Exam 1 Blueprint Flashcards
Subjective data collection
- what the patient says: chief complaint (CC)
- health history
- symptoms
Objective data collection
- what the nurse observes: physical exam
- lab and diagnostic testing
- signs
Focused questions for Review of Systems
targeted problems
Biased communication
be nonjudgmental
safe, judgment-free, and non-discriminatory verbiage on forms
pronouns and names
Verbal and non-verbal communication
appropriate verbal communication:
- simple, recognizable and clear words
- use non-stigmatizing language; don’t them to shut down
appropriate nonverbal communication:
- body orientation toward and physical proximity to patient
- eye contact
- head nodding w facial animation
- head nodding w gestures
- posture
- tone & use of voice; use of silence
- use of touch
Communicating with the Hearing and visually impaired
- medical interpreter if needed
Using open-ended and closed-ended questions
open-ended questions: patient’s own words; story of symptoms
close-ended questions: yes or no answers; pertinent positives and negatives”
what they are telling us vs what is being shown
Interviewing people with challenging needs
- altered state or cognition: needing to decipher what is true or not
- angry, aggressive, threatening violence: getting reinforcements if needed
- flirtatious: suggest someone else be there; restating not appropriate and direct to care
- discriminatory
- under drug or alcohol influence: asking what they have taken to better care for them
- limited intelligence
- low health literacy
Culture
beliefs, values, traits, social norms, communication, and behaviors of that group
characteristics of the culture are learned, shared and adapted
requires humility; continually engage in self-reflection and self-critique
examining cultural beliefs and systems of patients and providers
Social Determinants of Health (SDOH)
Education access and quality
Healthcare access and quality
Neighborhood and built environment
Social and Community context
Economic Stability
Clinical Reasoning
gathering initial patient information
- health history and physical examination
- additional info:
– prior health records
– comments from fam, caregivers, providers, someone w knowledge of patient
– patient’s symptoms from history
– signed observed in exam, lab and diagnostic tests
organizing and interpreting information to synthesize the problem
generate hypotheses
testing hypotheses until a working diagnosis is selected
planning diagnostic and treatment strategy
Nursing Process
Steps for patient care/Plan
ADPIE
ADPIE
Assessment
Diagnosing
Planning
Implementation
Evaluation
Clinical Judgment
Steps after making a POC
a decision made regarding a course of action by the nurse
- collect data
- analysis of data
- interpretation of data
- determine priority problem/concern
- apply knowledge to clinical situation
- identify appropriate nursing intervention
– problem solving
– decision making
– critical thinkin
Assessment across the lifespan: Newborns and Infants
birth to 30 days; infants - 1 month-1yr
parent/caregiver presence
unable to talk
react to the emotional and physical cues
speak in a calm voice
parents can feed the baby
1-2 hours after feeding
sleeping baby best for heart/lung sounds
OPQRST
Onset
Precipitating and Palliating factors
Quality
Region or Radiation
Severity
Timing or Temporal characteristics
OLDCART
Onset
Location
Duration
Character
Aggravating or Alleviating factors
Radiation
Timing
Abdominal Assessment - focused questions to ask patients
Adults, Infants, Adolescents, Aging adults
About:
- abdominal pain
- appetite
- dysphagia- difficulty swallowing
- food intolerance
- nausea, vomiting, diarrhea
- bowel habits, changes
- past abdominal history
- medications
- nutritional assessment
infants:
- breastfeeding/bottle
- table foods
- often eating/constipation
adolescents:
- weight concerns, activity/exercise
- calories consumed
aging adults:
- grocery acquisition
- meal prep - eat alone?
- bowel habits
RLQ and organs
cecum
appendix
right ovary and tube
right ureter
right spermatic cord
RUQ and organs
liver
gallbladder
duodenum
head of pancreas
right kidney and adrenal
LUQ and organs
stomach
spleen
left lobe of liver
pancreas
left kidney and adrenal
splenic flexure of colon
part of transverse & descending colon
LLQ and organs
part of descending colon
sigmoid colon
left ovary and tube
left ureter
left spermatic cord
9 regions of abdomen
right hypochondriac
right lumbar
right iliac (or inguinal)
epigastric (top middle)
umbilical
hypogastric (suprapubic)
left hypochondriac
left lumbar
left iliac (or inguinal)
Abdominal assessment sequence
(4)
Inspection, Auscultation, Percussion, Palpation
Inspection - abdomen
contour:
- flat
- rounded: slightly distended
- scaphoid: concave, sunken
- protuberant: distended
temperature: warm or cool and clammy
color: bruises, erythema, jaundice, rashes, ecchymoses, Nevi
scars: describe location & size
striae: silver are normal; pink-purple are hallmark of Cushing syndrome
dilated veins: seen in thin individuals; can indicate liver issues
symmetry
umbilicus - inverted/everted
pulsations or movement
visible organs or masses
hair distribution
Auscultation - abdomen
hyperactive, hypoactive, absent (established after 5 minutes of continuous listening), borborygmi
borborygmus: stomach growling - hyperperistalsis
bowel sounds: movement of air and fluid through intestine
- high pitched, gurgling, and irregular
start in RLQ at ileocecal valve area - bowel sounds normally present here
auscultate all 4 quadrants
note frequency and character; usually 5-30 per minute
occur every 5-20 seconds
auscultate for vascular sounds
- bruits in aortic, renal, iliac and femoral arteries (not normally heard)
- check esp in people w HTN
– occurs w stenosis or occlusion
– pulsatile blowing sounds
- AAA
Percussion - abdomen
findings associated with dullness and tympany, CVA tenderness (Costovertebral angle tenderness)
percuss lightly in all four quadrants to determine distribution of tympany and dullness
tympany usually predominates because of gas in GI tract
- stomach
scattered dullness from fluid and feces are common
- heard over solid organs, fluid, areas of consolidation (tumor or mass)
assess amount and distribution of air, gas, viscera and masses that are fluid-filled or solid
- assess size of liver and spleen
hyperresonance: distended abdomen
Palpation - abdomen
normal and abnormal findings; kidney and spleen
Abnormal findings of abdomen (described in abdominal assessment deck)
appendicitis, ascites (fluid shift/fluid wave), constipation, hernias, abdominal pain, abdominal masses - AAA, distended abdomen, intestinal obstruction, hepatomegaly, cholecystitis (Murphy sign), splenomegaly, pancreatitis
Developmental considerations for abdomen assessment
SBAR communication
talking to providers and giving info on patient -
Situation - this is me on ward X calling about X; concerned about X
Background - admitted, history, last vitals, normal condition vs now
Assessment - i think problem is X; not sure what is wrong but worried, etc
Recommendation - i need you to come see pt; is there anything i can do in meantime
Influences of culture
Influences parents’ decisions
– causes of illness; healthcare and treatment
– ex. Jehovah’s witness
defines family responsibility
– care of older adult
verbal and nonverbal communication (eye contact)
views of healthcare system
increased probability of miscommunication when nurse and patient are of different cultural backgrounds
Dimensions of Cultural Humility
self-awareness
respectful communication
collaborative partnerships
SDOH: Economic stability
employment, food insecurity, housing instability, poverty
Cultural Humility
5 R’s
Reflection: approach each encounter with humility & understanding
Respect: treat every person with utmost respect; strive to preserve dignity
Regard: hold every person in highest regard
Relevance: expect cultural humility to be relevant and apply this to practice
Resiliency: embody the practice of cultural humility to enhance personal resiliency
SDOH: Education
early childhood education and development, enrollment in higher education, high school graduation, language and literacy
SDOH: Social and community context
civic participation, discrimination, incarceration, social cohesion
SDOH: health and healthcare
access to healthcare, quality, access to primary care, health literacy
SDOH: Neighborhood and built environment
access to foods that support healthy eating, patterns, crime and violence, environmental conditions, quality of housing
SDOH at patient level
be alert to clinical flags, ask patients about social challenges in a sensitive and caring way, help them access benefits and support services
SDOH at practice level
offer culturally safe services, use patient navigators, ensure care is accessible to those most in need
SDOH at community level
partnering with local organizations and public health agencies, getting involved in health planning, improving environments for health if possible
Assessment across the lifespan: young and school-aged children
young: 1-4yrs
school age: 5-10 years
health history from parents
tantrums
play as a way to build rapport with child and parents
stuffed animals or drawing
use words the child understand
sitting or lying on the exam table
Assessment across the lifespan: adolescents
want to be treated as adults and to be given respect and choices
begin with client sitting on exam table
share questions or concerns w you through the use of broad open-ended questions
time alone with patient, no parent/caregiver
head-to-toe approach
Assessment across the lifespan: adult
head-to-toe assessment
standard precautions
is it a complete or focused assessment (focused - certain problem/complete - usually first time seeing them)
explain what you are doing to the patient
basic measurements
- vitals
- height and weight
- visual and hearing acuity
Assessment across the lifespan: older adults
elicit preferred way of being addressed
adjust the environment
put the patient at ease
enough space in exam room for pt to safely navigate
what assessment differences do you expect to find?
what is the patient’s functional ability?
SPICES
assess the care of the older client requiring nursing interventions
SPICES
Sleep disorders
Problems w eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
Clinical Reasoning/Clinical Adjustment
Recognize cues
Analyze Cues
Prioritize hypotheses
Generate Solutions
Take Actions
Evaluate outcomes
Tanner/Lasater
Noticing
Interpreting
Responding
Reflecting
NCLEX Client Needs
Safe and Effective Care environment
- management of care
- safety and infection control
Health promotion and maintenance
Psychosocial Integrity
Physiological Integrity
- basic care and comfort
- pharmacological and parenteral therapies
- reduction of risk potential
- physiological adaptation
Abdomen midline organs
uterus
bladder
aorta
Prep for abdominal assessment
appropriate lighting, warm room
supine position, pillow under head, arms at sides
draping patient
- raise gown below nipple line above xiphoid process
- level of symphysis pubis
empty bladder
warm hands and stethoscope
nails short
Abdomen development: infant and children
umbilicus is prominent
liver takes up more space at birth & may be palpable
urinary bladder located higher
less muscular - organs more easily palpated
Abdomen development: pregnant women
enlarged uterus
intestines displaced upwards and to the right
bowel sounds diminished
motility may cause constipation
skin changes - striae, linea nigra
CVA tenderness
indirect percussion to assess kidneys
place palm of one hand on patient back, thump with fisted hand
- pain with inflammation of kidney
- causes: renal colic, pyelonephritis
done over 12th rib and costovertebral angle on back
