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Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

acute care nurses

A
  • work with very sick patients, ICU, ventilators, recovering from open heart surgeries, stroke patients.
  • only has 1 or 2 patients at a time
  • checks patient every 5 minutes
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2
Q

critical care outreach nurses

A
  • go to small towns
  • stroke patients
  • refers to physician
  • not as critical as acute patients
  • check vitals every 2-4 hours
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3
Q

ambulatory care nurses

A
  • work in a physicians office
  • perform screenings
  • sometimes in a management position
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4
Q

home health nurses

A
  • patient is well enough to be home
  • gets medication ready
  • takes vitals
  • refers if needed
  • patient has the control, not the nurse
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5
Q

public health nurses

A
  • works directly with community
  • performs screenings
  • works in clinics, schools, community centers
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6
Q

School nurses

A

-daily routine of children (insulin, tube feedings, inhalers, medications, controls vaccines)

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7
Q

Hospice Nurses

A
  • end of life care
  • comfort care not solutions
  • works with patients families (coping)
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8
Q

Nursing informatics

A
  • works with data

- develops new policies/procedures

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9
Q

Holistic Assessment

A

-overall information collected from patients (subjective and objective) in order to determine level of function and make a clinical judgment

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10
Q

Physical medical assessment

A
  • listen, touch, feel

- work with clients physiological development

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11
Q

Initial comprehensive assessment

A
  • physicians office
  • collect subjective data from patient
  • insurance pays for this once a year
  • get medical history, family history, lifestyle, health practices
  • full physical check
  • holistic and medical assessment
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12
Q

ongoing or partial assessment

A
  • data collection after initial follow-up
  • focus on problem
  • offer solutions
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13
Q

focused/problem-oriented assessment

A
  • thorough assessment of a particular problem (do not check other areas)
  • examples: headache (you would check BP or do a neural assessment)
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14
Q

emergency assessment

A
  • rapid, life-threatening situations
  • ER
  • inpatient then loses a pulse/unresponsive (CPR or control bleeding)
  • only check emergency problem
  • THINK & ACT FAST
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15
Q

Phases of Nursing Process

A
  1. Assessment- collection of subjective and objective data
  2. Diagnosis- analyze data to make a nursing judgement (nurses diagnosis, collaborative problem, or referral)
  3. Planning- determine outcome criteria and make a plan- how to correct problem (check history)
  4. Implementation- carry out plan (inform physicians or get prescription)
  5. Evaluation- come back to patient and assess if intervention worked (outcome criteria met), if not start all over and asses intervention (what worked and what didn’t)
    - remember: ADPIE
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16
Q

Nuring Process

A
  • collecting subjective data
  • collective objective data
  • validating data: recollect data, validate patients info
  • documenting data: document EVERYTHING, if not documented then it was not done
  • analyzing: connecting all of the dots together
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17
Q

Phases of the interview

A
  1. Preintroductory- collect all data, look at file (prepare yourself)
  2. Introductory- Go to patients room, introduce yourself
  3. Working- collect data from patient, review & assess, ask about history & lifestyle, observe patient, listen
  4. Summary and Closing- Summarize info, validate, ask if they have any more concerns they would like to address
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18
Q

Observing patient

A
  • Non-verbal communication- quiet, anxious, withdrawn
  • appearance- dressed appropriate for weather, clean, groomed
  • demeanor- outward behavior
  • facial expressions
  • attitude
  • silence
  • listening
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19
Q

What to avoid in an observation

A
  • excessive or insufficient eye contact
  • distraction and distance (get close to patient)
  • standing (sit down when talking to patient)
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20
Q

Verbal communication

A

-open-ended questions
-close-ended questions (for a checklist)
-laundry list (giving patients options to choose; burning, itching, or pressure pain)
-rephrasing (you tell me your pain gets worse when you eat
-well-placed phrases (I understand, mhmm, I agree)
-inferring (since pain after eating…)
Provide information- answer patients questions HONESTLY

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21
Q

What to avoid with verbal communication

A
  • biased or leading questions (you feel this, right?)
  • rushing through interview- pretend you have all day
  • reading the questions
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22
Q

Special Considerations for verbal communication

A
  • gerontologic variations (ex. hard of hearing)
  • cultural variations
  • emotional variations (let them be and listen)
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23
Q

Health History

A
  • Biographical data- name, address, phone #, gender, preferred name
  • reasons for seeking healthcare
  • history of present concern- main concern
  • past health history
  • family health history
  • review of systems for current health problems
  • lifestyle and health practices
  • developmental level (mostly for children)
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24
Q

Genogram

A
  • Patient is first generation (spouse & kids included)
  • next group up 1 generation (parents, siblings)
  • last grandparents
  • collect data about all diseases
  • must have a key on it
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25
Q

What is the order of assessment techniques?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
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26
Q

Preparation for collecting data

A
  • Comfortable, warm temperature
  • Private area free of interruption
  • Quiet area with adequate lighting
  • Firm examination table or bed
  • Bedside table/tray to hold equipment
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27
Q

Standard Precautions

A
  • Hand hygiene
  • Gloves
  • Mask, eye protection, face shield
  • Gown
  • Patient care equipment; patient placement
  • Linen; occupational health and blood-borne pathogens
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28
Q

Equipment needed for assessment

A
  • Gloves and gown
  • Sphygmomanometer
  • Thermometer
  • Watch with second hand
  • Penlight
  • Stethoscope
  • Ophthalmoscope
  • otoscope
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29
Q

Client approach

A
  • Establish nurse–client relationship.
  • Explain the procedure and the physical assessment that will follow, describing the steps of the examination.
  • Respect client’s requests and desires.
  • Explain the importance of the examination.
  • Leave room while client changes clothes.
  • Provide necessary container in case of need for sample.
  • Begin exam with less intrusive procedures.
  • Explain procedure being performed.
  • Explain to client why position changes are necessary
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30
Q

Client Positioning

A
  • Sitting position
  • Supine position (laying on back)
  • Dorsal recumbent position (on back with knees up and arms above head)
  • Sims’ position (laying on side with leg up towards chest)
  • Standing position
  • Prone position
  • Knee–chest position
  • Lithotomy position (legs up in air)
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31
Q

What happens during the inspection phase of the assessment techniques?

A

Inspection: Room is comfortable temperature, good lighting, look and observe before touching, expose the body part you are inspecting, while draping the rest of the client, note characteristics; color, patter, size, location, consistency, compare appearance of eyes, ears, arms, and hands.

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32
Q

What happens during the Auscultation phase of the assessment techniques?

A

Uses a stethoscope to listen to hear sounds, movement of blood through cardiovascular system, movement of the bowel, air through the respiratory tract, eliminate distracting noise, expose body part being auscultated, warm the stethoscope before using.

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33
Q

What happens during a holistic nursing assessment?

A

Collects holistic subjective and objective data, determines a clients overall level of function in order to make a professional clinical judgement, nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client.

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34
Q

What happens during a physical medical assessment?

A

Focuses primarily on the clients physiological development, less focus on psychological, sociocultural, or spiritual well-being, a physical therapist would focus on the musculoskeletal system.

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35
Q

What are the five phases of the nursing process?

A
  1. Assessment
  2. Diagnoses
  3. Planning
  4. Implementation
  5. Evaluation
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36
Q

What happens during the assessment phase of the nursing process?

A

It is continuous and ongoing during every other phase, Collection of all the data, analyzing and synthesizing the data, making judgements about the effectiveness of nursing interventions and evaluating client care outcomes.

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37
Q

What happens during the diagnoses phase of the nursing process?

A

If you found a problem with your patient, you would make a professional nursing judgement for what you feel is wrong with your patient.

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38
Q

What happens during the planning phase of the nursing process?

A

Form a plan for how you will correct that problem, check the patients history, check medications.

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39
Q

What happens during the implementation phase of the nursing process?

A

Carrying out the plan, determine if you need to call the physician, may need a prescription and get the patient oxygen, or raise the head of the bed so the patient can breath better.

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40
Q

What happens during the evaluation phase of the nursing process?

A

After doing the steps you must come and assess your patient again, need to make sure your interventions worked and see if they are doing better, if not you may need to revise your plan.

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41
Q

What are the four types of nursing assessments?

A
  1. Initial comprehensive assessment
  2. Ongoing or partial assessment
  3. Focused- problem oriented assessment
  4. Emergency assessment
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42
Q

What happens during a initial comprehensive assessment?

A

Collection of subjective data about the client’s perception of health of all body parts or systems, past medical history, and lifestyle and health practices, insurance pays for one assessment a year.

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43
Q

What happens during an ongoing or partial assessment?

A

Data collection that occurs after the comprehensive database established, patient came in a couple weeks ago and the blood pressure was high, she was put on medication, and had a diet and exercise plan, so the physician wants to see the patient again, this is a follow up exam.

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44
Q

What happens during a focused-problem oriented assessment?

A

Does not replace the initial assessment, thorough assessment of a particular client problem does not cover all areas, if you came in with a headache we would only focus on that, asking about location, onset, and relieving symptoms.

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45
Q

What happens during an emergency assessment?

A

Very rapid assessment, choking, cardiac arrest, drowning, an immediate assessment focused on the problem to provide prompt treatment.

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46
Q

What are normal vital signs?

A

Temperature: 36.5 - 37.7 Degrees Celcius or 96.0- 99.9 Degrees Ferenheit orally.

Pulse: 60-100 beats per minute

Respirations 12-20 breaths per minute

Blood Pressure: Less than 120/80

Oxygen Saturation: 100

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47
Q

What are the four phases of client interview?

A
  1. Pre-introductory Phase
  2. Introductory phase
  3. Working phase
  4. Summary and closing phase
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48
Q

What happens during the pre-introductory phase of the client interview?

A

Nurse reviews the medical record before meeting the client, collect all your data, check the patients file, review all the labs, notes, medications, prepare yourself and have an idea about the patient

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49
Q

What happens during the introductory phase of the client interview?

A

Introduce yourself, explain the purpose of the interview, types of questions that will be asked, reason for taking notes, then start the interview.

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50
Q

What happens during the working phase of the client interview?

A

Collect biographical data, reason the patient is in the hospital, health history, family history, start assessing the patient, ask the patient about history and lifestyle.

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51
Q

What happens during the summary and closing phase of the client interview?

A

Summarize the information you obtained, validate the information from the patient, ask if there is something they would like to tell you, ask if there is anything else they would like to tell you.

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52
Q

What are the types of Palpation?

A

Light palpation, moderate palpation, deep palpation, and bimanual palpation.

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53
Q

What is light palpation?

A

Place dominant hand lightly on the surface of the structure, very little to no depression, less than 1 cm, feel using a circular motion, feel for: pulses, tenderness, surface skin texture, and temperature and moisture.

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54
Q

What is moderate palpation?

A

Depress the skin surface 1 to 2 cm with your dominant hand, an use a circular motion to feel for easily palpable body organs and masses, note size, consistency, and mobility.

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55
Q

What is deep palpation?

A

Place dominant hand on skin surface, and the non-dominant hand on top, depress 2.5 to 5 cm, allows you to feel very deep organs that are covered by thick muscle.

56
Q

What is bimanual palpation?

A

Use two hands, placing one on each side of the body part, use on hand to apply pressure and the other hand to feel the structure, note size, shape, consistency, and mobility, used on the uterus, breasts, and spleen.

57
Q

How do you use a stethascope?

A

Ear pieces into outer ear canal
Angle binaurals toward your nose
Diaphragm: High-pitched sounds
Bell: Low-pitched sounds

58
Q

What are the three types of percussion?

A
  1. Direct
  2. Blunt
  3. Indirect or Mediate
59
Q

What is direct percussion?

A

Two fingers, tap on the area to elicit possible tenderness.

Tenderness over the sinuses.

60
Q

What is blunt percussion?

A

One hand flat on the body while using the other hand as a fist and striking it.
Kidney stone or infection.

61
Q

What is indirect or mediate percussion?

A

Most commonly used method, produces a sound or tone that varies with the density of underlying structures, use your hand on the patient and tap the middle finger of the hand to produce sound waves.
As density increases, the sound becomes quieter
Solid tissue produces a soft tone
Fluid produces a louder tone
Air produces even louder tone

62
Q

Inspection

A
  • Room at comfortable temperature
  • Good lighting
  • Look and observe before touching
  • Completely expose part being examined while draping the rest of client as appropriate
  • Note characteristics
  • Compare appearance
63
Q

Palpation

A
  • Light palpation- less than 1cm
  • Moderate palpation- 1-2cm
  • Deep palpation- 2.5-5cm
  • Bimanual palpation- using both hands
64
Q

Things to notice when palpating

A
  • Texture (rough/smooth)
  • Temperature (warm/cold)
  • Moisture (dry/wet)
  • Mobility (fixed/movable/still/vibrating)
  • Consistency (soft/hard/fluid filled)
  • Strength of pulses (strong/weak/thready/bounding)
  • Size (small/medium/large)
  • Shape (well defined/irregular)
  • Degree of tenderness
65
Q

History

A
  • Biographical Data
  • History of present health concern
  • Personal health history
  • Family history
  • Lifestyle and health practices
66
Q

what sounds are elicited by percussion

A
  • resonance
  • hyper resonance
  • tympany
  • dullness
  • flatness
67
Q

Glasgow Coma Scale

A 
These three categories are each given a score, which is then summed to a maximum score of 15. 
Spontaneous eye response (1 to 4 points)
Verbal response (1 to 5 points)
Motor response (1 to 6 points)
68
Q

correct use of a stethoscope

A
  • Warm diaphragm and bell before use.
  • Explain what you are listening to and answer any questions.
  • Don’t apply too much pressure when using the bell as it will cause the bell to work like the diaphragm.
  • Avoid listening through clothes.
69
Q

Using the stethoscope

A
  • Ear pieces into the outer ear canal
  • Angle towards your nose
  • Diaphragm for high-pitched sounds
  • Bell for low-pitched sounds
70
Q

Data validation

A

Screen data- have all of the data and validate what is good/bad
Ways to validate data- talk to health care provider, talk to family, ask patient, computer/notes
Identify missing data- put it together
Discrepancies or gaps- what you look for versus what the patient tells you
Subjective data
Objective Data
Discrepancies from client statements
Abnormal/inconsistencies

71
Q

Factors affecting Mental Health

A
  • Economic and social factors: Stressful work conditions
  • Unhealthy lifestyle choices: substance abuse
  • Exposure to violence: Child Abuse
  • Personality Factors: Low self concept
  • Spiritual factors
  • Cultural factors
  • Changes or impairments in the structure and function of the neurologic system
  • Psychosocial developmental level and issue
72
Q

Risk factors for Mental Health Disorders and Substance Abuse

A 
A history of early aggressive behavior
Lack of parental supervision
A history of substance abuse
Drug availability 
Poverty
73
Q

Goal of prevention

A

Change the balance between risk and protective factors so that protective factors outweigh risk factors

74
Q

History

A 
Biographical Data
History of present health concern
Personal health history
Family history
Lifestyle and health practices
75
Q

what you need for a Mental Health and Risk for substance abuse assessment

A
  1. Prepare the client
  2. Equipment: pencil and paper, glasgow coma scale, depression questionnaire, SAD PERSONA suicide risk assessment tool, Saint Lois University Mental Status (SUMS) Assessment tool, Confusion assessment method (CAM)
76
Q

Glasgow Coma Scale

A

These three categories are each given a score, which is then summed to a maximum

77
Q

Methods of validation

A

Repeat Assessment
Clarify with client
Verify with another healthcare provider
Compare subjective/objective data

78
Q

purposes of documentation

A 
Chronologic data
Progressive record of assessment
Outline client course of care
Data easy to access for healthcare providers
Avoid repetitions
Prevent delays in plan of care
Help diagnosing new problems
Establishes educational needs
Financial reimburse/ eligibility
Legal record
Epidemiology data
Accreditation/professional standards requirement
79
Q

Diagnostic Reasoning Process

A

Step one—Identify strengths and abnormal data

  • Subjective data
  • Objective data

Step two—Cluster data

  • Identify strengths and abnormal findings for cues that are related.
  • Cluster both strength cues and abnormal cues
  • Consider, again, if additional data are needed.

Step three—Draw inferences

  • Write down “hunches” or assumptions about each cue cluster
  • Consider nursing diagnosis, collaborative problem, referral.

Step four—Propose possible nursing diagnoses

  • A wellness or health promotion diagnosis—opportunity for enhancement of health state
  • Risk diagnosis—potential noted
  • Actual diagnosis—currently noted

Step five—Check for defining characteristics

  • Use reference text such as NANDA Nursing Diagnoses: Definitions and Classifications 2015–2017.
  • Compare your findings to NANDA.

Step six—Confirm or rule out diagnosis

  • Validate diagnosis with client and other health care providers who are caring for the client.
  • Validation is also important if client has collaborative problem or requires a referral.

Step seven—Document conclusions

  • Wellness or health promotion diagnoses
  • Risk diagnoses
  • Collaborative problems and referrals
  • Nursing goals
  • Parameters that nurses monitor
  • Nursing responsibilities
80
Q

Assessment form types

A

Admission assessment forms
Frequent/ongoing assessment (flow charts)
Focus or specialty assessment form

81
Q

verbal communication of findings

A

SBAR (Situation, background, Assessment, Recommendations)
Face to face good eye contact
Allow time to receive/ask questions
Provide documentation
Validate information asking questions/ask receiver to summarize information
Telephonic communication, read back information

82
Q

Physical Assessment: level of consciousness and mental status (what to look for)

A
  • Level of consciousness
  • Posture, gait, body movements
  • Behavior and affect
  • Dress and grooming
  • Hygiene
  • Facial expressions
  • Speech
  • Mood, feelings, and expressions
  • Thought processes and perceptions
83
Q

Physical Assessment: Cognitive Abilities (what to look for)

A
  • Orientation
  • Concentration
  • Recent memory
  • Remote memory
  • Use of memory to learn new information
  • Abstract reasoning
  • Judgement
  • Visual, perceptual, and constructional ability
  • SLUMS Dementia/Alzheimer’s test exam
84
Q

Analysis of data and critical thinking

A
  • Data analysis: diagnostic or clinical reasoning phase
  • Diagnostic reasoning: form of critical thinking
  • Critical thinking: the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.
  • End result or purpose: the identification of a nursing diagnosis, collaborative problem, or need for referral to another health care professional.
85
Q

Critical thinking characteristics

A

Keep an open mind.
Use rationale to support opinions or decisions.
Reflect on thoughts before reaching a conclusion.
Use past clinical experiences to build knowledge.
Acquire an adequate knowledge base that continues to build.
Be aware of the interactions of others.
Be aware of the environment.

86
Q

Collaborative Problems

A

Cannot be prevented by nursing interventions

Medical Problems: signs and symptoms may require psychiatric medical diagnosis and treatment

87
Q

ways to increase accuracy of data

A 
Identify abnormal data and strengths.
Cluster data.
Draw inferences.
Propose possible nursing diagnoses.
Check for presence of defining characteristics.
Confirm or rule out nursing diagnoses.
Document conclusions.
88
Q

If a client’s suicide risk is high, they are put on suicide precautions (what are the suicide precautions?)

A
  • Psychiatric consultation
  • One on one observation
  • Modification of environment
  • Place client in a room near the nurse station
89
Q

Selected Nursing Diagnoses Includes:

A

Wellness and health promotion diagnoses: readiness for enhanced coping
Risk diagnoses: risk for self-directed violence related to depression and suicidal thoughts
Actual diagnoses: Anxiety, impaired verbal communication, acute or chronic confusion

90
Q

Collaborative Problems

A

Cannot be prevented by nursing interventions

Medical Problems: signs and symptoms may require psychiatric medical diagnosis and treatment

91
Q

General Survey (first step in head to toe assessment)

A 
Physical development and body build
Gender and sexual development
Apparent age as compared to reported age
Skin condition and color
Dress and hygiene
Posture and gait
Level of consciousness
Behaviors, body movements, and affect
Facial expression
Speech
Vital signs
Weight/height
92
Q

Interview

A 
General survey questions
History of present health concern
Personal history
Family history
Lifestyle and health practices
93
Q

How to begin for an assessment

A

-Preparing the client
-Equipment:
Thermometer
Protective, disposable covers for type of thermometer
Aneroid or mercury sphygmomanometer or electronic blood pressure measuring equipment
Stethoscope
Watch with second hand
Pulse oximeter
Dynamat (automatic vital sign machines)

94
Q

General impression in general survey

A

Observe physical development, body build, and fat distribution.
Compare client’s stated age with apparent age and developmental stage.
Observe skin condition and color.
Observe posture and gait.

95
Q

vital signs

A

-Hands-on physical examination begins with vital signs
-Provide data that reflect body systems status:
Cardiovascular
Neurologic
Peripheral vascular
Respiratory

96
Q

what are the vital signs

A 
Temperature
Pulse
Respirations
Blood pressure
Oxygen saturation (SpO2)
97
Q

oxygen saturation

A

hemoglobin carries oxygen- measures how many binding site are carrying oxygen

98
Q

Pulse oximeter probe

A

beams of light shine through tissues. the light absorbed by the blood varies with the oxygen saturation of hemoglobin

99
Q

Pulse amplitude

A

0: Absent
1+: Weak, diminished (easy to obliterate)
2+: Normal (obliterate with moderate pressure)
3+: Bounding (unable to obliterate or requires firm pressure)

100
Q

Blood Pressure

A

Systolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are contracted.

Diastolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are relaxed.

101
Q

pain

A
  • fifth vital sign
  • observe comfort level
  • Assess often and accurately
  • Initial assessment and every time you check vital signs
  • Check location, intensity, duration, quality, and any alleviating or aggravating factors
102
Q

Is evaluating level of consciousness part of a mental status exam?

A

True

103
Q

Which describes a client who is stuporous?

A

Awakes to vigorous shake or painful stimulus but returns to unresponsive sleep

104
Q

Neuropathic pain

A

Causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels

105
Q

A-Delta Primary Afferent Fibers

A

Small diameter lightly myelinated fibers and C fibers are unlimited primary afferent fibers. Classified as pain receptors, stimulated by noxious stimuli. Transmit fast pain to the spinal cord within 0-1 seconds. Felt as a pricking, sharp, or electric sensation usually caused by mechanical or thermal stimuli.

106
Q

C-fibers

A

transmit slow pain within 1 second. Felt as burning, throbbing, or aching. Caused by mechanical, thermal, or chemical stimuli usually resulting in tissue damage.

107
Q

Transmission

A

Initiated by this inflammatory process resulting in the conducting of an impulse in the primary afferent neurons to the dorsal horn of the spinal cord.

108
Q

Perception

A

Emotional status directly affects the level of pain perceived. Reported by clients.

109
Q

Modulation

A

Changes or inhibits the pain message relay in the spinal cord and involves the body’s own indigenous neurotransmitters in the course of processing the pain stimuli.

110
Q

Acute Pain

A

Usually associated with a recent injury

111
Q

Chronic Nonmalignant

A

Usually associated with a specific cause or injury and describe as a constant pain that persists for more than 6 months

112
Q

Tips for collecting Subjective Data on pain

A
  • Maintain a quiet and calm environment that is comfortable for the client being interviewed
  • Maintain the client’s privacy and ensure confidentiality
  • Ask the questions in an open-ended format
  • Listen carefully to the client’s verbal descriptions and quote the terms used
  • Watch for the client’s facial expressions and grimaces during the interview
  • Do not put words in their mouth
  • Ask the client about past experiences with pain
  • Believe the client’s expression of pain
113
Q

Cancer Pain Can Result From

A
  • Blocked blood vessels causing poor circulation
  • Bone fracture from metastasis
  • Infection
  • Inflammation
  • Psychological or emotional problems
  • Side effects from cancer treatments
  • Tumor exerting pressure on a nerve
114
Q

Cutaneous Pain

A

Skin and subcutaneous

115
Q

Visceral pain

A

abdominal cavity, thorax, cranium

116
Q

Deep somatic pain

A

Ligaments, tendons, bones, blood vessels, nerves

117
Q

Radiating pain

A

Perceived both at the source and extending to other tissues

118
Q

Referred

A

Perceived in body areas away form the pain source

119
Q

Phantom Pain

A

Perceived in nerves left by a missing, amputated, or paralyzed body part

120
Q

client considerations with vital signs

A
  • Temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F.
  • Osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis.
  • In older men, gait may be wider based, with arms held outward. Older women tend to have a narrow base and may waddle to compensate for a decreased sense of balance. Steps shorten, with decreased speed and arm swing. Mobility may be decreased, and gait may be rigid.
  • The older client’s artery may feel more rigid, hard, and bent.
  • In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging.
  • More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Systolic pressure over 140 with diastolic pressure under 90 is called isolated systolic hypertension.
  • Widening of the pulse pressure is seen with aging due to less elastic peripheral arteries.
121
Q

Reasons for a rise in temperature

A 
Strenuous exercise
Stress
Ovulation
Hyperthermia:
Viral or bacterial infection
Malignancies
Trauma
Various blood, endocrine, immune disorders
122
Q

Factors affecting Blood Pressure

A

Cardiac output
Elasticity of arteries
Blood volume
Carbon dioxide increases during exercise and cause it to rise
Arterial sclerosis- hardening of the arteries
Blood velocity- how fast blood is pumping, heartrate
Blood viscosity- thickness of blood, hydration status

123
Q

characteristics of radial pulse

A 
Rate
Rhythm
Amplitude (how far pulse goes)
contour
Most common area assessed- least invasive 
Easy to palpate 
Thumb side 
Rate- how many beats per minute 
Rhythm- regular or irregular 
Elasticity- spongy, hard
124
Q

validating and documenting findings

A 
Health promotion diagnoses
Risk diagnoses
Actual diagnoses
Collaborative problems
Medical problems
125
Q

Nociceptice

A

Response to noxious insult or injury of tissues such as skin, muscles, visceral, organs, joints, tendons, or bones

126
Q

Inflammatory

A

A result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation

127
Q

Phsyiologic Responses to Pain #1

A
  • Anxiety, fear, hoplessness, sleeplessness, thoughts of suicide
  • Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
  • Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilated pupils
  • Increased heart rate; peripheral, systemic, and coronary vascular resistance; and blood pressure
128
Q

Physiologic Responses to Pain #2

A
  • Increased respiratory rate and sputum retention, resulting in infection and atelectasis
  • Decreased gastric and intestinal motility
  • Decreased urinary output, resulting in urinary retention, fluid overload, depression of all immune responses
129
Q

Physiologic Responses to Pain #3

A
  • Increased antiduretic hormone, epinephrine, norepinephrine, aldostereone, glucagons, decreased insulin, testosterone
  • Hyperglycemia, glucose intolerance, insulin resistance, protein catabolsim
  • Muscle spasm resulting in impaired muscle function and immobility, perspiration
130
Q

What are the seven dimensions of pain?

A
  • Physical: physiologic effects
  • Sensory: quality of the pain and how severe the pain is percieved to be
  • Behavioral: verbal and nonverbal behaviors that the client demonstrates in response to the pain
  • Sociocultural: influences from the client’s social context and cultural background on the client’s pain experience
  • Cognitive: beliefs, attitudes, intentions, and motivations related to the pain and its management
  • Affective: feelings, sentiments, and emotions related to the pain experience
  • Spiritual: meaning and purpose that the client attributes to the pain, self, others, and the diving
131
Q

Subjective Data of Pain

A

Review past and family histories in terms of pain

Review lifestyle and health habits to determine how the pain interferes with the client’s life

132
Q

Tips for collecting Subjective Data on pain

A

-Maintain a quiet and calm environment that is comfortable for the client being interviewed
Maintain the client’s privacy and ensure confidentiality
Ask the questions in an open-ended format
Listen carefully to the client’s verbal descriptions and quote the terms used
Watch for the client’s facial expressions and grimaces during the interview

133
Q

Nursing Guidelines for Pain

A

-Explain to the client the purpose of rating the intensity of pain.
-Ensure privacy and confidentiality of the client.
Respect client’s behavior toward pain and the terms used to express it.
-Understand that different cultures express pain differently and maintain different pain thresholds and expectations
-Be aware of your own cultural and family values.
-Be aware of your personal biases and assumptions about people with different values than yours.
-Be aware and accept cultural differences between yourself and individual clients.
-Be capable of understanding the dynamics of the difference.
-Be able to adapt to diversity.

134
Q

An unpleasant and sensory and emotional experience, which we primarily associate with tissue damage is term pain

A

True

135
Q

QUESTT Principles for Pain in Children

A 
Question the child
Use pain-rating scales
Evaluate behavior and physiologic changes
Secure parents' involvement
Take cause of pain into account
Take action and evaluate results
136
Q

Hierarchy of Pain Assessment Techniques

A
  • Self-report
  • Search for potential causes of pain: surgery or IV
  • Observe client behaviors
  • Surrogate reporting: Family member or parent
  • Attempt an analgesic trial

Health Assessment (4 decks)

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