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Sequence 1 > HAP Midterm > Flashcards

HAP Midterm Flashcards

1
Q

“Normal” oral temperature is

A

35.8º C – 37.3º C (96.4º F – 99.1º F)

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2
Q

Vital signs

A
  • temperature
  • pulse
  • respirations
  • o2 sat
  • blood pressure
  • pain
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3
Q

Normal pulse rate

A

60-100 beats per minute

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4
Q

Pulse

A

Assess rate, rhythm, and force

Rhythm- if regular count for 30 seconds (irregular 1 minute)
Force- 0-4+

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5
Q

Respirations

A

Normal adult is 12-20 respirations per minute
Count for 30 seconds and multiply by 2
If irregular, count for a full minute
Also assess depth and effort of breathing

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6
Q

Falsely high blood pressure reading

A 
Falsely high
Person is anxious, angry, just exercised
Arm below heart level
Supporting own arm
Legs crossed
Improper cuff size (too small)
Deflate too slowly, re-inflate too soon
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7
Q

Abnormal 02 saturation

A

Below 90% requires further evaluation

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8
Q

Urgent assessment

A 
Altered LOC
Pulse 120 /minute
Systolic BP 170
Diastolic BP > 100
New onset CP
Acute significant change from patient’s  baseline
Sudden increase in respiratory effort  needed
Respirations  28 /minute
Pulse oximetry
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9
Q

Pain

A

THE FIFTH VITAL SIGN
Pain is always subjective
Pain is whatever the experiencing person says it is, existing whenever he or she says it does
Cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend support
Subjective report is most reliable indicator of pain

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10
Q

Pain in older adults

A

May have multiple health problems associated with pain
Changes in Functional status may be the presenting behavioral cue of pain
Fear of dependency, further testing or invasive procedures, may impact reporting of pain
During interview establish an empathic and caring rapport to gain trust.

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11
Q

Normal Rectal Temperature

A

Rectal temperature is 0.5º C (1.0º F) higher than temporal temp

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12
Q

Tachypnea

A

Fast shallow breathing

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13
Q

Bradypnea

A

Slow deep breathing `

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14
Q

Hyperventilation

A

Fast and deep breathing

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15
Q

Hypoventilation

A

Slow and shallow breathing

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16
Q

Cheyne-Stokes

A

Sleep apnea then followed by gradual increase and decrease in breathing.

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17
Q

COPD

A

longer expiratory phase than inspiratory phase due to air trapping.

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18
Q

Culture

A

All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview

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19
Q

Ethnicity

A

Social group within a cultural and social system that shares common cultural and social heritage that includes:
•Language, history, lifestyle, religion, or all of these

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20
Q

Race

A

is genetic in origin and includes physical characteristics:
•Skin color, bone structure, eye color, and hair color

Individuals from the same racial group are not necessarily from the same culture

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21
Q

Religion

A

an organized system of beliefs, rituals, and practices in which an individual participates

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22
Q

Spirituality

A

Broader concept that influences interpersonal behaviors and expectations

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23
Q

Health

A

Specific to individual and based on experience, upbringing, race/ethnicity, sex, gender identity

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24
Q

Biomedical health

A

Absence of diseases

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25
Q

Holistic health

A

the view that the mind, body, and spirit are interdependent and function as a whole within the environment

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26
Q

Wellness

A

“a dynamic process and view of health; a move toward optimal functioning”

A “positive” state of health

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27
Q

Health definition

A

state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity”

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28
Q

Role of the professional nurse

A
  • To promote health
  • To prevent illness
  • To treat human responses to health or illness
  • To advocate for individuals, families, communities, and populations
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29
Q

Health assessment

A

Health assessment is a systematic method of collecting and analyzing data

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30
Q

Benefits to the nursing process

A
  • Diagnose both actual and potential problems
  • Provide a blueprint or plan for patient care
  • Systematic
  • Dynamic
  • Humanistic
  • Outcome-focused
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31
Q

Primary components of the nursing assessment

A 
Health history (subjective data)
•Physical assessment (objective data)
•Other factors
•Psychological, sociocultural, spiritual, economic, lifestyle
•Documentation of data
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32
Q

Subjective data

A

Symptoms, history
•Information the patient (or the patient’s family or significant other) tells you
•“I have a headache”
•“My husband says he has a headache

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33
Q

Objective information

A

(signs, physical examination)
•The findings resulting from direct observation using all of your senses (sight, sound, touch, smell)
•Uses techniques of inspection, palpation, percussion, and auscultation
•BP 122/68
•Patient is restless
•WBC 12,000
•Lungs crackles bilaterally

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34
Q

Documentation

A
  • Improves plan of care
  • Legal document of patient’s health status
  • Baseline for
  • Evaluation
  • Changes and decisions related to
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35
Q

Types of assessment

A 
Emergency assessment
•Comprehensive health assessment
•Problem-based or focused health assessment
•Episodic assessment
•Shift assessment
•Screening assessment
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36
Q

Basic critical thinking

A

Concrete and based on a set of rules; early step in developing reasoning; not enough experience to individualize; weak competencies

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37
Q

Complex critical thinking

A

Analyze and examine choices independently; look beyond expert opinion; thinkers separate self from experts; each solution has benefits and risks

38
Q

Priorities in the assessment

A

High: life- threatening, or if high concern to patient

Prioritize patient assessment and care based on clinical experience, knowledge, expertise, and judgement

39
Q

Data organization

A

Organization and clustering of data
•Allows problems to be more clearly apparent
•Can be based on body system format:
•Cardiovascular, musculoskeletal, etc.
•Can be based on conceptual format:
•Oxygenation, perfusion, mobility

40
Q

Data analysis

A

Identifying abnormal findings
•Correctly interpreting findings to select appropriate plan of care
•Applying clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems
•After understanding the situation, the nurse responds by determining appropriate interventions

41
Q

Diagnosis

A 
Interpret Data
•Identify clusters of cues
•Make inferences
•Validate inferences
•Compare clusters of cues with definitions and defining characteristics
•Identify related factors
•Document the diagnosis
42
Q

Format of the nursing diagnosis

A

PES: P r/t E aeb S
P is for the problem
•E is for the etiology or medical diagnosis (may have a secondary etiology)
•S is for the defining characteristics (signs and symptoms)

43
Q

Medical diagnosis

A

Disease condition based on specific evaluation of signs and symptoms

44
Q

Nursing diagnosis

A

Judgment about the patient in response to an actual or potential health problem

45
Q

Collaborative diagnosis

A

An actual or potential physiological complication that nurses monitor to detect the onset of changes in patient’s status

46
Q

Potential risk nursing diagnosis

A

Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community

47
Q

Actual nursing diagnosis

A

Describes human responses to health conditions or life processes that exist in an individual, family, or community

48
Q

Wellness nursing diagnosis

A

Describes human responses to levels of wellness in an individual, family, or community

49
Q

Health promotion

A

Behavior motivated by desire to increase well-being and actualize health potential

50
Q

Health protection

A

Disease prevention

51
Q

Health promotion/ protection

A

Central component of nursing
•Begins with health assessment—data to identify patient’s health status, practices, and risk factors
•Interpretation of data allows the nurse to target health promotion needs

52
Q

Primary prevention

A

Optimize health and disease prevention through promotion of healthy lifestyles

53
Q

Secondary prevention

A

Identify at an early stage to initiate prompt treatment; screening efforts

54
Q

Tertiary prevention

A

Minimizing the effects of the disease or illness and allowing for the most productive life within limitations

55
Q

Healthy people 2020

A
  • Objectives address most significant preventable threats to health, with goals to reduce threats
  • Four overarching goals:
  • Attain high quality, longer lives, free from preventable diseases
  • Achieve health equity, eliminate disparities, and improve the health of all groups
  • Create social and physical environments that promote health for all
  • Promote quality of life, healthy development, and healthy behaviors across all life stages
56
Q

Order of assessment

A 
Inspection
Palpating
Percussion 
    Direct
    Indirect
57
Q

Order of ABDOMINAL assessment

A

Inspect
Auscultation
Percussion
Palpating

58
Q

Inspection

A

Observation with eyes as soon as patient is seen

Breathing rate, color, rate of speech, body position, alertness

59
Q

Palpating

A 
Use sense of touch
Temperature- back of hands
Moisture 
organ size and location (requires deep palpation)
Swelling
Vibration (base of fingers/ ulnar surface)
Consistency 
Pulse
Crepetation 
Lumps/ masses
60
Q

Percussion

A

Mapping out location and size of organ, signaling density in order to detect abnormal masses/ fluids/ tenderness, and elicit deep tendon reflexes

61
Q

Indirect percussion

A

Non- dominant is used as a sound board and dominate hand makes noise. Tap on distal portion of middle finger with dominant hand

62
Q

Direct palpation

A

Tapping directly on patient that is done in only 2 places: sinuses or costoveterbral angle- on the back behind the kidney to determine tenderness of inflammation

63
Q

Resonant quality

A

Clear, hollow due to air

64
Q

Resonant location

A

Normal lung tissue

65
Q

Hyper-resonant quality

66
Q

Hyper-resonant location

A

Abnormal lung tissue (barrel chested due to hyperinflation of lung)

Normal child lung

67
Q

Tympany quality

A

Musical and drum like

68
Q

Tympany Location

A

Air filled viscus (stomach, intestine)

69
Q

Dull quality

A

Muffled thud

70
Q

Dull location

A 
Dense organ (liver, spleen)
Abnormal tissue
71
Q

Flat quality

72
Q

Flat location

A

Large muscle (thigh), bone, tumor

73
Q

Physical appearance

Definition

A

How does the patient look?

  • Overall
  • hygiene, dress
  • sexual development
  • LOC, A&0
  • speech pattern, rate, volume
  • skin color
  • facial appearance
74
Q

Physical appearance: normal

A 
Appears stated age
Facial features, body, and movement are symmetrical
Well groomed
Clean clothing
Sexual development appropriate 
Even tone
No lesions
Skin normal for ethnicity 
No distress
75
Q

Physical appearance ABNORMAL

A

Pallor
Cyanosis
Jaundice
Mask like (no facial expressions, Parkinson’s)
Facial drooping (stroke)
Grimacing
Appears older than stated age
Disheveled
Malordorous
Ill fitting clothes/ loud wild clothes and make up
Delayed or early puberty in pre teens and teens

76
Q

Body structure definition

A

Length, width, Height of body parts
Nutrition
Symmetry
Posture

77
Q

Normal body structure

A 
Normal range for age, gender, genetic heritage
Height should be the same as wingspan
Normal weigh to height 
Pubis to ground same as ground to pubis 
Even body and fat distribution
Equally proportional bilaterally 
Erect posture
78
Q

Abnormal body structure

A 
Dwarfism
Gigantism
Conjoplastic dwarfism (prevents patient from turning cartilage into bone)
Cache is
Anorexia nervousa
Cushing syndrome
Obesity
Lordosis 
Kyphosis 
Scoliosis 
Tripod position
Marian syndrome 
Webbed digits 
Polydactly (extra digits)
Atrophy or hypertrophy
79
Q

Mobility

A

How well patient moves, walks and their gait, ROM

** think safety and risk of falls**

80
Q

Mobility normal

A

Shoulder- width base
Proper arm swing, smooth, even, balanced
Smooth coordinated ROM
No involuntary movements

81
Q

ABNORMAL mobility

A 
Shuffling
Wide base
Dragging
Limping
Stooped over and leaning 
Tremors, jerky
Limited movement
Stiff
Uncoordinated 
Tics 
Paralysis
82
Q

OLD CARTS

A 
Onset 
Location
Duration 
Character
Aggravating/ alleviating factors 
Related symptoms 
Time
Severity (0-10)
83
Q

Cranial nerve 1

A

Sense of smell/ olfactory

84
Q

Cranial nerve II

A

Vision/ olifactory

85
Q

Cranial nerves III, IV, VI

A

Ocular motor
Trochlear and abducens
PERRLA

86
Q

Cranial nerve V

A

Trigeminal nerve, TMJ,

Light tough on cheek

87
Q

Cranial nerve VII

A

Facial movements,

have patient smile, frown, lift up eyebrows

88
Q

Cranial nerve VIII

A

Acoustic or vistbulochochlear

Whisper voice test- if 2 words missed further assessment needed

89
Q

Cranial nerve IX and X

A

GLASSOPHARYNGEAL AND VAGUS NERVES

Depress tongue with depressor and say “ahh”

90
Q

Cranial nerve XI

A

Spinal/ accessory nerve

Motor
Head movement from side to side and shoulder shrug

91
Q

Cranial nerve XII

A

HYPOGLOSSAL, MOTOR
Voice, speech, movement
Stick out tongue and say “light, tight, dynamite”

Sequence 1 (21 decks)

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