Exam 1 Flashcards
Diagnostic Process
Assessment Diagnosis Planning Implementation Evaluation
Assessment- 2 types of data
Subjective- what pt states about himself
Objective- what the health professional observes/assesses
critical thinking
developed as the nurse progresses from novice to expert
Thinking like a nurse involves 3 nursing diagnoses:
- Actual- whats actually happening
- Risk- when patient is at risk for something (infection after surgery, sepsis.. etc)
- Wellness- how well can the pt cope with daily activities
what determines how a problem is prioritized?
the acuity of illness often determines order of priorities
3 levels of setting priorities
first-level priority: emergency and life threatening problem
2nd-level priority: when you don’t intervene promptly, pt starts to deteriorate
3rd-level priority: important but not as urgent
what type of health history is taken when patient is admitted into hospital?
Complete (total health) database
what type of health history is taken when pt is sent to emergency room?
Focused or Problem-Centered Database
What type of health history is taken when pt is discharged and sent to be re-assessed
Follow-up database
Type of health history usually taken when happening in emergency situations
Emergency Database
health promotion ____
encourages patients to do preventative care
The interview process is made up of 2 facrors:
Internal and External Factors
Internal factors that should be used during the interview process are:
- liking others
- empathy
- listening
External factors that should be used during the interview process are:
Privacy
Interruptions
Environment
Note-taking
The 2 most used techniques of communication that can be used in the interview process;
- Open-ended question: “tell me what you’re in for today”
2. Closed or directed question: “what medication are you taking, rate your pain on a scale of 0-10”
When do you use an open-ended question?
- to facilitate beginning of interview
- introduce a new section of questions
- introduce new topic
- to end an interview and ease into closure
when do you use a closed or directed question?
- need specific info where short answers are rquired
- to force a choice
Common nonverbal skills you project onto patient
- physical appearance
- posture
- gestures
- facial expressions
- eye contact
- voice
- touch
Interpreters are ___
- mandated by law
- NEVER a family member
A complete health history includes 7 aspects:
- biographic data
- source of history
- reason for seeking care
- present health history/illness
- past health information
- family history
- cultural
What type of assessment is geared towards how the pt takes care of themselves?
Functional Assessment
should leave towards the end of the assessment
Assessment Techniques
Inspection- look at skin, breathing, smell, use senses
Palpation- always comes after inspection
Percussion- to determines whats beneath a structure
Auscultation- listening to normal body structures
Percussion Sounds:
Amplitude- how loud or soft the sound is
Pitch- high vs low pitch (based off of vibration)
Quality- what makes different area of body sound diff.
Duration- how long does sound last?
Percussion Characteristics
Resonant- over lungs, normal sound for lung tissue
Hyperresonant- booming sound (lungs) in kids
Tympany- drum like sound, found in abdomen
Dull- muffled thud
Flat- bones
Ausculation is mainly used in what 3 body areas
heart, lungs, abdomen
The diaphragm and bell are used for which sounds?
diaphragm- high pitched sound
bell- low pitched sound
A general survey includes:
- physical appearance
- body structure
- mobility
- behavior
Measurement of Pt includes:
- Weight
- Height
- BMI
- Waist Circumference
Vital Signs:
Temperature Pulse Respirations Blood Pressure 5th vital sign: PAIN
vital signs should be assessed:
Every 4 hours
Types of temperature that can be taken
Oral- most used, most reliable Axillary Tympanic Temporal Artery Rectal
Pulse should be taken:
count 30-60 seconds
begin at zero
use pads of fingers for radial pulse
Assess: rate, rhythm, force
You should count respirations for how many seconds?
30-60
30 if they are healthy, 60 if not so you can observe abnormality
how many feet should you be standing from your pt to ensure comfortability?
4-5ft
when interviewing adolescents, what should you avoid doing?
long bouts of silence,
reflection
be aware of your nonverbal communication skills. they are more sensitive to this.
HEEADSSS is used as a questionnaire for what patient population and what does it stand for?
adolescents- moves from non threatening questions to personal
-Home environment, Education/employment, Activities, Drugs, Sexualtiy, Suicide/depression, safety from injury and violence
what are the most common assessment techniques?
inspection, palpation, percussion, Auscultation
what is defined as concentrated watching and is the first step of assessment
Inspection
the step that always follows inspection in the assessment of a new pt
Palpation
palpation feels for:
texture temp moisture organ location and size swelling vibration or pulsation crepitation lumps or masses tenderness or pain
fingers-
grasping action of fingers and thumb-
Dorsa-
Palm-
skin texture, swelling, pulsation, lumps
position, shape, and consistency of an organ or mass
Temperature (back of hand)
vibration
tapping of the skin with short, sharp strokes to assess underlying structures
Percussion
Light palpation: cm?
Deep Palpation: cm?
1cm deep (usually abdomen) start with this then move into deep if needed 5-8cm (deep circular motion in clockwise direction)
Percussion sounds: 4
Amplitude: volume
Pitch: based on vibration speed
Quality: different places make different sounds
Duration: how long does the sound last?
The Resonant sound comes from
the lungs: clear, hollow sound
Sounds dense if theres a tumor or extra mass
Hyperresonnant sound comes from
Child’s lung (normal)
Adult lung (Abnormal) –> emphysema, COPD
“Booming” sound
Tympany sound comes from
air filled visuc (stomach, intestine)
“drumlike”
Dull sound comes from
an organ
“muffled thud”
Flat sound comes from
the bone or thigh muscles, tumor.
“dead stop to sound”
vital signs should be assessed every ____
4 hours
what is the purpose of taking someones vital signs?
to assess cardiovascular & Pulmonary status
give you info on if pt is declining
include pain scale
what are the 4 vital signs>
Temp
Puls
Respirations
BP
5 types of temperature:
- Oral- most used/reliable
- Axillary- 1 degree lower than normal (Farenheit)
- Tympanic- ear
- Temporal Artery- wave magic wand, not as accurate
- Rectal- closest temp to core body, avoid in cardiac pt
What influences a temperature reading?
diurnal cycle- time of day (^ at night)
menstruation- 1 degree higher
Exercise
Age
When you’re taking the pulse what should you be assessing for?
Rate (50-95 beats per minute)
Rhythm
Force
the pressure exerted against arteries when the heart is contracting
Systolic BP
the resting pressure when ventricles are filling between contraction
Diastolic BP
Amount of blood ejected from L ventricle per minute
Cardiac Output
Factors that affect BP (5)
- Cardiac Output
- Vascular Resistance
- Volume
- Viscosity
- Elasticity of arterial walls
The Sphygmomanometer measurements
width- 40% of pt’s arm
length- 80% of pt’s arm
To test a patients orthostatic pressure you should follow these 3 steps:
- Have pt rest supine for 2-3 minutes
- Take BP with them lying down
- Assist pt to sitting position and wait 2-3 minutes
- Take BP with them sitting
- Stan patient up wait 2-3 minutes
- Take BP with them standing
- Compare diastolic pressures. if there is a decrease of 20 mmHg its considered positive orthostatic BP
3 common abnormalities of the blood/heart
- Arterial Obstruction
- Coarctation of the aorta
- Auscultatory Gap
Arterial Obstruction
- stenosis or narrowing of artery
- difference in systolic BP of 10-15 mmHg between arms
- check BP in both arms
Coarctation of the aorta
when your arm BP reads higher than your thigh BP
- in healthy person BP is always higher in thigh*
- congenital narrowing of aorta
An Auscultatory gap is common in:
hypertensive clients or older adults
*caused by atheroscelorsis
Order of measurement for infants and toddlers:
- take an apical pulse*
- watch for respirations in the abdomone
- Tame temp last ** will cry***
Order of measurement for preschoolers:
- Take BP for 3yrs and older
2. take temp last
School-aged kids can be coaxed to cooperate through:
explanation of what you are doing
In older adults, temperature may be ___
lower.
harder to catch a fever and more at risk for hypothermia
A normal pulse ox rate is:
92-100%
when you are unable to palpate a pulse, what do you do?
- Grab a doppler before documentation that they didn’t have a pulse.
- if still cant find pulse– get doctor immediately
Chart documentation follows a simple acronym of:
SOAP S- subjective data first O- objective data next A- assessement and documentation of info P-- plan, develop a plan and document their work
What are the types of pain? (4)
- Acute
- Chronic (persistent)- assoc. with disease process
- Malignant- cancer
- Nonmalignant- arthritis or some type of musculoskeletal condition
What are the sources of pain? (4)
- Deep Somatic- from joint or vessel (ischemia or injury)
- Cutaneous- scrape or born. skin levele
- Referred- originates in 1 area but felt in another
- Neuropathic- damage of nerve fibers (diabetes, shingles)
What is the most reliable indicator of pain?
the subjective report given by pt
- allow pt to describe it
What are the assessment tools for pain?
- Numeric rating scale
- descriptor scale
- faces pain scale
