Exam 1 HA Flashcards
goals of nursing
-promote health
-prevent illness
-treat responses to illness
-advocate
purposes of the health assessment
-gather info of the health status, analyze data, make judgements on interventions, evaluate outcomes
-get health hx & do physical assessment which is the START of the nursing process
types of assessments
- emergency assessment
- comprehensive assessment
- focused assessment
what type of assessment is for unstable, life threatening, NOT a head to toe, focus on main issue & how to stabilize
Emergency Assessment
what type of assessment is a complete health hx & physical assessment, annual outpatient visit, admission & discharge, q8 in critical care settings but always depends on the setting
comprehensive assessment
what type of assessment occurs in all settings but a smaller scope & increased depth (ex: open heart surgery- going to assess cardio, pulmonary, wound & edema)
Focused Assessment
when assessments are performed:
-frequency may depend on setting & pt status
-Long term care (LTC)comprehensive assessment is done monthly
-acute care may have assessments every shift
-critical care may be q4 or hourly
well visits may be annual or as needed to assess care & outcomes
what are the 3 levels of prevention?
- primary prevention: preventing problems, health education, immunizations)
- secondary prevention: early diagnosis & prompt treatment, health screenings like mammogram
- Tertiary prevention: preventing complications of a disease, promoting the highest health possible, meds, monitoring
something a pt said, in quotes, ex: “I have a headache”
subjective data
objective data
measurable data, ex: blood pressure
steps of nursing process
ADPIE
1. assess
2. diagnose
3. planning
4. implementation
5. evaluate
feeling what the pt feels, you’re not being therapeutic bc you’re interpreting the situation as YOU perceive it
sympathy
feeing what the pt is feeling from THEIR perspective, keeps the focus on the pt & what they’re feeling
empathy
therapeutic communication techniques
-basic tool to use when showing care w/ patients
-active listening (ability to focus & see their perspective)
-restatement (help w/ clarification & elaboration)
-reflection (summarizing main themes)
-silence (allows pt to gather thoughts & speak)
-focus (redirecting to the pt’s topics)
primary data comes from who?
the PATIENT! their answers aka subjective data
secondary data from from?
family members, the chart, other HCPs
the representation of family health hx, composition, & structure. Also helps to assess pts & their genetic patterns
genogram
what mnemonics for assessing HPI (hx of present illness) is OLDCARTS
onset, location, duration, character, associated/aggravating factors, relieving factors, timing, severity
what mnemonics for assessing HPI (hx of present illness) is PQRSTU
provocative/palliative, quality, region, severity, timing, understanding patient perception
what mnemonics for assessing HPI (hx of present illness) is COLDSPA
character, onset, location, duration, severity, pattern, associated factors/how it affects the pt
techniques for preventing infection
-hand hygiene
-glove use
-PPE
-standard precautions (prevent transmission, mucous membranes, blood borne, nonintact skin, respiratory hygiene, cough etiquette, masks, physical distancing)
what are standard precautions
-prevent transmission, mucous membranes, blood borne, nonintact skin
-respiratory hygiene & cough etiquette
-masks
-physical distancing
how to access temperature
using clean hands, palpate w/ dorsal side of hand
purpose of medical record
for communication, care planning, quality assurance, financial reimbursement, education, research
legal document
medical record
what must you do in the medical record
-always be accurate
-it must reflect your assessment data
-use correct & legal abbreviation use (example: don’t type SOB, type dyspnea)
-use logical organization that ensures systemic grouping of organization
-always be timely
-always be short, concise & complete (use of sentence fragments is acceptable)
why is it important to be timely in medical records
-prompt discussion allows for up to date assessment information (ex: change in weight also makes a change in med dosage)
-point of care documentation: document assessment as you gather it, helps include pt as you chart & can be done in many settings like hospital or home health care)
factors that lead to incorrect BP readings
-noisy environment
-inappropriate cuff size
-stethoscope not on brachial artery
-stethoscope not in ears correctly
-deflating cuff too quickly
-failing to palpate radial artery for estimated SBP
-arm positioned above heart
-assessing immediately after activity
how to take height & weight (anthropometric measurements)(
-remove shoes & heavy clothing
-record in cm or inches
-record in kg
-calculate BMI
BMI (body mass index)
> 30 = obese
40 = extremely obese
<18.5 = underweight
19-25 = normal
25.5-29.9 = overweight
red flags for abuse
-making excuses
-lying about bruises or fractures
what is the collection of beliefs, values, behaviors, & ways of life that are shared by a group of people
culture
what pertains to human soul, it is the path to achieve better understanding of nature, harmony, others, & a higher power
spirituality
how to asses lungs
- assess general appearance
- inspect
- palpate
- percuss
- auscultate
how to assess general appearance of lungs for part of the lung assessment
-evaluate general appearance of pt
-observe chest movement when breathing & respiratory movements (count RR)
-assess O2 levels & nail color (cyanosis, clubbing, pallor)
how to inspect lungs for part of the lung assessment
-move side to side & inspect posterior chest for expansion
-compare AP(front to back) and transverse (side to side)
-look for thoracic cage (barrel chest)
-look at breathing & use of accessory muscles to breathe
-look for retractions at supraclavicular or intercostal areas
how to palpate the lungs during lung assessment
-palpate for tender areas using finger tips
-go bilaterally & start at the scapula & end at the lung, go to midaxillary line
-look for lumps, lesions, masses, & crepitus
-chest expansion to assess symmetry
-density of lung tissue (look for tactile fremitus: say 99, place hands above scapula & work your way down the lungs… vibrations should be symmetrical)
how to percuss the lungs for lung assessment
-percuss to assess density of underlying tissue (should be dull over bone)
-begin at apex & work towards base, bilaterally (sounds will also be dull when open cavities are filled w/ fluid aka pneumonia)
how to auscultate the lungs
work bilaterally on posterior and anteriorly starting from top and working down (look at pics)
percussion sounds
-resonance (loud, low pitched heard over lung tissue)
-tympany (loud, higher pitched sound over air filled spaces)
-dullness (heard over solid spaces)
-flat (higher pitched over dense tissue like pleural effusions & ascites)
percussion sound that is loud & low pitched, heard over normal lung tissue
resonance
percussion sound that is loud & higher pitched sound, heard over air filled spaces
tympany
percussion sound that is heard over solid spaces
dullness
sound that is higher pitched over dense tissue like pleural effusions & ascites
Flat
adventitious sounds
**if heard listen for more than 1 cycle, ask pt to cough
-crackles/rales (fluid in airway, velcro sound, chest hair can sound like crackles)
-wheezes (musical & high pitched, narrowing or partially obstructed airway, typically occurs w/ inspiration). Stridor is a worsened wheeze that required ER visit
-rhonchi (continuous coarse, low pitched snoring sound, results from secretions moving around, may clear w/ coughing)
-decreased or absent breath sounds (indicates problem, ex: pneumothorax, mucus plug, atelectasis, fluid, large tumor)
-bronchophony (listen & have pt say “99”. normal sounds = muffled, abnormal = sounds clear)
-egophony (say “eee” , should be muffled, abnormal will sound like “aaa”)
-whispered pectoriloquy (say “123” which should sound muffled)
fluid in airway, velcro sound, chest hair can sound like this too
crackles, rales
musical & high pitched, narrowing or partially obstructed airway, typically occurs w/ inspiration
wheezes
continuous, coarse, low pitched snoring sound, results from secretions moving around, may clear w/ coughing
rhonchi
this indicates a problem, ex: pneumothorax, mucus plug, atelectasis, fluid, large tumor
decreased or absent breath sounds
this is when you have the pt say “99” and it will sound muffled if normal OR it will be clear as day if abnormal
bronchophony
this is when you have the pt say “eee” and should be muffled. it will sound like “aaa” if abnormal
egophony
this is when you have the pt say “123” which should sound muffled
whispered pectoriloquy
what are the age related changes in lungs
- older adults (risk for immobility & atelectasis aka collapse of lung)
- pregnant women (as uterus expands & moves up, thoracic cage may widen & train rib)
- newborns & young children (always listen to breath sounds for 1 minute, infants may have spells of apnea which is normal, do NOT percuss chest of infants as their RR is faster)
how to assess cardiac
-inspect (appearance, color changes, inspect chest for waves/pulsations)
-palpate (the apical pulse/PMI aka point of maximal impulse) at the 4th-5th ICS, left midclavicular line)
-no percussion needs for cardiac
-auscultation (2nd R ISC for aorta, 2nd L ICS for pulmonic, 3rd L ICS for Era’s point, 4th L ICS for tricuspid valve, 5th L ICS for mitral valve)
-“lub dub” (S1 = lub, S2 = dub)
abnormal heart sounds
-S3 (Kentucky) & S4 (Tennessee) sounds
-murmurs: swooshing
-rubs: pericardial friction, scratchy, creaking
-gallops: heard in pregnant women or athletes, S3 gallop happens before S2, S4 gallop occurs before S1)
-clicks: heart disease, aortic or pulmonic valve, quickly after S1
-snaps: mitral stenosis, quickly after S2, hard to differentiate, sudden bulge of aortic or pulmonic valve
sounds Kentucky
S3 heart murmur
sounds Tennessee
S4 heart murmur
swooshing heart sound
heart murmur
pericardial friction, scratchy, creaking heart sound
rubs
heart sound heard in pregnant women or athletes, S3 gallop happens before S2, S4 gallop occurs before S1
gallops
heart disease, aortic or pulmonic valve, quickly after S1
clicks
mitral stenosis, quickly after S2, hard to differentiate, sudden bulge of aortic or pulmonic valve
snaps
correlates w/ carotid pulse, systole, LUB, louder at apex, tricuspid & mitral valve closing
S1
correlates w/ beginning of diastole (rest), DUB, loudest at base, aortic & pulmonic valve closing
S2
right 2nd ICS
aortic
left 2nd ICS
pulmonic
3rd L ICS
Erb’s point
4th to 5th L ICS
PMI aka point of maximal impulse
swooshing sounds, turbulent blood flow related to atherosclerosis
Bruits
artery is somewhat obstructed, increased risk of stroke (don’t mistake this w/ murmur), swooshing sound
Bruit
this is best heard at carotid pulse, NOT heard in precordium. this will also not be heard if totally obstruction of carotid occurs
Bruit
-associated w/ heart failure, tricuspid regurgitation, & fluid volume overload
-neck veins appear full & greater than 3cm above sternal angle
JVD (jugular venous distention)
when does the general evaluation take place?
the moment you walk into the room
when does inspection take place?
the first step on the assessment phase
aortic & pulmonic valve close. this occurs during diastole
S2
what is the carina?
where the bronchi bifurcate
where would you auscultate for the mitral valve?
the 5th intercostal, left sternal border (LSB)
Systole, the contraction phase
S1
diastole, the relaxation phase
S2
the contraction phase
systole, S1
the relaxation phase
diastole, S2
sounds like balloons high pitched, scratching, grating. Heard at the left sternal border.
pericardial friction rub
how you can be culturally aware
active listening
where is the PMI (point of maximal impulse) palpated or seen with the eye?
4th-5th intercostal space, midclavicular line
PMI
point of maximal impulse
mitral & tricuspid valve closure, occurs during systole
S1
the volume of blood in the right atrium that will be transferred to the ventricles
Preload
the resistance the left ventricle must overcome to circulate blood
Afterload
pneumonia is more likely to be found in which lung?
the right lung bc it’s larger
what type of process is expiration
PASSIVE
what is a key aspect for breathing sufficiently?
sufficient innervation
why do pts with problems in C3-C5 possibly require ventilator support?
because C3-C5 are the nerves that INNERVATE the lungs
what is the main trigger for breathing?
increased level of CO2 in blood
*(but not COPD pts due to them already having increased CO2 in their blood
What phase of the interview are open ended questions used?
Working phase
cardiac output
= heart rate x stroke volume
how would you measure fluid volume overload?
by obtaining jugular venous pressure (JVP)
what 3 factors play a role in stroke volume?
Preload, Contractility, Afterload
strategies aimed at preventing problems (ex- educating, prior to a pt is sick)
primary prevention
early diagnoses, prompt treatment, screening pts (ex: Pap smear, bp)
secondary prevention
preventing complications of existing disease, promoting highest health level possible (ex: place them on meds, send to another doctor etc)
tertiary prevention
how to palpate the abdomen?
go around with light palpation (1cm) then go back around for deep palpation (2 to 4cm)
first component of the assessment
general survey
normal temp
97.7 - 98.6
normal RR
16-20
talking too fast/rapid/forceful
Pressured speech-
emotionless
Flat affect
underweight BMI
<18
normal BMI
19 - 24
obese BMI
> 30
extreme BMI
> 40
anthropometric measurements
height/weight, vital signs
what is not taken into consideration for BMI?
muscle mass and bone mass
greater than 103.1 temp
hyperthermia
1 degree higher than normal temp
rectal and temporal
1 degree less than normal temp
axillary
when is temp lower?
in the evening/first thing in the AM
hypernea vs apnea
hyperpnea = deeper/more active breathing (too much CO2 in body)
apnea = not breathing
S3
ventricular gallop
Kentucky
S4
Atrial gallop
Tennessee
boney ridge that joins the sternum to the manubrium
sternal angle AKA Angle of Luis or Manubrio
PNA will congregate where?
lower lobes first then go up, more common in right lung!
what part of lungs is responsible for gas exchange?
Bronchioles and alveoli responsible for gas exchange
Cannot breathe spontaneously if you injur what?
C3-C5 spinal cord
feels like Rice Krispies or bubble wrap, can’t see it but CAN feel this air leak
crepitis
PNA, fluid in lung, or collapse of lung, consolidation
atelectasis
vibration, have pt say “99” and feel for vibrations using ulnar surfaces
Tactile fremitus /
Bronchophony
breath sounds
Bronchial BS– over the trachea and larynx, loud, coarse high pitch
Broncho vesicular BS – over major bronchi
Vesicular BS – soft, low-pitched, found at distal airways
What are the 3 layers of the heart?
Endocardium: thin; lines interiors of chambers, valves
Myocardium: thick; muscular for pumping
Epicardium: thin; muscle, exterior layer
cardiac output
amount of blood ejected from LV each minute. It can be calculated by multiplying HR x stroke volume (How much blood is ejected with each beat or stroke)
the volume in the right atrium at the end of diastole, an indicator of how much blood will be forward to & ejected from the ventricles. More blood in the RV causes a stronger force of contraction
Preload
the amount of pressure in the great vessels, arteries/arterioles, the resistance
Afterload
the ability of the heart to shorten muscle fibers, producing a contraction during systole (this is saying strong heart if it is a heart that can contract!) (ex: CHF does NOT contract bc it is weak, floppy heart)
contractility
What are P waves,
PR interval,
QRS complex,
T wave?
P – depolarization in atria that causes atrial contraction
PR – time from firing of SA to beginning of ventricular depolarization
QRS – spread of depolarization and NA release in ventricles that causes contraction
T – cellular repolarization and return of intracellular Na
this is an abnormal heart rhythms (example: Afib)
Arrhythmias
diaphoresis
sweating
S1 and S2 equal here
Erb point
This is louder in mitral and tricuspid areas
S1
This is louder in aortic and pulmonic areas
S2
