Final Review Flashcards
holistic health assessment
assessing patient as a whole- incorporating mind, body, and spirit
purpose of physical assessment
- determine level of client functioning (ability to participate in ADL’s)
- identify signs and symptoms that indicate changes in health status
- determine nursing interventions
- determine effectiveness of nursing interventions
- determine health promo opportunities
- determine baseline data
physical assessment techniques
inspection
palpation
percussion
auscultation
inspection
- first step when you meet patient
- using senses (eyes, ears, nose) to observe body parts and notice deviations from normal
inspection techniques
- look before touching
- use good lighting
- only expose area being inspected
- provide warm, private enviornment
- look for size, shape, moisture, color, swelling, odor, sounds, movement, etc.
general survey
- noticing client as whole to get an idea of the client
- helps guide further assessment to determine health issues/needs
- helps develop a care plan
characteristics of general survey
A- airway B- breathing C- circulation D- disability E- exposure
A- appearance S- speech E- emotion/ affect P- perception I- insight C- cognition
palpation
technique used to assess for edema, moisture, temperature, and tenderness
palpation technique
- clean, warm hands
- short, clean fingernails
- palpate tender areas last
- wear gloves if coming into contact with bodily fluids
light palpation
- around 1 cm deep
- tells you about skin and structures directly below the skin
deep palpation
- 3 to 4 cm deep
- tells you about deeper structures under the skin
fingertips
- moisture
- contour
- conscitency
- pulsations
- texture
palm
vibrations
ulnar edge
- vibrations
2. temperature
dorsal side
temperature
circular motion palpation
place fingers together and move skin surface over underlying structures in a circular motion
-assessing for consistency, size, shape
dipping motion palpation
place fingers together and make gentle, quick depressing movements over abdomen
-assess for feces, pregnant uterus, tenderness
direct palpation
place fingers together and apply direct preassure on skin
- used to palpate blood vessels, skin lesions, masses, muscles
- assess pulse, tenderness, fluid content, blanching
grasping (pincher) motion palpation
pinch skin with index finger & thumb
- used to assess masses
- assess turgor, thickness, consistency, size, shape, pulsations
percussion
- tapping over body structures to elicit a sound with a specific pitch, quality, duration, and intensity
- tells you about density, location, size, tenderness of organs
- most commonly used on abdomen
ausculation
- assess pitch, intensity, timing, rate, duration of body sounds with stethoscope
- can ausculate pulse, chest cavity, abdomen
diaphragm use
high pitched sounds (heart rate, pulse)
bell use
low pitched sounds (heart murmurs)
Tanner’s Clinical Judgement Model
- Noticing
- Interpreting
- Responding
- Reflecting
Clinical Judgment
Interpreting clients needs, wishes, and challenges and using previous knowledge, experience, ethical belifs, critical thinking to determine actions that would provide best care
family- Potter & Perry
set of relationships/ network of indiviuals who influence each others lives
family- Vanier Institute
two/ more people who are bound together by mutal ties of consent, birth/ adoption, and share the following future obligations:
- care/ support of family members
- addition to family through procreation/ adoption
- socialization of children
- love & nurture
T or F: family is whoever the patient says it is
true
- have to consider how other people view family and how your own biases/ belifs about family may impact the care you provide
how are families changing?
- aging population: “sandwiched” generation
- increased diversity in families (cultural blending, interacial families, same- sex couples)
- gender roles in families have changed due to social, political, economic factors
- nuclear family on decline
- multigeneritational households
- more single parent households
- more lone person households
- more couples not having kids
characteritics of healthy families
- incorporate the need for stability for growth and change
- show hardiness and resiliance in coping
- influence their enviornment
- act as a cohesive unit
- flexible
- willing to accept outside help
how does family influence health
- views on health and lifestyle behaviours (what was normalized in your family is what your normalize)
- generational views on health and healthcare are passed down
- relationships in healthcare settings (ex. mom with sick child)
- embedded in SDOH (housing, socioeconomic status)
what makes up a community?
- people (members of community)
- place (geographic location)
- function (collective interest/ purpose)
characteristics of healthy community
- supportive
- lies on stable economy
- safe
- has sustainable resources
- access to social services (health care, education)
- celebrates culture & history
- adequate housing
- acts as cohesive unit
what are routine practices
IPAC practices that are followed with every patient in every health care setting
chain of transmission
- infectious agent
- resevoir
- portal of exit
- mode of transmission
- portal of entry
- susceptiable host
infectious agent
virus, bacteria, fungi- any microorganism that can make somebody sick
resevoir
where infectious agents live
-people, animals, food, water, surfaces, equipment
portal of exit
how infectious agent leaves resevoir
- bodily openings (mouth, vagina, urethra, skin)
- bodily fluids (blood, mucus, excretions)
- open wounds (lesions, surgical wounds, cuts)
mode of transmission
how infectious agents spread from one host to another
- contact
- airborne (droplets)
- vectors (mosquitoes)
portal of entry
how infectious agent enters new host
- sex
- respiratory tract
- GI tract
- mucous membrane (eyes, ears, mouth)
- broken skin
- artifical openings
- contaminated food/ instruments
susceptible host
people who can get infections easily
-old people, babies, immunocomprimised people
whats the best way to break the chain of transmission?
handwashing
whats the most important part about proper handwashing
friction
why is understanding growth and development important?
- allows you to be able to understand & recognize normal
- allows nurses to promote health oppurtunities and provide indiviualized care
is growth quantitative or qualitative
quantitative- easily measured
T or F: development is quantitative
False, development is qualitative (not easily measured) and looks different in different indiviuals
what influences growth & development
- family: if you recieved love and nurture growing up
- socioeconomic status
- quality and accessibility to health care
- nutrition
- genetics
- childhood trauma
- choices mothers make during pregnancy (ex. drug use, drinking)
Erikson’s Developmental Theory
- 8 stages covering lifespan that include differenet psychosocial tasks
- indiviual must move onto next stage even if tasks in previous one have not been completed
Trust vs. Mistrust
Stage 1: infancy to 18 months
- gaining trust in people around me
Autonomy vs Shame & Doubt
Stage 2: infancy- 3 years
-how can I control myself?
Initative vs Guilt
Stage 3: 2- 5 years
-how do I control myself in my enviornment?
Industry vs Inferiority
Stage 4: 5- 13 years
- learning skills necessary to survive and be successful in life
Identity vs Role confusion
Stage 5: 13- 21 years
- where do I belong in the world?
- what is my purpose?
- finding out/ exploring who you are
Intimacy vs Isolation
Stage 6: 21- 39 years
- looking to partner up, form meaningful connections, and start families
Generavitity vs Stagnation
Stage 5: 39- 65 years
- giving back to community, younger generations
- nurturing all the other stages
Ego Integrity vs Despair
Stage 6: 65+
-looking back on life and feeling fulfillment/ regret
Piaget’s Development Theory
- 4 stages: infancy- 18
- indiviual must complete tasks in previous stage to move onto next stage
- using previous experiences to move stages
Stage 1: infancy- 2 years
Sosiomotor stage
- exploring the world using sensory and motor skills
- object permanance and seperation anxiety
Stage 2: 2- 6 years
Preoperational Stage
- able to use symbols (words and images) to represent objects
- doesn’t reason logically
- child is still egocentric
- develops ability to pretend
Stage 3: 7-12 years
Concrete operational stage
- develops ability to think logically
- understands conversation
Stage 4: 12- 18 years
Formal operational stage
-develops ability to think abstractally and hypothetically
Infancy (0-1 years) growth & development
- weight gain & grow in lenght
- hold head up at 2 months
- roll over at 4-5
- crawl and babble at 9 months
assessing infants
- reliant on caregiver for information
- observe child- caregiver intercations, note strenghts & challenges, and offer advice/ help
- no head to toe: just assess as quick as possible & whatever is necessary
- least to most invasive so baby doesn’t get fussy
Early childhood (1-3 years) growth & development
Growth: -exponential growth -baby teeth grow in Development: - 2-3 word sentances - potty training - fine & gross motor skills develop - more control over motor skills (running, jumping, skipping)
assessing early childhood
- still reliant on caregiver
- scared of HCP
- show them what you’re doing on a teddy bear, parent, yourself
- let them see & touch things that aren’t dangerous
- incorporate play & be creative
Late childhood (3-6 years) growth & development
- psychosocial tasks: creating relationships (friends at pre- school)
- want for privacy: become more self- aware
- know when its appropriate/ not appropriate to do things like go to the bathroom
considerations late childhood
- constipation: become self- aware might be embarassed to use bathroom at school
assessing late childhood
- involve them in assessment
- explain what you’re doing
- don’t lie to them
School age (6-11 years) growth & development
Growth:
- weight gain and growth
- skeletal growth happens before muscle growth: lanky
Developmental:
- fine motor skills (shoe tying, playing instruments)
- peers at school have big influence on them
- begin to understand discipline, boundaries, consequences
- begin teaching them about healthy lifestyle choices
- increased body- awarness: increased need for privacy
assessing school aged
- can begin to rely on them more for information and less on caregivers
- involve them in assessment
Adolescents (12- 18 years) growth & development
Growth:
- growth spurts
- weight gain
- puberty
- sex specific changes
Development:
- independce
- begin exploring relationships
- impulsivness
- risk taking
- big need for privacy
- begin exploring sexuality
- peers and belonging are important
considerations adolescents
- mental health issues
- promoting safe sex
assessing adolescents
- privacy and confidentiality is particularly important
- rely primairly on them for information
- don’t avoid important questions because they’re uncomfortable topics
Young adults (18- 35 years)growth & development
Growth:
-bodily systems continue growing and developing to fit adult body size
Development:
- forming interdependence on another person
- finding purpose to make life meaningful
- starting families
- building foundations for good health
assessing young adults
- prevention of chronic illness
- health promotion for healthy behaviours and lifestyle choices
Middle age (35-65 years) growth & development
Growth:
- aging (hair, skin changes)
- metabolism slows
Development:
- mental health/ self-image changes
- role changes (children moving out of home)
- life reflection
assessing middle age
- screening for and preventing chronic illness
- promote sense of fulfillment by giving back to community\
- Osteoperosis screenings at 65
- Mamograms at 50
Older people (65+) growth & development
Growth:
- body systems age
- immune system diminishes
- more health complications
- impaired cognition is NOT a normal sign of aging
Development:
- loss of autonomy/ independence
- loss of role
- reflecting upon life
- dealing with loss of spouse/ friends/ family
- isolation/ loneliness
assessing older people
- hearing impaired: speak slowly, loudly, clearly
- if completley deaf position yourself so they can lip read/ write things down
- vision impaired: explain your actions so you don’t startle them & provide therapeutic touch
- if cognitively sharp speak to them in assessment, rely on caregiver if cognitive issues are present
ineffective communication consequences
- poor patient outcomes
- misscommunications regarding patient needs, health status, and plan of care
- decreased professional credibility
- increased adverse incidents
therapeutic interviewing
interviewing with specific purpose with focus on specific content area
active listening
finding meaning behind patients words by noticing non- verbal cues, emotions, word choice, and being fully present in conversation
subjective data
what patient tell you