Exam1 Flashcards
What is the purpose of the interview? What factors affect the quality?
The purpose is data collection, establish rapport and trust, and teaching.
Both internal and external factors
Internal liking others, empathy, connection, the ability to listen.
External is privacy, interruptions, physical environment.
What are the phases of the interview?
Introduction, the working phase, closing of interview
What are the forms of nonverbal communication?
Physical appearance, posture, gestures, facial expressions, eye contact, touch
What are the 10 interview traps?
False assurance, unwanted advice, using authority, avoidance language, distancing, professional jargon, bias, talking too much, interrupting, asking why.
What are the four different areas of a general survey?
Physical appearance - age, sex, level of consciousness, skin color, facial features.
Body structure - structure, nutrition, symmetry, posture, position, bodybuild/contour, obvious physical deformities, exceptions.
Mobility - gate, no and voluntary movement.
Behavior - speech, dress, personal hygiene.
What are the medical history sequence?
biographical data, source of history, reason for seeking care, history of present illness, medical history, review of systems, lifestyle health practice and functional level.
Biographical data
Name, address and phone number, age and birthday, birthplace, sex, marital status, race, ethical origin, occupation
Source of history
The person giving the information. Note reliability of information, willingness to disclose, and other factors such as if interpreter was used.
Reason for seeking care
Statement in person’s own words describing reason for visit and closed in question marks to indicate patients exact words.
History of present illness ( HPl )
Setting, location, character equality, quantity or severity, timing, aggravating or relieving factors, associated factors, patients perception.
Health history
Surgical and medical history, immunizations, allergies, current prescriptions / medications
Family history
Age, health, or cause of death of relatives. Family history of all health conditions.
Review of systems (RoS)
General overall health state. Mental status. Neurological. Musculoskeletal system. Head face neck. Lymphatic system. Mouth, nose and throat. Heart and neck vessels. Thorax and lungs. Ears and eyes. Abdomen. Nutrition. Skin, hair and nails. Peripheral vascular. Urinary system. Male genital system. Female genital system. Hematological system.
Lifestyle, health practices, and functional level
Functional level activity and exercise, sleep and rest, nutrition and elimination.
Lifestyle and health environmental factors ( IE smoking or drinking ), occupational health, illicit or street drug use, safety from partner, spirituality
What is PQRST?
Provocative or palliative- What makes it worse? What makes it better?
Quality - What does it feel like? Sharp dull achy etc
Region or radiation - where is it? Does it move?
Severity- usually on a scale 0 to 10
Tim ing - when did it start? How long does it last? Frequency?
Understanding - understanding patients’ perception of the problem. As k what do you think it is?
What are the infant and preschooler ages?
1 through 6-year-olds
What are the school-aged children?
7-year to 12-year-old
What is important when treating an adolescent?
Respect, honesty, confidentiality
What is functional level
Activity and exercise
Sleep and rest
Nutrition and elimination
What is lifestyle and health
Environmental hazards: smoking and drinking enter occupational health: work environment
Illicit or street drug use
Intimate partner violence: safety
Spirituality
What is in the general survey
Physical appearance.
Body structure.
Mobility.
Behavior.
What is in the physical appearance?
Age: person appears his or her stated age
Sex: sexual development appropriate for gender and age.
Level of consciousness: person alert and oriented, attends to your questions and responds appropriately.
Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesions.
Facial features: symmetric with movement.
No signs of acute distress present
What is in body structure?
Stature: height appears within normal range for age, genetic heritage.
Nutrition: weight appears within no more range for height and body build; body fat distribution even
Symmetry: body parts look equal bilaterally and are in relative proportion
Posture: person stands comfortably erect as appropriate for age
Position: person sits comfortably in chair or on bed or examining table.
Bodybuild, contour: proportions are correct.
Obvious physical deformities: note any congenital or acquired defects.
What do you look for in mobility?
Gait: how a person walks
What do you look for in behavior
Facial expression: person maintains eye contact expressions appropriate to situation.
Mood and affect: person comfortable and cooperative with examiner and interacts pleasantly
Speech: articulating clear and understandable
Dress: appropriate to climate looks clean and fits body and is appropriate to person’s culture and age group.
Hygiene: person appears clean and groomed appropriate for his or her age occupation and socioeconomic group.
Developmental confidence in infants and children
Physical appearance body structure mobility.
Behavior: note response to stimuli and level of alertness
Parental bonding: note child’s interactions with parents, that parent and child show a mutual response and are warm and affectionate.
Parent provides appropriate physical care of child and promotes new learning.
What are the five phases of the nursing process?
Assessment - data collection.
Diagnosis - interpret data.
Outcome identification, planning - identify expected outcomes and establish a plan.
Implementation - implement plan and a safe and timely manner.
Evaluation - evaluate progress toward outcome.
What is a nursing diagnosis?
clinical judgments about a person’s response to an actual or potential health state that are amenable to primary nursing interventions.
What are the types of a nursing diagnosis?
Actual: existing problems and menable to independent nursing interventions.
Risk: potential problem that an individual does not currently have but is particularly vulnerable to developing.
Wellness: focus on strengths and reflect on individual transitions to a higher level of wellness.
What is the difference between a medical versus nurse diagnosis?
Nurses evaluates the whole person to actual or potential health problems.
Medical evaluates the etiology of diseases.
What is soap?
Subjective data.
Objective data.
Assessment.
Plan.
What is subjective
Information reported by patient
What is objective?
Results of physical exam
What is assessment?
nursing diagnosis based on the subjective and objective findings
What is plan?
Short and long-term goals and interventions.
AEB
As evidenced by
R/t
Related to
What does ABCV stand for?
Airway problems.
Breathing problems.
Cardiac/circulation problems.
Vital sign concerns.
What are second level priorities?
Acute pain. Mental status change. Untreated medical problems needing attention. A cute urinary elimination problems. Abnormal lab values. Risks of infection, safety, security. NT
What are third level priorities?
Those important to patients health but can be addressed after more urgent problems.
What are the four skills performed when doing a physical exam? In order.
Inspection.
Palpitation.
Percussion.
Auscultation.
What is normal BMI?
18.5 - 24.9
What is abnormal waste circumference
Greater than 35 in in woman.
Greater than 40 in in men
What is normal temperature range?
35.8°C to 37.3°C (96.4°F to 99.1°F)
Which measurement of temperature is not considered a core temp?
Tympanic
What temperature is considered hypothermia and what is considered hyperthermia?
Hypothermia - less than 35°C
Hyperthermia -greater than 40°C
What is considered normal pulse
60 to 100 BPM
What is less than 60 BPM mean
Bradycardia
What does More than 100 BPM mean
Tachycardia
How is the strength of pulse measured
3 - full, bounding.
2 - normal.
1 - weak, thready.
0-Abscent
What is considered normal pulse ox? What is considered clinically significant?
Normal is 97 to 100%.
Below 95% is clinically significant.
What is normal blood pressure?
120 / 80 to 90/60
What are normal vitals for infant?
HR 90 to 180
Respiration 30 to 60
Temperature 37°C
What is normal respiration for adult
12 to 20
What is pain?
Pain is a subjective experience that originates from the central nervous system, the peripheral nervous system, or both
What is Nociception pain?
Is pain from physical damage to the body.
The four phases are Transduction. Transmission. Perception. Modulation.
What is neuropathic pain?
Pain with no purpose, no benefit, does not adhere to typical phases of pain.
What is visceral pain
Pain and pulls transmitted along the nerve fibers of autonomic nervous system
What is somatic pain
Cutaneous pain- superficial, from injury of skin.
Deep somatic pain results from pressure trauma or itchmia of blood vessel joints tendon muscles and bones.
What is referred pain?
Pain that is fell at a particular site but originates from another location
What is acute pain?
Acute pain is short-term less than 6 months
What is chronic pain
Pain that continues for 6 months or longer
