hypercapnia
irregular periods of breathing with apnea
Cheyne-Stokes
abnormally deep, regular with high rate
Kussmal’s
abnormally shallow, 2-3 breaths, then irregular period of apnea
Brot’s
peak of maximum pressure when ejection occurs
contraction
SBP
minimal pressure exerted against arterial walls at all times
relaxation
DBP
how to find the pulse pressure
SBP minus DBP
factors that affect BP
biological
–age, ethnicity
psychological
–stress, anxiety
when is BP generally the lowest?
AM; peaks in late afternoon or evening
BP with INCREASE with __ where as HR will decrease
age
HTN
> 140/90
hypotension is usually associated with ___
illness
s/sx of hypotension
pallor mottling clamminess confusion ^ HR
SBP drop of 20 and DBP drop of 10
orthostatic hypotension
pts at risk for orthostatic hypotension
dehydrated
anemic
prolonged bedrest
recent blood loss
how to obtain orthostatic VS
assess BP, HR when pt is lying, then sitting, then standing
take BP, HR 1-3 minutes between position changes
s/sx high BP
HA
flushing of face
nosebleed
s/sx of high BP
dizziness
mental confusion
cool skin
what should be avoided 30 minutes prior to assessing BP?
caffeine
smoking
positioning when assess BP on thigh
prone
how to measure BP cuff size
2/3 of arm length from shoulder or 2/3 length from hip to knee
how to assess BP using palpation method
place cuff correctly place 2 fingers over brachial artery inflate cuff 30 above point where palpated slowly release bulb valve 1st palpable pulse = SBP
T or F. palpable BP only measures SBP.
True
sound sequence for SBP and DBP
SBP: 1st
DBP: 5th
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or describe in terms of such damage
pain
what are 3 theories of pain?
specificity
pattern
gate control
gate control pain is either ___ or ___
open; closed
receptors that transmit pain sensation
nociceptors
transmission of pain occurs in how many phases?
3
what occurs during the 1st phase of pain transmission?
pain impulse is transmitted from the peripheral nerve fibers to the spinal cord
what occurs during the 2nd phase of pain transmission?
pain impulses travel to the spinal cord, ascend the spinothalamac tract to the brainstem and thalamus
what occurs during the 3rd phase of pain transmission?
signals are transmitted between the thalamus and the somatic sensory cortex which is the site of pain perception
which type of dx causes a reduce pain receptions?
DM
those with back injuries
pain that does not last longer than 6 months
acute pain
prolonged, usually recurring or persistant pain last 6 months or longer
chronic
when is it considered malignant pain?
associated with cancer or other life threatening conditions
pain that occurs in the skin or subcutaneous tissue
cutaneous pain
ex: paper cut
pain that arises from ligaments, tendons, bones, blood vessels, and nerves
deep somatic pain
ex: sprained ankle
pain that occurs in the abdominal cavity, cranium, and thorax
burning, aching, or feeling of pressure
visceral pain
ex: bowel obstruction
pain that is felt in a part of the body that is considered removed
ex: abdominal pain after organ removal
referred pain
perceived at the source of pain and extends to nearby tissue
ex: cardiac pain
radiating pain
long last, unpleasant, and can be described as burning, dull, and aching. Episodes of sharp, shooting pain can be experienced
neuropathic pain
Dx associated with neuropathic pain
trigeminal neuralgia
peripheral neuropathy
shingles
pain perceived in a body part that is missing or paralyzed
phantom limb pain
factors that influence pain
race
ethnicity
sex
culture
behavior responses to pain
facial grimacing moaning crying screaming guarding immobilizing body part tossing, turning rhythmic body movements such as rubbing
which body system is stimulated during early stages of acute pain?
sympathetic nervous system
elevated BP, HR, RR
pallor
diaphoresis
which body system is stimulated during visceral pain?
parasympathetic nervous system
low BP, HR
warm, dry skin
factors that affect nutrition
physical
psychosocial
cultural
economic
examples of pts who may have under nutritional status
dysphagia myasthenia gravis MS stroke ALS
what is included in a diet recall (24 hour recall)
meals
snacks
liquids, including alcohol
herbs, supplements, vitamins
this questionnaire assesses intake of a variety of food groups on a daily, weekly, or longer basis
food frequency questionnaire
how long do pts record their dietary habits for a food record?
3 days
where to measure waist circumference
bony landmark on the lateral border of the ilium
areas where skin folds can be measured
triceps chest subscapular midaxillary suprailiac regions abdomen upper thigh
noninvasive tool for assessing body composition employing principles of electroconduction through water, muscle, and fat
bioelectrical impedance analysis (BIA)
minimum body fat standard for men
3%
suggested 12-20%
minimum body fat standard for women
12%
suggested 20-30%
protein-calorie malnutrition
maramus
protein malnutrition
kwashiorkor
inorder to be Dx with metabolic syndrome (MetS) 3/5 of these biomarkers must be met
waist circumference glucose level high-density lipoprotein (HDL) triglyceride level >150 HTN
