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NUR3120 HEALTH ASSESSMENT > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Pressure Ulcer Stage II

A

Partial thickness skin erosion

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2
Q

Definition of Pain

A
  • An unpleasant sensory and emotional experience associated with potential or actual tissue damage or described in terms of damage
  • pain is subjective
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3
Q

Interview Guidelines

A
  • keep intro short/formal
  • address by last name
  • cultural sensitivity
  • explanation of interview
  • make eye contact
  • ask follow up questions
  • avoid bombarding
  • demonstrate appreciation
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4
Q

Nursing Diagnoses for Spiritual Health

A
  • anxiety
  • grief
  • hopeless
  • ineffective family coping
  • altered family processes
  • altered self-esteem or concept
  • spiritual distress
  • potential for enhanced spiritual well-being
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5
Q

Pressure Ulcer Stage IV

A

Full thickness involving all skin layers and extends into supporting tissue

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6
Q

Passive ROM

A
  • performed when patient has limitation
  • anchor the patient’s joint with one hand while your other hand slowly moves it to its limit
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7
Q

Types of Databases

A
  • complete or total health
  • focused or problem centered: mini-database
  • follow-up
  • emergency
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8
Q

Physiological Effects of Pain : GASTROINTESTINAL

A
  • N&V
  • ileus : intolerance of oral intake
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9
Q

Types of Evidence

A
  • patient preferences & values
  • clinical expertise of provider
  • evidence from research & evidence-based theories
  • physical examination & assessment
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10
Q

Basal Cell Carcinoma

A
  • most common skin cancer
  • usually on sun-exposed areas
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11
Q

The Nursing Process : ASSESSMENT

A
  • collect data : objective & subjective
  • use evidence-based assessment techniques
  • document relevant data
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12
Q

Interview Traps

A
  • derails interview
  • creates communication obstacles
  • provides false assurance
  • giving unwanted advice
  • using authority
  • using avoidance language
  • distancing
  • using professional jargon
  • using leading questions
  • talking too much
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13
Q

Types of Data

A
  • subjective data
  • objective data
  • patient record
  • lab & diagnostic testing results
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14
Q

?s Nurses might ask Regarding Spiritual Health

A
  • tell me what life means to you
  • are you in need of religious/spiritual or emotional support
  • is this illness causing any major life changes for you or a loved one
  • have you had any major stress or change in lifestyle recently
  • is there anything we need to know about your religion, culture, or background
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15
Q

Assessment Tool for Substance Abuse : CAGE

A
  • have you ever felt the need to CUT down on your drinking
  • have people ANNOYED you by criticizing your drinking
  • have you ever felt GUILTY about your drinking
  • have you ever felt you needed a drink first thing in the morning, EYE-OPENER, to steady your nerves or get rid of a hangover
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16
Q

Nutritional Developmental Considerations

A

AGING ADULT
- physical/mental health
- social isolation
- chronic alcoholism
- limitations
- poverty
- polypharmacy
- decreased energy
- socioeconomic

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17
Q

Health Effects of Violence, Abuse, & Neglect : IMMEDIATE

A

injuries including: cutaneous injuries, blunt-force trauma, lacerations, cuts or incisions, or strangulation

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18
Q

Blood Pressure

A
  • Normal : 120/80
  • Use left arm when possible
  • 1st sound : systolic
  • 2nd sound : diastolic
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19
Q

Components of Mental Status Exam : BEHAVIOR

A
  • LOC
  • facial expression
  • speech
  • mood & affect
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20
Q

Health History Purpose

A
  • collect data
  • screening tool
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21
Q

Health Effects of Abuse on Elders

A
  • complications from intentional injury
  • infections
  • cardiac complications
  • sexually related complications
  • dehydration
  • malnutrition
  • skin breakdown
  • self neglect
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22
Q

OLDCARTS
(history of present illness)

A

O = onset - acute vs gradual
L = location/radiation
D = duration
C = characteristics
A = aggravating/associated factors
R = relieving factors
T = treatments
S = severity of symptoms

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23
Q

Why assess mental status?

A

To determine if there is a dysfunction with:
- consciousness*
- language
- mood & affect*
- orientation*
- attention*
- memory*
- abstract reasoning*
- thought process & content*
- perception*

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24
Q

Pulse

A
  • Normal : 60-100 bpm
  • regular, 2+
  • irregular rate needs to be counted for a full minute
  • regular rhythm = 30 secs X 2
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25
Q

Body Movements

A
  • flexion & extension
  • abduction & adduction
  • pronation & supination
  • circumduction
  • rotation
  • elevation & depression
  • eversion & inversion
  • protraction & retraction
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26
Q

Vital Signs

A
  • temperature
  • pulse
  • respirations
  • blood pressure
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27
Q

4 basic cultural characteristics

A
  • culture is learned
  • culture is shared
  • culture is adapted
  • culture is dynamic
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28
Q

Respirations

A
  • normal : 10-20 breaths/min
  • do not tell pt when performing
  • 30 secs X 2, unless irregular = one full minute
  • even & unlabored
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29
Q

Physiological Effects of Pain : IMMUNE SYSTEM

A
  • impaired cellular immunity
  • impaired wound healing
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30
Q

Active ROM

A
  • patient does the movements themselves
  • you can model movement yourself for patient
  • performed when patient has no limitations
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31
Q

Interfering Factors for Auscultation

A
  • extra room noise
  • cold room = shivering
  • hairy chest = friction
  • gown or article of clothing
  • examiner sounds
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32
Q

Objective Data of Nutritional Assessment

A
  • growth & development
  • body compositions
  • height & weight
  • derived weight measures
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33
Q

Nutritional Assessment Screenings

A
  • performed @ admission
  • dietary history
  • labs
  • physical exam
  • 24hr dietary & 3 day recal
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34
Q

Verbal vs. Non-Verbal Communication

A
  • Verbal: spoken word, vocalization, voice tone
  • Non-Verbal: body language, posture, gestures, facial expression, eye contact, foot tapping, touch, chair placement
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35
Q

Diagnosing Substance Abuse

A
  • alcohol pattern: social, moderate, severe
  • alcohol dependence: chronic progressive disease
  • highly treatable, not curable
  • if undiagnosed leads to serious complications
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36
Q

Pressure Ulcer Stage III

A

Full thickness extending into subcutaneous tissue

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37
Q

Nurses role in treating substance abuse concerns

A

ADVISE & ASSIST
- state that their drinking is unsafe
- recommend they stop or cut down
- offer to help : referral to counselor of AA

38
Q

Dependence

A

Physical reliance & expectation of substance

39
Q

Melanoma

A
  • less common than basal and squamous carcinoma
  • if not detected & treated early can be dangerous
  • can spread
  • may begin in or near mole or dark spot
40
Q

Pressure Ulcer Stage I

A

Intact skin appears red but unbroken, does not blanch

41
Q

Braden Scale

A
42
Q

Considerations Related to Pain

A
  • developmental factors
  • aging adult
  • pain is not a normal process of aging
  • indicates pathology, injury
  • underreporting
  • culture
43
Q

Physiological Effects of Pain : PULMONARY

A
  • hypoventilation
  • hypoxia
  • atelectasis : collapse of or part of lung
  • dcrd cough
44
Q

Tolerance

A

Using more substance than normal to continue to get desired effect

45
Q

External Factors that affect Communication

A
  • environment/setting
  • geographical privacy
  • psychological privacy
  • interruptions
  • dress
  • note taking
46
Q

4 Point Scale for Assessing Edem

A

0 = absent
1+ = mild, slight indentation
2+ = moderate pitting, indentation rapidly subsides
3+ = deep pitting, indentation remains for a short time & area looks swollen
4+ = very deep pitting indentation that lasts long time

47
Q

Physiological Effects of Pain :
CNS

A
  • fear
  • anxiety
48
Q

Intoxication

A

Consumed enough substance to receive desired effects

49
Q

Components of Mental Status Exam : COGNITIVE FUNCTION

A
  • orientation
  • attention span
  • recent & remote memory
  • new learning
50
Q

The Nursing Process : EVALUATION

A

determine if goals met & outcomes achieved

51
Q

Nutritional Cultural Considerations

A
  • unique heritage
  • cultural patterns
  • cultural food preferences
  • religious practices
52
Q

Abuse

A

Using substances despite having negative consequences

53
Q

Physiological Effects of Pain : MUSCULOSKELETAL

A
  • spasms
  • joint stiffness
  • immobility
54
Q

Health Promotion Regarding Musculoskeletal System

A
  • consume a balanced diet: calcium & vit D
  • avoid activities that cause muscle strain or stress to joints
  • encourage maintenance of normal weight
  • participation in regular exercise program
  • contact HCP if joint or muscle pain occur, or limitations in ROM develop
55
Q

Physical Assessment Skills

A
  • Assessment
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
56
Q

Components of Mental Status Exam : APPEARANCE

A
  • posture
  • body measurement
  • dress
  • grooming & hygiene
57
Q

Key Subjective Data of Hair, Skin, & Nails Assessment

A
  • hx of skin disease, allergies, surgery, or trauma (tattooing)
  • changes in pigmentation
  • changes in moles
  • excessive dryness or moisture
  • pruritus (itching)
58
Q

Health Effects of Violence, Abuse, & Neglect : LONG TERM

A

chronic health problems including significantly more neurologic, gastric, & gynecologic symptoms & chronic pain

59
Q

Mental Status Definition

A

A person’s emotional and cognitive functions

60
Q

Squamous Cell Carcinoma

A
  • less common than basal cell
  • grows rapidly
  • usually on hands or head
  • areas exposed to UV radiation
61
Q

Intimacy vs Isolation
(early adulthood)

A
  • young adult; 19-40
  • gain independence from parents’ home
  • establish a career & vocation
  • form an intimate bond
  • setting up & managing a household
  • learning to cooperate in a marriage
  • making friends & establishing a social group
  • assuming civic responsibility
  • beginning a parental role
  • forming a meaningful philosophy of life
62
Q

Components of Spiritual Assessment

A
  • faith/beliefs
  • life & self responsibility
  • life satisfaction
  • fellowship & community
  • rituals & practice
  • vocation
  • expectations
63
Q

Observations of Hair, Skin, & Nails

A
  • excessive bruising
  • rashes or lesions
  • medications
  • hair loss
  • nail change
  • environmental or occupational hazards
  • usual self-care behaviors
64
Q

Integrity vs Despair
(late adulthood)

A
  • old age; 65+
  • adjusting to changes in physical strength & health
  • forming a new role as in-law and/or grandparent
  • affiliating with one’s age group
  • developing postretirement activities that enhance self-worth & usefulness
  • arranging safe & satisfactory living quarters
  • adjusting to the death of. spouse, family members, & friends
  • conducting a life review
  • preparing for one’s own death
65
Q

Nutritional Status Risk Factors for Disease

A
  • lifestyle
  • poor diet
  • smoker
  • hyperglycemia
  • exercise
  • alcohol
  • high BP
  • waist circumference
66
Q

Open-Ended vs. Closed Questions

A
  • Closed: elicit specific info, 1 or 2 word answers, speed up interview
  • Open-Ended: elicit a narrative response, feelings, and opinions, client can determine how much to share, useful for starting interview or expanding topic
67
Q

Physiological Effects of Pain : RENAL

A
  • oliguria : abn small amnts of urine outout
  • urinary retention
68
Q

Temperature

A
  • Normal : 98.6
  • wait 15 mins if ate, drank, or smoked
69
Q

ABCDEF Warning Signs for Skin Cancer

A

A = Asymmetry
B = Border irregularity
C = Color variation
D = Diameter greater than 6mm
E = Elevation & enlargement
F = Funny looking

70
Q

The Nursing Process : PLANNING

A
  • setting priorities
  • identify patient centered goals & expected outcomes
  • plan individualized nurse interventions
  • SMART
71
Q

PQRSTU

A

P = Provocative/Palliative
Q = Quality/Quantity
R = Region/Radiation
S = Severity
T = Timing/Treatment

72
Q

The Nursing Process : (nursing) DIAGNOSIS

A

Use clinical judgment about actual or potential health problems to prioritize & plan care

73
Q

Health History Components

A
  • date/time
  • biographical data
  • source
  • reason for seeking care
  • past health
  • family history
  • review of systems
  • ADLs
74
Q

Purposes of Nutritional Assessment

A
  • identify at risk patients
  • collect data
  • establish baseline
  • nutritional state & support
75
Q

Withdrawal

A

Discontinued use of substance causes unwanted side effects

76
Q

Substance

A

product consumed; alcohol, weed, cocaine, sedatives

77
Q

Physiological Effects of Pain : CARDIAC

A
  • tachycardia
  • hypertension
  • incrd myocardial oxygen demands
  • incrd cardiac output
78
Q

Mini-Mental State Exam (MMSE)

A
  • time & place orientation
  • register/recall 3 words
  • serial 7s calc
  • name object
  • repetition
  • comprehension
  • reading
  • writing a sentence
  • intersecting polygons
79
Q

Generativity vs Stagnation
(middle adulthood)

A
  • middle age; 40-65
  • accepting & adjusting to physical changes
  • reviewing & redirecting career goals
  • attaining desired career performance
  • developing hobby & leisure activities
  • adjusting to aging/death of parents
  • helping adolescent children int heir search for identity
  • accepting & relating to spouse a
  • coping with an empty nest
80
Q

Components of a General Survey

A
  • general obvious physical characteristics
  • overall impression
  • physical appearance
  • body structure
  • mobility
  • behavior
  • age & gender
  • LOC
  • skin color
  • facial features
  • ROM
81
Q

Indicators of Pain

A
  • complex biopsychosocial phenomenon
  • most reliable = pt’s report
82
Q

The Nursing Process : IMPLEMENTATION

A

initiate interventions & actions designed to achieve goals & expected outcomes to support/improve health status

83
Q

Physiological Effects of Pain : ENDOCRINE

A

incrd adrenergic activity

84
Q

Subject Data of Nutritional Assessment

A
  • eating patterns/habits
  • usual weight
  • changes: appetite, taste, smell
  • recent surgery, trauma, burns, infections
  • chronic illnesses
  • food allergies or intolerances
  • alcohol or drug use
  • family hx
85
Q

Substance Abuse Definition

A

Excessive use of alcohol and drugs

86
Q

Internal Factors that affect Communication

A
  • listening abilities : passive, active, demanding, ask questions, verbal & nonverbal, no interruptions
  • self awareness : personal biases, prejudices, stereotypes
87
Q

Components of Mental Status Exam : THOUGHT PROCESSES & PERCEPTIONS

A
  • thought process & content
  • perceptions
  • screen for anxiety, depression, suicidal thoughts
88
Q

The nurse is taking a family history. Which specific disease or problem should be included in the assessment?

A

Mental illness

89
Q

What does the review of systems provide the nurse?

A

Info regarding health promotion practices

90
Q

When assessing the quality of a client’s pain, the nurse should as which question?

A

What does your pain feel like (PQRST)

91
Q

Acute Pain

A

Pain the lasts less than 6 months, is short term, self-limiting, often follows a predictable trajectory and dissipates after injury heals

92
Q

Which assessment technique uses the sense of touch to assess texture, temperature, moisture, and swelling?

A

Palpation

NUR3120 HEALTH ASSESSMENT (3 decks)

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