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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
Q

purpose of genogram

A

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

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26
Q

performing the physical exam

A

Inspection
Palpation
Percussion
Auscultation
Olfaction

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27
Q

inspection

A

always first, Use of sight to gather data
Used throughout physical examination
Tools to enhance inspection
Otoscope
Ophthalmoscope
Penlight

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28
Q

palpation

A

Warm hands
Start light to deep
Palpate tender areas last
dorsum part of hand to test for skin temp

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29
Q

flatness percussion

A

bone or muscle

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30
Q

dullness percussion

A

heart, liver, spleen

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31
Q

dullness percussion

A

heart, liver, spleen

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32
Q

resonance

A

air filled lungs (hollow)

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33
Q

hyperresonance

A

emphysematous ling (hyperinflated)

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34
Q

tympany

A

air-filled stomach (drumlike)

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35
Q

diaphragm auscultation

A

listen to heart, belly, bp

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36
Q

bell auscultation

A

picks up lower pitched sounds (murmurs)

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37
Q

general survey

A

physical appearance, body structure, mobility, behavior

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38
Q

physical appearance

A

level of consciousness, skin color (appropriate for ethnicity), facial features (drooping, expressions)

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39
Q

body structure

A

normal height, nutritional status, symmetry, posture

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40
Q

mobility

A

walking, arms swinging

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41
Q

behavior

A

mood and affect (presented, flat), speech (slow, fast), manic, drug use, stroke, alc use, depression, dress and personal hygiene

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42
Q

measurements

A

weight, height, BMI

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43
Q

infant approach to assessment

A

Preparation
Speak softly
Heart & lung exam first
Use touch but varies with infant’s age
Position- parents holding
Sequence- ENT last

44
Q

toddler approach to assessment

A

Preparation
Focus on a favorite toy
Divert attention
Establish trust
Allow for choices
Position- caregiver lap
Sequence

45
Q

preschooler approach to assessment

A

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
Q

school-age approach to assessment

A

Preparation
Offer explanations.
Teach about health and provide demonstrations.
Protect modesty
Position
Sequence

47
Q

adolescents approach to assessment

A

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
Q

older adult approach to assessment

A

Preparation
Position
Sequence

49
Q

vital signs

A

temp, pulse, breathing (in and out=1 respiration), bp

50
Q

what does skin do for you

A

Protection
Prevents penetration
Perception
Temperature control
identification
Communication
Wound repair
Absorption & excretion
Produces Vitamin D

51
Q

Skin History

A

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
Q

changes in hair

A

hair loss (eating disorder, bariatric surgeries, alopecia, anxiety)
distribution (bald spots?)
change in color or texture

53
Q

change in nails

A

change in shape or consistency
clubbing? (respiratory- smokers, COPD)
nail biting?

54
Q

ROS- Infants/children

A

birthmarks
jaundice/cyanosis (newborn)
Rash
Introducing new foods
Diaper rash
Exposure to
scabies, lice, impetigo
chicken pox, measles
toxic plants

55
Q

ROS Adolescents

A

Acne (product use, nutrition, hygiene)

56
Q

ROS aging adult

A

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
Q

Inspection

A

Assess first: cleanliness, odor, superficial veins/arteries

58
Q

Palpation of skin

A

temp (dorsal part of hand), moisture, texture, lesions, turgor

59
Q

poor turgor

A

tenting

60
Q

assessing skin

A

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
Q

skin color variations

A

Pallor- conjunctiva pale?, anemia?, poor circulation?
Cyanosis
Jaundice
Erythema- red (rash)
Ecchymosis- bruised area
Vitiligo- spots/patchy areas
Mottling- marbeled skin (blue)

62
Q

ABCDE

A

asymmetry, border, color, diameter, evolution

63
Q

document description of suspicious skin lesions

A

Color
Elevation
Shape
Size- measure (growing?)
Location- lateral, medial, 12 o’clock
Exudate-pus/ drainage (color)

64
Q

document description of suspicious skin lesions

A

Color
Elevation
Shape
Size- measure (growing?)
Location- lateral, medial, 12 o’clock
Exudate-pus/ drainage (color)

65
Q

annular

A

circular (ringworm)

66
Q
A

annular

67
Q

target

A

lyme disease, antibiotic reaction

68
Q
A

target

69
Q

linear

A

scratch, poison ivy

70
Q
A

linear

71
Q

zosteriform

A

unilateral, herpes, shingles

72
Q
A

zosteriform

73
Q

confluent

A

hives

74
Q
A

confluent

75
Q

grouped

A

clustered fluid vesicles (poison ivy)

76
Q
A

grouped

77
Q

gyrate

A

snake-like, twisted keloid (healing)

78
Q
A

gyrate

79
Q

polcyclic

A

lesions grow together, cirrhosis

80
Q
A

polycyclic

81
Q

pregnancy normal variations

A

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
Q

aging adult normal variations

A

Senile lentigines-hyperpigmentation
Keratoses- raised, thickened areas
Seborrheic keratosis
Actinic keratosis
Acrochordons “Skin tags”

83
Q

lesions: normal variations

A

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
Q

aging

A

Decrease (thinner, subcutaneous fat): elasticity (elastin)
Increase: vascular fragility, thinning
Hair and nails- brittle and thin

85
Q

culture/race relating to skin

A

Melanoma- high risk (26X higher risk for whites than blacks)
Keloid formation- more common in black people
Hair

86
Q

primary lesions

A

appear as a direct result of the disease
occur at the onset of disease
Macule-petechiae, measles, freckles

87
Q

secondary lesions

A

may develop from primary lesions or result from external trauma- scratching, infections
Scales, crusts, ulcers

88
Q

macule

A

flat

89
Q

papule

A

raised

90
Q

nodule

A

> 2cm, fluid filled

91
Q

excoriation

A

losing top layer of epidermis

92
Q

erosion

A

losing epidermis and part of dermis

93
Q

fissure

A

linear break in skin

94
Q

ulcer

A

loss of tissue

95
Q

pressure injury stage 1

A

no break in skin

96
Q

pressure injury stage 2

A

partial thickness skin loss, abrasion, blistering, small crater

97
Q

pressure injury stage 3

A

full thickness of skin loss (through epidermis and dermis)

98
Q

pressure injury stage 4

A

damage to bone, muscle, tendons

99
Q

pressure injury- unstageable

A

wound/pressure injury, don’t know stage until cleaning away eschar

100
Q

deep tissue injury (DTI)

A

skin is intact, purplish, boggy (squishy), eschar on it

101
Q

pressure injury prevention

A

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
Q

assessing hair

A

color, texture, distribution, scalp (should be smooth), pediculosis (lice)

103
Q

assessing nails

A

nail color (pink), nail shape (convex), nail texture (smooth), capillary refill (brisk)

104
Q
A

160 degrees

105
Q

clubbing

A

angle > 180

106
Q

beau’s lines

A

trauma, acute illness, toxic reaction

107
Q

splinter hemorrhages

A

trauma, bacterial endocarditis

Ellie-NUR 265 (10 decks)

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