Exam 1 Flashcards
Health Histoy consits of what type of data?
Subjective date
Subjective Data
Info about current state of health of patient, meds they take, previous illnesses, and surgeries, family history, and review of systems
Primary source data
Subjective data acquired directly from the patient
Secondary source data
Data acquired from another individual like family
Physical examination
A collection of objective data, sometimes referred to as signs. Data is collected by using techniques of inspection, palpation, percussion and auscultation. Also includes height, weight, blood pressure, temp, pulse rate, and respiratory rate
Signs
Objective data observed, felt, heard, or messured. Exp: rash, enlarged lymph nodes, and swelling of extremity
Symptoms
Subjective data perceived and reported by the patient. Exp: pain, itching, and nausea
Documentation of data
Require data to be recorded accurately, concisely, without bias or opinion, and at the point of patient care
Context of care
Circumstances contribute to the setting or environment; physical, psychological, or socioeconomic circumstances involving patients, and nurse expertise
Patient needs
Patient’s: age, general level of health, presenting problems, knowledge level, and support systems are among the variables that impact patient need
Types of health assessments(5)
Comprehensive assessment, Problem-based/focused assessment, Episodic/follow-up assessment, Shift assessment, and Screening assessment/examination
Comprehensive assessment
A detailed history and physical examination performed at the onset of care in a primary care setting
Problem-based/focused assessment
History and examination that are limited to a specific problem or complaint
Episodic/follow-up assessment
The assessment is done when a patient is following up with a health care provider for a previously identified problem
Shift assessment
Identify changes to a patient’s condition from the baseline
Screening assessment/examination
A short examination focused on disease detection
The nursing process(systemic)
Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
Health promotion
A behavior motivated by the desire to increase well-being and actualize human health potential
Health protection
A behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within constraints
3 levels of health promotion
Primary prevention: promotion of healthy lifestyles
secondary prevention: screening efforts for early detection
tertiary prevention: minimizing the disability from acute and chronic disease and maximize health
Interview process
How the health history is obtained and the success of an interview is the communication skills of the nurse
Phases of the interview(3)
Introduction, discusion, and summary
Introduction phase
Introduce self to patient and describes her role in the patients care, describe the purpose and process of the interview, you want a respectful and effective relationship
Discussion phase
Facilitates and maintains a patient-centered discussion and uses various communication techniques to collect data, detect disease early and prevent complications
Summary phase
Summarizes the data with the patient, allows the patient to clarify the data, and communicates an understanding of the problems to the patient, emphasize health promotion and disease prevention
Physical settings
Patient should be physically comfortable during the interview, the amount of space the patient needs varies and is influenced by her culture and previous experiences in similar situations
Techniques that enhance data collection
The question-answer format is the esential tool, active listening facilatation, clarification, restatement, reflection, confrontation, interpretation, and summary
Techniques that diminish data collection
Using medical terminology, expressing value judgements, interurupting the patient, being authoritarian or paternalistic, and using why questions
Silence in an interview
Silence is awkard and there is often an urge to break it with a comment or question, patient may need the silence as time to reflect or gather courage. May indicate that they are not ready to discuss this topic or that the approach needs to be evaluated
Interpretation
Nurse uses interpretation to share with patients the conclusion drawn from data they have given
Clinical judgement
Influenced more by the nurse’s experience, knowledge, attitudes, and perspectives that the data alone. There are four components: noticing, interpreting, responding, and reflection
Symptom analysis: OLD CARTS
Onset, location, duration, characteristics, aggravating factors, related symptoms, treatment by the patient, and severity
Onset
Exp:When did the symptoms begin? Suddenly or over a period of time? Where were you when symtoms began?
Location
Exp: Where are the symptoms? Are they in a specific area? Do the symptoms radiate to another area?
Duration
Exp: How long do the symptoms last? Have they become worse? Are they constant? If so does the severity fluctuate?
Characteristics
Exp: Describe the characteristics of the symptoms, describe how they look or feel, and describe the sensation
Aggravating factors
Exp: What affects the symptoms? What makes the symptoms worse? What makes the symptoms better?
Related symptoms
Exp: Have you noticed other symptoms?
Treatment
Exp: What methods of self-treatment have you tried? Have any of those methods been effective? Have you seen a doctor for this before?
Severity
Exp: Describe the severity of the symptoms, describe the size, extent, number, or amount. Rate you symptoms on a scale of 0-10
General inspection
Requires paying attention to details and provided clues about any possible problems they may be experiencing, beginning this the moment you meet the patient
Initial impressions
Physical appearance, body structure and position, body movement, emotional status, disposition, and behavior
Initial impressions
Exp: Dressed appropriate for the weather, mood is appropriate, emotional state appropriate, what is the patients body posture, is patient sluped and seem sad or are they walking briskly with a smile, tone of voice, monotone or happy, is the conversation flow logical
Physical appearance
Exp: appearance, age, skin, and hygiene, tremors or facial drooping, do they appear close to their age, some look older due to drugs, alcohol use, excessive sun exposure, chronic disease, and endocrine disorders. Notice color and condition of skin, presence of lesions, what is the hygiene of the patient, are they clean, and are the odors?
Baseline indicators
Vital signs, temp, heart rate, respiratory rate, bp, oxygen saturation, height, and weight. Assessing for presence of pain is standard base line data
Full physical examination
Inspection, palpation, auscultation, and percussion will all be used
Vital signs
All are within normal limits. bp 84-120 systolic, 54-80 diastolic, heart rate 75-100, and respirations 18-30
Hand hygiene
Single most important action to reduce the transmission of infection, it’s an essential element of standard precautions. Preformed before and after contact with patients
Inspection
Physical examinations begin with inspection of every body system. A visual examination of the body including body movement and posture. Data can also be obtained by smell
Tangential lighting
Penlight used to increse light in certain places like looking in a mouth or skin lesions or to create shadows by directing light at right angles to the area being inspected
Palpation
Involves using the hands to feel texture, size, shape, consistency, palpation, and locating several parts of patients body. Used to identidy areas the patient reports as being painful or tender
Palmar surface
Of the fingers and pads are more sensitive to palpation than the finger tips
Ulnar surface
Of the hands extending to the 5th finger is the most sensitive to vibration
Dorsal surface(back)
Of the hand is more sensitive to temperature
Light palpation
Accomplished by pressing down to a depth of approx 1cm and is used to assess skin, pulsations, and tenderness
Deep palpation
Accomplished by pressing down a depth of 4cm with one or two hands used to determine organ size
Bimanual palpation
Uses both hands, one anterior and one posterior to assess shape and size of organs
Percussion
Preformed to evaluate the size, borders, and consistency of internal organs: detect tenderness: and determine the extent of the fluid in a body cavity. There are two techniques: direct and indirect
Direct percussion
Striking a finger or hand directly against the patient’s body
Indirect percussion
Use of both hands, place the nondominant hand palm down and gently tapping with fist
5 percussion tones
Tympany, resonance, hyperresonance, fullness, and flatness
Tympany
Heard over the abdomen
Resonance
Heard over healthy lung tissue
Hyperresonance
Heard over in over inflated lungs(emphysema)
Dullness
Heard over the liver
Flatness
Heard over bones and muscles
Auscultation
Listening to sounds within the body, a stethoscope is usually used because it blocks out extra noises. Listen for intensity, pitch, duration, and quality
Equipment
Thermometer, stethoscope, equipment to measure bp, pulse oximeter, scales for weight and height, visual acuity charts, opthalmoscope, otoscope, penlight, ruler and tape measure, nasal speculum, tuning fork, percussion hammer and neurologic hammer, doppler, goniometer, calipers for skinfold thickness, vaginal speculum, audioscope, monofilament, transilluminator, wood’s lamp, and magnification device
Thermometer
Used to measure temperature which is regulated by the hypothalamus, expected temp ranges from 96.4-99.1 with an average of 98.6 or 35.8-37.3 with an average of 37
Standard electronic thermometer
Used for measuring oral, axillary, or rectal temps
Tympanic membrane thermometer
Measures temp near the tympanic membrane in the ear
Temporal artery thermometer
Measures temp from the temporal artery across the forhead. High level of accuracy amongs kids and adults in critical care
Stethoscope
Used to auscultate sounds within the body that are not audible with the naked ear. There are four parts: earpieces, binaurals, tubing, and the head that has two parts the diaphragm and the bell
Diaphragm
A flat surface used to hear high pitched sounds such as breath, bowel, and normal heart sounds
Bell
Used to hear soft, low pitched sounds such as extra heart or vascular sounds
Bp equipment
Bp is measured noninvasively using a manual or automated bp device, the automated bp can be used with confidence to measure systolic accurately but caution when reading diastolic
Pulse oximeter
Measures the O2 saturation in arterial blood, LED probe emits light waves that reflect off oxygenated and deoxygenated hemoglobins, estimates the % of oxygenated saturation in arterial blood and a pulse rate, accurarate over the 70-100% usually applied on finger, toe, or earlobe
Visual acuity charts
Used as screening examination for visual acuity, color perception, and field perception
Distance vision charts
Snellen charts is hung 20 feet from patient and top # is distance from chart and bottom number is the line they can read. E chart is for kids or non english speaking individuals
Near vision examination
Rosenbaum used to evaluate near vision consits of Es, Xs, Os
Opthalmoscope
Consits of a series of lenses, mirrors, and light apertures. It permits inspection of the internal structure of the eye
Head of opthalmoscope
Has two movable parts: Lens selector dial that allows the nurse to adjust a set of lenses that control focus, unit strength is diopter
Aperture: permits light variations
PanOptic head
Designed to allow for a wider field and greater magnification
Otoscope
Used for inspection of the external auditory canal and tympanic membrane, choose the largest size speculum that fits in the ear canal
Head of the otoscope
Consits of magnifying lens, a light source, and a speculum that is inserted into the auditory canal
Nasal speculum
Used to spread the opening of the nares so the internal surface can be inspected, there are two types: simple nasal speculum and a broad-tipped-cone-shaped device
Tuning fork
Two purposes: auditory screening and assessment of vibratory sensation
Percussion Hammer and Neurologic Hammer
Deep tendon reflexes
Doppler
Amplifies sounds that are difficult to hear with a stethoscope, ultrasonic waves are used to hear fetal heartbeats or peripheral pulses
Goniometer
Two piece ruler jointed in the middle with a protractor type used to meassure the degree of flexion or extension of a joint
Transiluminator
Used to differentiate the characteristics of: tissue, fluid, and air withing a specific body cavity
Wood’s lamp
Produces a blacklight effect and used to detect fungal infections or corneal abrasions to the eye
Magnification device
Helps inspect: wounds, skin lesions, and parasites
Oral temperature
Safe and relatively accurate
Axillary temperature
Infrequently used site for temp measurement in adults, usually one degree below the normal temp taken orally
Rectal temperature
Reflecta core body temp and is considered more accurate than non invasive approaches
Heart rate
Commonly assessed indirectly by palpating the pulse. Changes in heart rate include: physical excersion, fever, anxiety, hypotension, hormonal imbalances
Respiratory rate
Factors that increase rates: fever, anxiety, exercise, and increased altitude. Assess the rythm regular or irregular, depth is normal or shallow. Shallow breathing can be observed by the effort. Normal breathing should be even and quiet and efortless
Blood pressure
Force of blood against the arterial walls reflects the relationship between cardiac output and peripheral resistance and it is measured in millimeters of mercury, and ankle site is prefered when upper arm is unavailable
Cardiac output
Volume of blood ejected from the heart
Peripheral resistance
The force that opposes the flow of blood through the vessels
Systolic bp
The maximum pressure exerted on arteries when the ventricles contract or eject blood from the heart
Diastolic bp
The minimum amount of pressure exerted on the vessels this occurs when the ventricles are relaxed and fill with blood
Types of pain
Acute, persistent(chronic), nociceptive, and nerupathetic
Acute pain
Recent onset of pain, less than 6 months and results from tissue damage, usually self limiting, and ends when the tissue heals
Persistant pain(chronic)
May be intermittent or continuous, lasting more than 6 months
Nociceptive pain
Pain arises from stimulation of somatic structures such as bone, joint, muscle, skin, and connective tissue or from stimulation of visceral organs such as gi tract or pancrease
Nerupathic pain
Occurs from an abnormal processing of sensory input by the central or peripheral nervous system
Standards for pain assessment
- Initial assessment of pain and regular assessment, taking into account the patients personal, cultural, spiritual, and ethnic beliefs
Standards for pain assessment
- Education of all relevant health care personnel in pain assessment and management
Standards for pain assessment
- Education of patients and their families on their roles in managing pain and the potential limitations and side effects of the treatment of pain
Pallor
Loss of color white/lighter than normal
Location: face, conjunctivia, nail beds, palms, lips, buccal mucosa
Indication: Anemia, shock, or lack of blood flow
Cyanosis
Bluish color/ashen gray color
Location: nail beds, lips, oral mucosa, skin palms
Indication: hypoxia or impaired venous return
Jaundice
Yellow to orange color/yellowish green
Location: skin, sclera, mucous membranes
Indication: liver dysfunction, red blood cell destruction
Erythema
Redness/deeper brown purple
Location: face, skin, trauma, and pressure sore areas
Indications: inflammation, localized vasodilation, substance use, sun exposure, rash, and elevated body temp
Turgor
Elasticity of skin, you assess by pinching the skin on forearm or under the clavicle, should return when released
INSPECT SKIN: general skin color and localized variations
N:Color should be even
A:abnormal skin color could be local or systemic disease: cyanosis, pallor, and jaundice
N:Pigmented nevi moles 10-40 less than 5 mm, freckles are small flat macules, patch a darker skin pigmentation, and striae are pink or silver stretch marks
A:elanoma and vitiligo are abnormal
PALPATE SKIN: texture, temperature, moisture, mobility, turgor, and thickness
N:smooth, soft, calluses, skin should be dry, the skin should be elastic
A:cool and hot skin, diaphoresis, edema, and tenting, increase in skin thickness
Inspect and Palpate the scalp and hair
N scalp:smooth, no flaking, lesions, no redness, soft, shiny
A scalp: dull, coarse, brittle hair, lice, alopecia
Inspect facial and body hair
N: normal distribution evenly where hair is meant to be
A: hair loss in legs may mean poor peripheral perfusion, thining eyebrows is related to hypothyroidism, hirsutism hair growth in women
ABCDEF Carcinoma
A: asymmetry not round B: border irregular C: color uneven D: diameter greater than 6mm E: elevation change from flat to raised F: feeling, itching tingling
Macule
Flat, change in color
Freckles, flat nevi moles, measles
Papule
Elevated firm
Wart, elevated moles, cherry angioma
