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Ellie-NUR 265 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

evidence based assessment

A

most current best practice techniques

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2
Q

objective data

A

my assessment of the patient

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3
Q

subjective data

A

information from patient or patient family

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4
Q

diagnostic reasoning

A

attending to cues, formulate diagnostic hypotheses, gather data relative to each hypotheses, evaluate each hypotheses with the new collected data to form final diagnosis

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5
Q

nursing process

A

assessment, diagnosis, plan, implement, evaluate

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6
Q

first level

A

emergent/ life threatening
patient is not breathing

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7
Q

second level

A

urgent
acute pain, mental status change, safety risk

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8
Q

third level

A

need attention, but not priority
problems with lack of knowledge, mobility, rest, coping

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9
Q

complete database

A

subjective info and completing objective (head to toe and getting history)

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10
Q

focused database

A

focusing on 1 system

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11
Q

follow-up database

A

checking after treatment

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12
Q

emergency database

A

rapid collection of crucial info

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13
Q

the interview

A

gather data about health status, establish positive relationship with pt, educate pt

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14
Q

internal factors

A

compassion, sympathy, respect, listening, self awareness, and body language

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15
Q

external factors

A

looking at environment (pt. privacy…sexual partners) and assessing (skin, expression, clothing) (lighting and temp are also factors)

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16
Q

open ended questions

A

describe …

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17
Q

closed questions

A

do you have …

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18
Q

complete health history

A

Biographical data
Reason for seeking health care
History of Present Illness
Past Medical History
Family History
Psychosocial
ROS
Functional Assessment

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19
Q

history of present illness critical characterisitcs

A

Location
Character/Quality
Quantity/Severity
Timing
Setting
Aggravating/Relieving
Associated Factors
Client’s Perception

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20
Q

PMH (past medical history)

A

Allergies
Meds, herbals, OTC
Childhood illnesses
Immunizations
Hospitalizations
Surgeries
Serious injuries
Chronic illness
Travel history

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21
Q

ROS (review of systems)

A

Questions asked about each Body System
Past
Present
Questions about Health Promotion for each body system

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22
Q

functional assessment

A

Measures self-care ability in the areas of general physical health
(ADLs and IADLs)

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23
Q

ADL (activities of daily living)

A

walking, brushing hair, teeth

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24
Q

IADLs (instrumental activities of daily living)

A

cooking, banking

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25
purpose of genogram
Comprehensive, holistic picture Assessment tool & intervention strategy Various types of information can be gathered Gender, relationship, and age of immediate blood relatives Organized, at least 3 generations Visual picture Patterns Risk factors
26
performing the physical exam
Inspection Palpation Percussion Auscultation Olfaction
27
inspection
always first, Use of sight to gather data Used throughout physical examination Tools to enhance inspection Otoscope Ophthalmoscope Penlight
28
palpation
Warm hands Start light to deep Palpate tender areas last dorsum part of hand to test for skin temp
29
flatness percussion
bone or muscle
30
dullness percussion
heart, liver, spleen
31
dullness percussion
heart, liver, spleen
32
resonance
air filled lungs (hollow)
33
hyperresonance
emphysematous ling (hyperinflated)
34
tympany
air-filled stomach (drumlike)
35
diaphragm auscultation
listen to heart, belly, bp
36
bell auscultation
picks up lower pitched sounds (murmurs)
37
general survey
physical appearance, body structure, mobility, behavior
38
physical appearance
level of consciousness, skin color (appropriate for ethnicity), facial features (drooping, expressions)
39
body structure
normal height, nutritional status, symmetry, posture
40
mobility
walking, arms swinging
41
behavior
mood and affect (presented, flat), speech (slow, fast), manic, drug use, stroke, alc use, depression, dress and personal hygiene
42
measurements
weight, height, BMI
43
infant approach to assessment
Preparation Speak softly Heart & lung exam first Use touch but varies with infant's age Position- parents holding Sequence- ENT last
44
toddler approach to assessment
Preparation Focus on a favorite toy Divert attention Establish trust Allow for choices Position- caregiver lap Sequence
45
preschooler approach to assessment
Preparation Use simple questions and words without double meaning. Allow the child to manipulate equipment. Use toys, puppets, and play! Allow for choices Position Sequence- ENT last
46
school-age approach to assessment
Preparation Offer explanations. Teach about health and provide demonstrations. Protect modesty Position Sequence
47
adolescents approach to assessment
Preparation Maintain confidentiality. Facilitate trust and ask to speak to the adolescent alone. Encourage open and honest communication. Use open-ended questions. Position Sequence
48
older adult approach to assessment
Preparation Position Sequence
49
vital signs
temp, pulse, breathing (in and out=1 respiration), bp
50
what does skin do for you
Protection Prevents penetration Perception Temperature control identification Communication Wound repair Absorption & excretion Produces Vitamin D
51
Skin History
History of skin diseases Change in color or pigmentation Change in mole Dryness or moisture Pruritus (itching) Excessive bruising (blood thinner, abuse, falling) Rash or lesion (mole, wound, any other disorder on skin) Sun exposure and sunscreen Medications (sensitive to sun exposure) Environmental/Occupational exposure
52
changes in hair
hair loss (eating disorder, bariatric surgeries, alopecia, anxiety) distribution (bald spots?) change in color or texture
53
change in nails
change in shape or consistency clubbing? (respiratory- smokers, COPD) nail biting?
54
ROS- Infants/children
birthmarks jaundice/cyanosis (newborn) Rash Introducing new foods Diaper rash Exposure to scabies, lice, impetigo chicken pox, measles toxic plants
55
ROS Adolescents
Acne (product use, nutrition, hygiene)
56
ROS aging adult
Delayed wound healing (chronic disease) Itching- dry skin Feet- bunions etc Diabetes/PVD (poor circulation to lower extremities) skin becomes more frail blood flow needed
57
Inspection
Assess first: cleanliness, odor, superficial veins/arteries
58
Palpation of skin
temp (dorsal part of hand), moisture, texture, lesions, turgor
59
poor turgor
tenting
60
assessing skin
Skin color Skin characteristics Temperature Moisture Texture Turgor Edema (swelling...fluid overload...heart failure) Skin lesions- size, shape, pattern, asymmetrical, tenderness (possible infection), pus/drainage, surface relationship (raised?)
61
skin color variations
Pallor- conjunctiva pale?, anemia?, poor circulation? Cyanosis Jaundice Erythema- red (rash) Ecchymosis- bruised area Vitiligo- spots/patchy areas Mottling- marbeled skin (blue)
62
ABCDE
asymmetry, border, color, diameter, evolution
63
document description of suspicious skin lesions
Color Elevation Shape Size- measure (growing?) Location- lateral, medial, 12 o'clock Exudate-pus/ drainage (color)
64
document description of suspicious skin lesions
Color Elevation Shape Size- measure (growing?) Location- lateral, medial, 12 o'clock Exudate-pus/ drainage (color)
65
annular
circular (ringworm)
66
annular
67
target
lyme disease, antibiotic reaction
68
target
69
linear
scratch, poison ivy
70
linear
71
zosteriform
unilateral, herpes, shingles
72
zosteriform
73
confluent
hives
74
confluent
75
grouped
clustered fluid vesicles (poison ivy)
76
grouped
77
gyrate
snake-like, twisted keloid (healing)
78
gyrate
79
polcyclic
lesions grow together, cirrhosis
80
polycyclic
81
pregnancy normal variations
Striae (stretch marks)- 2nd trimester Linea nigra- dark line (pubis to belly button) Chloasma- patches on face Spider angiomas- swollen bv's...high estrogen
82
aging adult normal variations
Senile lentigines-hyperpigmentation Keratoses- raised, thickened areas Seborrheic keratosis Actinic keratosis Acrochordons “Skin tags”
83
lesions: normal variations
Milia (little white bumps... sebaceous glands)- newborns Mongolian spot (darkened skin areas... common in blacks, indians, and asians)- newborns Acrocyanosis (blue lips and hands)- newborns Nevi- moles and freckles
84
aging
Decrease (thinner, subcutaneous fat): elasticity (elastin) Increase: vascular fragility, thinning Hair and nails- brittle and thin
85
culture/race relating to skin
Melanoma- high risk (26X higher risk for whites than blacks) Keloid formation- more common in black people Hair
86
primary lesions
appear as a direct result of the disease occur at the onset of disease Macule-petechiae, measles, freckles
87
secondary lesions
may develop from primary lesions or result from external trauma- scratching, infections Scales, crusts, ulcers
88
macule
flat
89
papule
raised
90
nodule
>2cm, fluid filled
91
excoriation
losing top layer of epidermis
92
erosion
losing epidermis and part of dermis
93
fissure
linear break in skin
94
ulcer
loss of tissue
95
pressure injury stage 1
no break in skin
96
pressure injury stage 2
partial thickness skin loss, abrasion, blistering, small crater
97
pressure injury stage 3
full thickness of skin loss (through epidermis and dermis)
98
pressure injury stage 4
damage to bone, muscle, tendons
99
pressure injury- unstageable
wound/pressure injury, don't know stage until cleaning away eschar
100
deep tissue injury (DTI)
skin is intact, purplish, boggy (squishy), eschar on it
101
pressure injury prevention
Inspect skin daily- bony prominences (less skins) Manage Moisture- changing sheets Skin Care- clean, mild soap, moisturizer Minimize Pressure- reposition every 2 hours, elevate heels Avoid Friction to skin Optimize Nutrition & Hydration- heals wounds
102
assessing hair
color, texture, distribution, scalp (should be smooth), pediculosis (lice)
103
assessing nails
nail color (pink), nail shape (convex), nail texture (smooth), capillary refill (brisk)
104
160 degrees
105
clubbing
angle > 180
106
beau's lines
trauma, acute illness, toxic reaction
107
splinter hemorrhages
trauma, bacterial endocarditis

Ellie-NUR 265 (10 decks)

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