HA FINAL Flashcards
ETHNOCENTRISM
TENDENCY TO VIEW YOUR WAY OF LIFE AS THE MOST DESIRABLE AND BEST
STEPS TO CULTURAL COMPETENCY
1) Understand your own heritage on the basis of cultural beliefs, attitudes, and practices that are relevant to health and illness.
2) Identify the meaning of health to the person you are working with.
3) Understand the health care delivery system, how it works, what it does, and meanings, costs, and consequences of procedures that are important to you and patient
RESPECT AS RELATED TO CULTURAL SENSITIVITY
Realize your and your patient’s heritage
Examine patient within the context of his cultural health and illness practices
Select simple questions and ask them slowly
Pace your questions throughout the exam
Encourage patient to discuss meanings of health & illness from their prespective
Check patient’s understanding & acceptance of health practices
Touch patient according to their cultural heritage- very important
STEPS OF THE NURSING PROCESS
ASSESSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
stages of assessment
inspection
palpation
percussion
auscultation
*use your senses
subjective data
biographical data
reason for seeking care
present health aka hpi
past history aka pmh
family history
review of systems ros
functional assessment
present health or hpi
location, character or quality, quantity or severity, timing (onset, duration, frequency), setting, aggravating or relieving factors, associated factors, patient’s perception
objective data
the numbers
you can verify
techniques for good communication
establish parameters
avoid roadblocks
introductory phase- intro and establish contract
working phase- get the info
summary-
termination
10 traps of interviewing
Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using “Why” questions
NONVERBAL COMMUNICATION
physical appearance, posture, gestures, facial expression, eye contact, touch, personal space, territoriality
ROADBLOCKS TO COMMUNICATION
lack of privacy, uncomfortable, loud noises, distractions, distance- too close or too far, height- too tall or too short, shifting eyes
OPEN QUESTIONS
enables person to express more information
CLOSED QUESTIONS
ASK FOR SPECIFIC INFO
YES/NO
ASSESS MENTAL STATUS
ABCT
APPEARANCE
BEHAVIOR
COGNITION
THOUGHT PROCESS
APPEARANCE
POSTURE
BODY MVMTS
DRESS
GROOMING
HYGIENE
BEHAVIOR
LOC
FACIAL EXPRESSION
SPEECH
MOOD
AFFECT
COGNITION
A&OX3
ATTENTION SPAN
RECENT MEMORY
REMOTE MEMORY
NEW LEARNING
JUDGEMENT
THOUGHT PROCESS
THOUGHT CONTENT
PERCEPTIONS
SUICIDAL THOUGHTS- SCREEN
ALERT
Awake or easily aroused, fully aware of environment, responds appropriately
Lethargic/Somnolent-
Not fully alert, drifts off to sleep when stimulated, drowsy, will answer correctly to questions when aroused but quickly goes back to sleep
Obtunded-
Difficult to arouse
Stupor/ Semi-Coma-
Spontaneously unconscious,responds only to persistent and vigorous shake or pain. Reflexes are present
coma
Completely unconscious. No response topain or to any external or internal stimuli. May ormay not have reflexes present
RESPIRATORY ASSESSMENT
MUST ASSESS RATE, DEPTH, EFFORT, USE OF ACCESSORY MUSCLES
DYSPNEA
SOB
Paroxysmal nocturnal dyspnea (PND)
is a sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.
ORTHOPNEA
SOB WHEN LYING DOWN
DIAPHORESIS
EXCESSIVE SWEATING
RESPIRATORY ASSESSMENT OF CHILDREN
4-6 URI PER YEAR
CONSIDER NEW FOODS FOR ALLERGIES
CHILDPROOF HOME TO STOP INHALATION/CONSUMPTION OF POISONS
RESPIRATORY ASSESSMENT OF OLDER ADULTS
DECREASED FUNCTIONAL RESERVE
LONGER TO RECOVER FROM ACTIVITY
DECREASED VITAL CAPACITY
DECREASED SURFACE AREA
DECREASED PAIN RESPONSE- RISK FACTOR
RR 0-1 YRS
30-35
RR 1-2 YRS
25-30
RR 2-6 YRS
21-25
RR 6-12 YRS
19-21
RR 12+ YRS
12-20
CRACKLES
HIGH PITCHED POPPING SOUNDS
RHONCHI
LONG, LOW PITCHED, COARSE GURGLING SOUNDS
FRICTION RUB
HARSH GRATING SOUND
WHEEZES
HIGH PITCHED WHISTLING SOUNDS
TACHYPNEA
RAPID AND SHALLOW BREATHING
BRADYPNEA
SLOW BREATHING
EUPNEA
REGULAR BREATHING
CHEYNE STROKES RESPIRATIONS
CYCLIC
GRADUALLY WAX AND WANE IN REGULAR PATTERN
PERIODS OF APNEA
HYPERVENTILATION
INCREASED RATE AND DEPTH
HYPOVENTILATION
IRREGULAR SHALLOW PATTERN
BIOTS RESPIRATIONS
IRREGULAR PATTERN WITH PERIODS OF APNEA
TRIPOD POSITION
ON SIDE OF BED
OVER BEDSIDE TABLE WITH PILLOWS
FOR COPD
Tactile fremitus:
is a palpable vibration, produced by the larynx and transmitted through patent bronchi & lung tissue to the chest wall
Increased fremitus occurs with
compression or consolidation of lung tissue. indicates increased density of lung tissue (must have a patent bronchus)
Decreased tactile fremitus results from
obstruction of vibrations (obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema)
Pleural friction fremitus:
results from inflammation of the pleura (visceral or parietal) with decrease in the normal lubricating fluid
- Barrel chest:
anteroposterior-to-transverse diameter is equal (with aging, emphysema, asthma)
Pectus excavatum:
“funnel chest”, sunken sternum
Pectus carinatum:
“pigeon breast” forward protrusion of sternum
Scoliosis:
lateral S-shaped curvature of the thoracic and lumber spine
Kyphosis:
exaggerated posterior curvature of the thoracic spine (humpback)
ASTHMA
REACTIVE AIRWAY DISEASE
ATELECTASIS
COLLAPSED LUNG
ONE LUNG WILL SOUND DIFFERENT
BRONCHITIS
INFLAMMATION OF THE LINING OF THE BRONCHIAL TUBES
COPD
a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.
PNEUMOTHORAX
a collection of air outside the lung but within the pleural cavity
Bronchophony-
have pt. say “99” (increased transmission of voice sound with increased lung density or consolidation)
Egophony
– have pt. say “ee” (sounds like “a” with consolidation)
- Respiratory considerations for elderly
Decreased mobility of thorax from calcified cartilage
- Decreased muscle strength
- Decreased elasticity of lungs
- Decreased vital capacity (max exhalation)
- Increased residual volume (what’s left over after exhale)
- Histologic changes with loss of intra
-alveolarseptum & number of alveoli
decreased surface area for gas exchange- Increased risk of dyspnea & pulmonary complications
symptoms of chronic hypoxia
Restlessness.
Headache.
Confusion.
Anxiety.
(tachycardia).
(tachypnea).
dyspnea
barrel chest
clubbed fingers
cyonosis
review flow of blood
picture in power point
- Cardio- age related changes
- Hemodynamic changes:
- Increased systolic BP
- Left ventricule (wall) thickens
- Heart rate: unchanged at rest
- Cardiac output: unchanged at rest
- Decreased adaptation to exercise
- Dysrhythmias: supraventricular & ventricula rIncreased cardiovascular diseases
cardio assessment
angina- onset, charactor, precipitating factors, associated symptoms
need to differentiate between cario and noncardio origin
dyspnea
cough
fatigue
cyanosis
edema
nocturia
increased fluid absorption/excretion
cardiac Hx
family cardia Hx
cardiac dysfunction
fatigue worse in evening
edema and cardiac
unilateral or bilateral, dependent edema with heart failure (bilateral, increases in the evening, decreases with elevation of legs)
pregnancy and cardiac
htn
protein in urine
edema- feet, legs, face
excessive weight gain
- For regional cardiovascular assessment, use the following order:
- Pulse and BP
- Extremities
- Neck vessels
- Precordium
Auscultate the carotid arteries for bruits
(for persons > 40 age or have S/S of CV disease
* Bruit: blowing, swishing sound, indicates turbulent blood flow from a local vascular cause; audible when the lumen is occluded by ½ to 2/3
* Use the bell side of the stethoscope for bruits
* Absence of bruit does NOT necessarily exclude partial occlusion
Inspect the jugular venous pulse
- Unilateral distension of external jugular veins indicates local cause (aneurysm or kinking)
- Bilateral distension of external jugular veins above 45 degrees indicates increased central venous pressure (CVP) from systemic disorder such as heart failure.
- Symptoms of arterial insufficiency-
pallor, coolness, diminished pulse strength
unilateral swelling is a local problem,
bilateral swelling indicates systemic problem
Deep muscle pain, pain with walking aka claudication, thin and shiny skin, absence of hair, necrotic ulcers on toes heels lateral malleolus
- Symptoms of venous insufficiency-
brownish discoloration,
venous ulcers on medial malleolus-wheeping
dull ache,
heaviness in lower leg pain,
pulses present,
thick brawny edematous skin,
- Abnormal findings when palpating precordium-
- Heave or lift (sustained forceful thrusting of ventricle during systole) – indicates ventricular hypertrophy from increased workload.
- Palpate the apical pulse (for the apex beat) and note its normal characteristics:
- Location: normally at 4 or 5th intercostal space at or medial to midclavicular line & only occupying one intercostal space
- Size: normally 1cm X 2cm
- Amplitude: normally a short, gentle tap
- Duration: normally occupies only one half of systole
Left ventricular dilatation (volume overload) –
increases its size,displaces it more laterally, increases its duration & amplitude.
Palpate across the precordium for
a thrill (palpable vibration)
*Note its timing if present auscultate or use carotid artery as a guide)
* Thrill: generally indicates a significant murmur
* Auscultate the precordium using the Z pattern technique from the base of the heart and down
Locations of the heart valves:
- Second right interspace – aortic valve
- Second left interspace – pulmonic valve
- Left sternal border – tricuspid valve
- Fifth interspace near the left midclavicular line –mitral valve
- ALL PIGS EAT TOO MUCH
normal heart sounds
s1 and s2
s1
closure of mitral and tricuspid valves
s2
closure of aortic and pulmonic valves
extra heart sounds
s3
s4
murmurs
Murmurs:
- Result from turbulent blood flow caused by:- Increased velocity- Decreased viscosity- Structural defects
know pulse locations
know general ones but also remember picture from powerpoint
all pigs eat too much
aortic
pulmonic
erb’s point
tricuspid
mitral
apex
bottom
s1>s2
base
top
s2>s1
how to assess pulse
apical- one minute
others usually 30 seconds x 2
pulse abnormalities
bruits
splits
clicks
murmurs
cervical nodes
drain head and neck
axillary nodes
drain breast and upper arm
epitrochlear node
drains hand and lower arm
in the antecubital fossal
inguinal nodes
drain le, external genitalia, and anterior abdominal wall
palpate lymphnodes
use gentle circular motion with your fingerpads
start with preauricular
deep cervical chain
tip patient head toward side being examined
supraclavicular nodes
patient to hunch shoulders and elbows forward
abnormalities in lymph nodes
abnormal to palpate in adults
if palpable note location, size, shape, discrete, matted, mobility, consistency, tenderness
intervention for an enlarged lymphnode
describe all aspects
note source they drain
refer for follow up
pay attention between acute infection and cancer or hiv
Air conduction (AC) -
normal pathway
Bone conduction (BC) -
alternate route* directly transmit vibrations to inner ear & to CN VIII
tonsil grading
1+ Visible just beyond the anterior pillar (normal)
2+ Halfway between tonsillar pillars and uvula
3+ Touching the uvula
4+ Touching each other
- Facial symmetry assessment-
note symmetry: asymmetry with central brain lesion, damage to the CN VII (Bell’spalsy
- How to assess tm in kids
out and down
how to assess tm in older children and adults
out and up
Pupillary light reflex:
normal constriction of the pupils when bright light shines on the retina
* Direct light reflex: constriction of that pupil exposed to the bright light*
* Consensual light reflex: simultaneous constriction of the other pupil.
accomodation
refers to the adaptation of the eye from far to near vision
- Results from the increased curvature of the lens by movement of the ciliary muscles
- Normal finding: convergence of the axis of the eyeball & pupillary constriction
snellen chart
normal vision is 20/20 (you can read at 20 feet what the normal eye could read at 20 feet)
* Top number (numerator) notes the distance the person is standing from the chart; the bottom number (denominator) gives the distance at which a normal eye could read that particular line
jaeger card
visual acuity
persons over 40 or difficulty reading
near vision
hold 14 inches from the eye
normal is 14/14
move farther away = presbyopia
confrontation test
visual fields
* Indication of peripheral field loss: person unable to see the object as the examiner does
hirschberg test
corneal light reflex
Assess the parallel alignment of the eye axes
* Asymmetry of the light reflex indicates deviation in alignment from muscle weakness or paralysis
cover test
detects small degrees of deviated alignment
* Abnormal finding: eye jumps to fixate on the designated point (indicates muscle weakness).
Diagnostic position test (Six cardinal positions of gaze)
- Normal response: parallel tracking of the object with both eyes
- Abnormal finding: unparallel movement of the eyes (indicates extraocular muscle weakness or dysfunction of the cranial nerve)*
- Strabismus:
crossed eye, one eye deviates off fixation point, can disconjugate vision.
- TEST FOR ACCOMODATION
Normal response=
1. pupillary constriction and
2. convergence of the axis of the eyes
3. * Abnormal finding: absence of constriction or convergence, asymmetric response
4. * Record normal response as PERRLA
PERRLA
(Pupils Equal, Round, React to Light and Accommodation)
Red reflex-
Direct the beam of light through the pupil to illuminate the inner structures
Match sides with patient (ex. use your right eye for viewing pt’s right eye
Start at 10 inches away from pt. at an angle 15% lateral to the pt’s person’s line of vision
Note the red reflex filling the pt’s pupil and steadily move closer to the eye, keeping sight of the red reflex
- Age related eye change- Infants and Children:-
Limited eye movement at birth but peripheral vision is intact;
iris less pigmented-
Macula is absent at birth; developing byage 4 months & mature by 8 months
- Binocularity and the ability to fixate on asingle object by 3-4 months
- Eyeball is adult size by age 8
AGE RELATED EYE CHANGES- ELDERLY
Lacrimal glands involute
- Arcus senilis: infiltration of degenerative lipid material around the limbus
- Pupil size decreases- Loss of elasticity of the lens
- Common causes of decreased visual functioning in the aged adult:- Presbyopia:
- senile cataract
- floaters
- glaucoma
- md
presbyopia
the lens decreased ability to change shape in order to accommodate for near vision.
senile cataract
: lens opacity, fibers of the lens thickens & yellows (nuclear sclerosis)
Floaters:
from debris accumulating in the vitreous
Glaucoma:
increased ocular pressure
Macular degeneration: md
loss of central vision (area of clearest vision); inability to read fineprint; peripheral vision is unchanged
* Most common cause of blindness (greater incidence in woman)
shapes of abdomen
flat
scaphoid
rounded
distended
protuberant
distended abdomen
bulging outward
scaphoid
sunken
protuberant
bulging or convex
- Cva tenderness-
Use indirect fist percussion to vibrate over the 12th at the costovertebral angle (CVA)
* Hold one hand over the CVA, then thump hand with the ulnar edge of your other fist
* * Normal finding: patient feels only the thud but no pain
* * Sharp pain (costovertebral angletenderness) indicates inflammation of the kidney or paranephric region
dysphagia
any difficulty swallowing
painful
gi order of assessment
inspection
auscultation
percussion
palpation
palpation of spleen
- Located on posterolateral region of the abdominal cavity beneath the diaphragm, from the 9th to 11th rib lateral to the midaxillary line (approximately 7 cm in length)
- Normally not palpable
when not to palpate the spleen
Palpable only if it is 3 times its normal size*
Do not continue to palpate an enlarged spleen as it is friable (bleeds easily) & can rupture
* Note how many centimeters it extend sbelow the left costal margin
cranial nerve 1
olfactory
smell
cranial nerve 2
optic
how well you see
cranial nerve 3
oculomotor
3,4,6 make the eyes do tricks
adjusts and coordinates eyes during movement
cranial nerve 4
trochlear
look down or to nose
3, 4, 6 make eyes do tricks
cranial nerve 5
trigeminal
hree-part nerve in your head that provides sensation.
forehead, cheek, chin
cranial nerve 6
abducens
3, 4, 6 make eyes do tricks
makes eye move out
look to the side
cranial nerve 7
facial nerve
facial expression
smile
lift eyebrows
puff cheeks
cranial nerve 8
acoustic
hearing
cranial nerve 9
glossopharyngeal
swallow
moves pharynx/larynx
say ahh
gag reflex
cranial nerve 10
vagus
coughing, sneezing, vomitting
gag
cranial nerve 11
spinal accessory nerve
push shoulders or head against pressure
cranial nerve 12
hypoglossal
tongue movement
gcs
glasgow coma scale
review chart in ppt
mild 13-15
moderate 9-12
severe 3-8
what do balance test check for
cerebellar function
balance tests
gait- regular walking
tandem walk- heel to toe
romberg test- close eyes and maintain balance for 60 seconds
hop in place/shallow knee bends
coordination tests
rapid alternating movements ram
thumb to finger test
finger to finger test
finger to nose test
heel to shin test
rapid alternating movement
Rapid alternating movements (RAM) of the hands test several aspects of coordination. When a patient has cerebellar disease, one movement cannot be quickly followed by its opposite and movements are slow, irregular, and clumsy.
finger to finger test
. The patient is asked to touch the tips of the index finger of each hand together. A, A truly blind patient can easily perform this task. B, A patient with nonorganic visual loss may demonstrate the inability to touch the fingers together.
finger to nose test
Finger to nose & finger to finger test. Ask patient to fully extend arm then touch nose or ask them to touch their nose then fully extend to touch your finger.
detecting disorders in the cerebellar region and neural circuits involving the cerebellum. It has also been used to detect disorders related to cerebellar function.
heel to shin test
For the lower extremities, the examiner asks the patient to move their heel across the shin in a proximal to distal motion. In a hemispheric cerebellar lesion, the patient will not be able to trace the shin in a straight line and will move the heel from side to side.
