HA Final Flashcards
Expected outcomes or goals should be in SMART format:
Specific, Measurable, Achievable, Relevant, Time-bound
EG: “Pt will move from bed to chair at least three times per day”
“patient will rate pain as tolerable by end of shift”
Episodic/focused:
Complete:
Follow-up:
Emergency:
Episodic/focused: obtain for a specific problem or condition i.e. sore throat, dysuria, surgery
The subjective data you obtain is directly related to the episode
Complete: first encounter with patient
Complete health history and full physical exam to determine baselines
Follow-up: status of identified acute or chronic problems i.e. new medication, post-surgery
Emergency: collect crucial subjective data while simultaneously assessing ABCs
Cultural Competence:
Hispanic
Asian
Questions to ask in cultural assessment
Hot/Cold – Hispanic
Yin/Yang - Asian
Questions to ask in cultural assessment
What are your religious or spiritual preferences?
What cultural practices are important to you?
What are your health goals?
A patient reports smoking 1 pack of cigarettes per day for 30 years. The nurse reports this as:
30 pack years
Test to indicate chronic alcohol abuse:
Elevated GGT (gamma glutamyl transferase) levels.
Be aware that nonalcoholic liver disease also can increase GGT levels in the absence of alcohol.
Measurements:
- growth chart
- kg to lbs
- Head and chest circumference
- BMI categories
Document on CDC growth charts; should be growing along curve
<5th and >95th percentiles are considered risky
1 kg = 2.2 lbs
Head circ about 2cm greater than chest; will even out around 6 mo-2 years
BMI categories Underweight <18.5 Normal 18.5-24.9 Overweight 25-29.9. Obese 30-39.9 Extreme/morbid obesity 40+
Temperature: normal range F and C fever levels hyperthermia hypothermia
Normal Range: 35.8- 37.3 (96.4 – 99.1)
> 38 (100.5) considered a fever
Hyperthermia >41.1 (106): infection, exposure, hyperthyroidism/thyroid storm
Hypothermia <35 (95): shock, exposure
Pulse deficit
(common with heart failure, arrhythmias, PAD) =
Difference between apical and radial
Abnormal LOC: Delirious somnolent Stuporous Comatose
Delirious = restless, confused Lethargic/drowsy/somnolent = drowsy; common post-op Stuporous/Semi-coma = vigorous stimulation needed; sedation, drug overdose Comatose = no response
test for Anxiety:
test for Depression:
Anxiety: GAD-7
Depression: PHQ-9
BMI <18.5 = Underweight: Check…
BMI >24.9 = Overweight : Check…
prealbumin
Nursing Diagnosis = Nutrition Imbalance; Less than Body Requirements
triglycerides and cholesterol
Nursing Diagnosis = Nutrition Imbalance: Greater than Body Requirements
Protein Vitamin C Vitamin A Thiamine Calcium and Vitamin D
Protein
Dull, dry hair
Muscle wasting
Vitamin C
Splinter hemorrhages (nails)
Bleeding gums
Joint pain
Vitamin A
Eye changes: dryness, plaques
Thiamine
Often associated with alcoholics
Neuro changes including hyporeflexia and neuropathy
Calcium and Vitamin D
Muscle pain, weak bones, rickets
skin Color:
ecchymosis
erythema
ecchymosis: pooling of blood under the skin poss unrelated to trauma
erythema: superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.
senile purpura-
increased vascular fragility so minor trauma may produce dark red discolored areas
Physiological jaundice
common after 3rd or 4th day of life (at birth is abnormal)
Lanugo-
fine hair
Atopic dermatitis- Pediculosis capitis Chronic renal failure: Lyme Disease: Types of Alopecia:
Atopic dermatitis- very dry skin, erythematous rash, possible edema
Pediculosis capitis (head lice)
Chronic renal failure: pruritus; also ammonia breath, fatigue, muscle cramps, irritability, oliguria
Lyme Disease: bull’s eye rash
Types of Alopecia: toxic, areata, traumatic
Carcinomas:
Basal =
Squamous =
Melanoma =
Basal = slow growing Squamous = fast growing, scaly Melanoma = ABCDE
Braden Scale uses a scores from less than or equal to 9 to 23.
what s being tested?
The lower the number, the higher the risk for developing an acquired ulcer/injury. 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk less than 9 = severe risk
sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Test Eye Muscles: Corneal light reflex Cover-uncover test Diagnostic Positions Test Nystagmus
- Corneal light reflex should be symmetric
- Cover-uncover test done if light is not in same spot in both eyes
- Diagnostic Positions Test/6 cardinal positions- CNs III, IV, and VI- oculomotor, trigeminal, abducens
- Nystagmus is indicative of disease of cerebellum or brainstem
Arcus Senilis:
lipid material causes grey/white arc around the cornea (normal)
Fixed & dilated pupil = Pupillary dilation: Pinpoint: Nystagmus: Ptosis:
Fixed & dilated pupil = increased ICP
Pupillary dilation: amphetamines, cocaine–stimulants
Pinpoint: opiates—depressants. Then withdrawal and opposite happens—dilate. Flu-like symptoms
Nystagmus: neuro damage
Ptosis (upper eyelid droops over the eye): CN III or VII
Retinal detachment
- emergency
Sudden onset of spots or flashing, curtain or veil like loss of vision in one quadrant of eye
Papilledema-
optic disc swelling that is caused by increased ICP.
Otitis Media
(middle ear infection)
Subjective: ear pain
Objective: bulging, immobile, red ear drum, no cone of light
Epistaxis
(bloody nose)
Xerostomia =
dry mouth (lips will lock white, cracked)
Fruity breath =
DKA
Thyroid assessment:
First inspect
Then palpate: usually not palpable, posterior approach is preferred, ask pt to swallow
Auscultate for bruit if enlarged
may be enlarged in pregnancy
Tactile Fremitus: “blue moon”
Decreased fremitus:
Increased fremitus:
Tactile Fremitus: “99” or “blue moon”
Decreased fremitus: emphysema, pneumothorax, pleural effusion
Increased fremitus: areas of consolidation (pneumonia)
Tracheal (bronchial)-
Bronchovesicular-
Vesicular-
Tracheal (bronchial)- supraclavicular, near trachea
Bronchovesicular- major airways; next to sternum, between scapulae
Vesicular- alveoli and smaller bronchioles; remainder of lungs
Vocal fremitus:
sounds will be clearer with pathology that increases lung density i.e. pneumonia
Crackles (rales):
Wheezes:
Rhonchi:
Stridor:
Crackles (rales): PNA, HF, pulm edema, CF; pulm fibrosis; may be fine (high-pitched, popping) or coarse (low-pitched, bubbling); often heard upon inspiration
Wheezes: high pitched, musical, inspiratory or expiratory
Aspiration, foreign body, asthma, chronic bronchitis, bronchiolitis
Rhonchi: low-pitched wheeze; snoring, rattling sound; coughing or suctioning may clear or change sounds; common with bronchitis
Stridor: Upper Airway obstruction i.e. Croup or anaphylaxis; inability to speak, wheezing, dyspnea, anxiety, cyanosis; loud, high pitched; inspiration; Life-threatening
Systole/diastole
Diastole- mitral/tricuspid open & aortic/pulmonic closed ( A/P closing = S2)
Systolic- contraction!, M/T close = S1 sound beginning
APETM
s1 and s2
S1 (apex) & S2 (base) - rate and rhythm
Physiologic split S2- inspiration can cause pulmonic to close later than aortic (heard 2nd ICS)
S3 (ventricular gallop; heard just after s2) - rapid ventricle filling; cardinal sign of heart failure; can be normal young adults and children, pregnant women
S4 (atrial Gallop; heard in late diastolic): listen L lateral position - slow ventricle filling; hypertension, elderly, aortic stenosis, CAD
Pericardial friction rub- “scratchy rubbing quality”, rubbing, grating, leather
Deep Vein Thrombosis (DVT) who is most at risk s/s measurement test
Elderly and those on bed rest most at risk
Unilateral pain, redness, swelling
Asymmetry >1cm considered abnormal
Homan’s sign = calf pain with dorsiflexion
Hyperreflexia –
Hyporeflexia –
DTRs:
Superficial:
Hyperreflexia – UMN i.e. CVA, MS, ALS
Hyporeflexia – LMS i.e. spinal cord transection, herniated disk
DTRs: Biceps, triceps, quads (patellar), brachioradialis, achilles
Always use reinforcement if you can’t elicit a DTR
Superficial: Cremasteric, abdominal, plantar reflex
when infant reflexes disappear
Babinski:
Primative: infants
Palmar Grasp, Moro, Rooting should disappear by 4 months
Babinski: disappears by 2 years
Absence of persistence of reflexes can indicate CNS damage
