HEALTH ASSESSMENT Flashcards
Ethics
the study of conduct and character
code of ethics
a guide for the expectations and standards of a profession
basic principles of ethics (4)
advocacy
responsibility
accountability
confidentiality
advocacy
support of client’s health/wellness/safety/and personal rights, including privacy
responsibility
willingness to respect obligations and follow through on promises
accountability
ability to answer for one’s own actions
confidentiality
protection of privacy without diminishing access to high-quality care
ethical principles for client care
autonomy
beneficence
fidelity
justice
nonmaleficence
veracity
autonomy
the right to make one’s own personal decisions, even when those decisions might not be in that person’s best interest
beneficence
action that promotes good for others, without any self-interest
fidelity
fulfillment of promises
justice
fairness in care delivery and use of resources
nonmaleficence
a commitment to do no harm
veracity
a commitment to tell the truth
ethical dilemma
problems that involve more than one choice and stem from differences in the values and beliefs of the decision makers
a problem is an ethical dilemma when (3)
1) a review of scientific data is not enough to solve it
2) it involves a conflict between two moral imperatives
3) the answer will have a profound effect on the situation and the client
what to do when making an ethical decision (7)
1) identify whether the issue is indeed an ethical dilemma 2) gather as much relevant information as possible about the dilemma 3) reflect on your own values as they relate to the dilemma 4) state the ethical dilemma, including all surrounding issues and the individuals it involves 5) list and analyze all possible options for resolving the dilemma, and review the implications of each option 6) select the option that is in concert with the ethical principle that applies to this situation, the decision maker’s values and beliefs, and the profession’s values for client care. Justify selecting that one option in light of the relevant variables 7) apply this decision to the dilemma and evaulate the outcomes
examples of ethical dilemmas nurses may face
1) caring for an adolescent client who has to decide whether to undergo an abortion even though her parents believe it is wrong
2) discussing options with a parent who has to decide whether to consent to a blood transfusion for a child when his religion prohibits such treatment
unintentional torts
1) negligence (a nurse fails to implement safety measures for a client at risk for falls)
2) malpractice (a nurse administers a large dose of medication due to a calculation error, the client has a cardiac arrest and dies)
quasi-intentional torts
1) breach of confidentiality (a nurse releases a client’s medical diagnosis to a member of the press)
2) defamation of character (a nurse tells a coworker that she believes the client has been unfaithful to her partner)
intentional torts
1) assault (a nurse threatens to place an NG tube in a client who is refusing to eat)
2) battery (a nurse restrains a client and administers an injection against her wishes)
3) false imprisonment (a nurse uses restraints on a competent client to prevent his leaving the health care facility)
professional negligence
the failure of a person who has professional training to act in a reasonable and prudent manner
– what typically leads to a malpractice suit
five elements necessary to prove negligence
1) duty to provide care as defined by a standard (care a nurse should give or what a reasonably prudent nurse would do)
2) breach of duty by failure to meet standard (failure to give the standard of care)
3) foreseeability of harm (knowledge that failing to give the proper standard of care could harm the client)
4) breach of duty has potential to cause harm (failure to meet the standard had potential to cause harm - relationship must be provable)
5) harm occurs
five elements of negligence in nursing with client who has fall risk
1) standard of care exists
- - the nurse should complete a fall risk assessment for all clients during admission
2) failure of standard
- - the nurse does not perform a fall risk assessment during admission
3) know of consequences of no standard care
- - the nurse should know that failure to take fall risk precautions could endanger a client at risk for falls
4) relationship between 2&3
- - without a fall risk assessment, the nurse does not know the client’s risk for falls and does not take the proper precautions
5) harm occurs
- - the client falls out of bed and fractures his hip
informed consent
a legal process by which a client or the client’s legally appointed designee has given written permission for a procedure or treatment
1) the reason the client needs the treatment or procedure
2) how the treatment or procedure will benefit the client
3) the risks involved if the client chooses to receive the treatment or procedure
4) other options to treat the problem, including not treating the problem
nurses role in informed consent
to witness the informed consent
- ensure that the provider gave the client the necessary information
- ensure that the client understood the information and is competent to give informed consent
- have the client sign the informed consent document
- notify the provider if the client has more questions or appears not to understand any of the information. the provider is then responsible for giving clarification
- document questions the client has, notification of the provider, reinforcement of teaching, and use of an interpreter
nurses role in advanced directives
1) provide written information about advance directives
2) document the client’s advance directives status
3) ensure that the advance directives reflect the client’s current decisions
4) inform all members of the health care team of the client’s advance directives
nursing process
cyclical, critical thinking process that consists of five steps to follow in a purposeful, goal-directed systematic way to achieve optimal client outcomes
– dynamic/continuous/client-centered/problem-solving/decision making framework
steps of the nursing process
1) assessment/data collection
- - collect information about a client;s present health status to identify need, and to identify additional data to collect based on findings
2) analysis
- - interpret or monitor the collected databse, reach an appropriate nursing judgement about a client’s health status and coping mechanisms, and provide direction for nursing care
3) planning
- - establish priorities and optimal outcomes of care to measure and evaluate. then, select the nursing interventions to include in a client’s plan of care to promote, maintain, or restore health
4) implementation
- - provide care based on assessment data, analyses, and the plan of care
5) evaluation
- - examine a client’s response to nursing interventions and form a clinical judgement about meeting goals and outcomes
sources for data collection (4)
1) primary subjective (symptoms)
- - what the client tells the nurse (my should hurts)
2) primary objective (signs)
- - data the nurse obtains through observation and examination (client grimaces when attempting to lift arm)
3) secondary subjective
- - what others tell the nurse based on what the client has told them (she told me her shoulder is sore)
4) secondary objective
- - data the nurse collects from other sources (family/friends/medical records/etc)
3 types of nursing interventions
1) nurse-initiated/independent
2) provider-initiated/dependent
3) collaborative
nurse initiated interventions
nurses use evidence and scientific rational to take autonomous actions to benefit clients. they base these actions on identified problems and health care needs, and make sure they are within their scope of practice. nurses perform or delegate the interventions and are accountable for them
– an example is repositioning a client at least every 2 hours to prevent skin breakdown
provider initiated interventions
interventions nurses initiate as a result of a providers prescription (written, standing, or verbal) or the facilities protocol (such as blood administration procedures
goals should be (7)
client-centered/singular/observable/measurable /time-limited/mutually-agreeable/reasonable
factors that can lead to lack of goal achievement (4)
1) an incomplete database
2) unrealistic client outcomes
3) nonspecific nursing interventions
4) inadequate time for the client to achieve the outcomes
3 levels of critical thinking
1) basic critical thinking
- - trusts the experts and thinks concretely based on the rules
- - a client reports pain 1 hour after receiving a pain medication, instead of reassessing the client’s pain, the nurse tells the client he must wait two more hours before he can receive his next dose
2) complex critical thinking
- - begins to express autonomy by analyzing and examining data to determine the best alternative
- - a nurse realizes that a client is not ambulating as often as prescribed because of a fear of missing her daughters phone call. the nurse assures the client that the staff will listen for and answer the phone when she is out of her room
3) commitment
- - able to make choices without help and fully assume the responsibility
- - a nurse increases the rate of an IV fluid infusion when a client’s blood pressure indicates hypovolemic shock 24 hours after surgery
chain of infection (6)
1) causative agent
- - bacteria/virus/fungus/prion/parasite
2) reservoir
- - human/animal/food/water/soil/insects
3) portal of exit (from host)
- - respiratory tract/GI tract/GU tract/skin/mucous membranes/blood/body fluids/transplacental
4) mode of transmission
- - contact (direct/indirect/fecal-oral)/droplet /airborne/vector
5) portal of entry (to new host)
- - may be same as exit portal
6) susceptible host
- - compromised defense mechanisms leave the host more vulnerable
stages of an infection (4)
1) incubation
- - interval between the pathogen entering the body and the presentation of the first symptom
2) prodromal stage
- - interval from onset of general symptoms to more distinct symptoms, during this time the pathogen is multiplying
3) illness stage
- - interval when symptoms specific to the infection occur
4) convalescence
- - interval when acute symptoms disappear. total recovery could take days to months
Some things to avoid while communicating therapeutically include the following.
Using inappropriate plural pronouns (“we”) Assuming the client knows about a health interview or physical Asking personal questions that are not relevant to the situation Giving personal opinions Using automatic responses and false reassurances Relaying disapproval of client statements or health practices
Some of the key elements of therapeutic communication include the following.
Ask what the client prefers to be called, otherwise address the client by using their surname. Keep questions focused and relevant to the context and situation. Ask open-ended questions. Redirect the client as needed. Engage in active listening. Restate the client’s view to indicate your understanding. Use everyday language and stay away from medical terms as much as possible. Keep any emotionally charged conversations for last in order to receive any other pertinent information. Give positive reinforcement and reassurance without passing judgment or disapproval
ISBARR
ISBARR is a tool to have clear communication for effective client care. Identify. State the team member’s name and title. Situation. Provide the circumstances that have required the communication to occur. Background. Provide the background data regarding the client to assist the provider with familiarity. Assessment. Provide the most recent set of vital signs or other data relevant to the communication. Recommendations. Provide any suggestions that may be helpful to the situation. Read back orders. Repeat the orders that are given and clarify anything that is unclear.
select the action the PN participates in with the nursing process
assist the RN with collecting data from the client
what does HIPAA refer to
Health Insurance Portability and Accountability Act
therapeutic communication involves which of the following
- touch
- open-ended questions
which of the following techniques is used with palpation
use the palmar side of the hands or the pads of the fingers
which of the following actions by the nurse are examples of infection control?
>hand washing with soap and water for 15 seconds
>using an alcohol-based rub when hands are not visibly soiled
>using an alcohol pad to wipe the diaphragm of the stethoscope between clients
which of the following are tools used with auscultation
>stethoscope
>doppler
place each step of the nursing process in the correct order
>assessment
>analysis
>planning
>implementation
>evaluation
place the steps for communicating with members of the health care team in the correct order
identify
current info
background
give
suggestions
repeat order
which of the following is the first action during the physical assessment of the client
inspect the client
justice
>being open and fair
autonomy
>having self-control
Nonmaleficence
>avoiding hurt or harm to others
Confidentiality
>protecting the privacy of others
Beneficence
>helping others in a positive manner
Therapeutic communication
>keep any emotionally charged conversations for last
>be vigilant throughout the conversation
>clarify to see if the information is accurate
>redirect the client as needed
>keep questions focused and relevant to the context and situation
nontherapeutic communication
>use plural pronouns like “we”
>give personal opinions
>give approval and disapproval
>give false reassurances
>ask for explanations
ISBARR
- Identify
- Situation
- Background
- Assessment
- Recommendations
- Read back orders
assessment
gather data from the client through interview, physical exam, and observation to judgments
Implementation
carry out the interventions that have been established, use clinical judgments to monitor the client’s progress towards achieving their goals
analysis
use clinical judgment to evaluate data collected to formulate the client’s problems
evaluation
assess the effectiveness and achievability of the goals and the need for interventions to be adjusted
planning
use problem-solving and decision-making skills to prioritize outcomes and goals, and develop interventions to meet those goals
It is the responsibility of the ___________ to validate and analyze the information collected by the PN (LPN) and plan and initiate the interventions to address the client’s health care needs
RN
Therapeutic communication involves which of the following? (select all that apply)
A. touch
B. open-ended questions
C. sharing you own personal experiences with the client
D. if the client speaks a different language than the nurse, finding someone in the facility that speaks their language
A
B
Which of the following tolls used with auscultation? (select all that apply)
A. dorsal sides of hands
B. stethoscope
C. penlight
D. doppler
E. tape measure
B
D
(dorsal sides of hands are used with precision)
What assessment tools are used for feet?
inspect
palpate
doppler
What assessment tools are used for the chest?
inspect
auscultate
stethoscope
What assessment tools are used for abdomen?
inspect
auscultation
palpate
tape measure
stethoscope
What assessment tools are used for the eyes?
inspect
penlight
palpate
Diaphragm of stethoscope is used for?
(larger side)
high-pitched noises (breath sounds, bowel sounds, and normal heart sounds
bell side of stethoscope is used for?
(smaller side)
soft, low-pitched sounds (extra heart sounds, murmurs
When using therapeutic communication ensure a distance of ____________ feet to respect personal space
4 to 5
In what order do you take vital signs?
temperature
pulse
pulse oximetry
respirations
blood pressure
_________ data is obtained through direct assessment of a client (inspection, percussion, palpitation, and auscultation)
objective
____________ data is information that the client tells you in response to assessment questions
subjective
__________ = sweaty
diaphoretic
____________ = pallor
whitish
___________ = cyanosis
blueish
_____________ = jaundice
yellowish
______________ = erythema
reddish
If the client can only whisper or has a hoarse voice this may indicate ___________
laryngeal disease
If the client’s word choice is appropriate but speech sounds are unclear this may indicate____________
dysarthria
If the client struggles to find words or express an idea this may indicate _____________
form of aphasia
If the client’s word choice is unusual this may indicate _____________
a thought process abnormality such as echolalia
Specific abnormal breath odors such as alcohol; fruity breath which can indicate ___________, malnutrition, or dehydration; and ammonia which could be possible related to ____________
diabetes
kidney disease
musty body or breath odor can indicate ____________
liver disease
A fetid (extremely unpleasant) odor can indicate _____________
dental or respiratory infection
A fecal breath odor can indicate _____________-
vomiting due to problems of the bowels
Older adults are hunched over known as ___________
kyphosis
___________ is alteration in muscle tone manifested as increased tonicity.
spasticity
increased resistance when attempting to passively extend a joint
____________ is alteration in muscle tone manifested as resistance to any manipulation of the joint
rigidity
___________ is alteration in muscle movement seen as continuous, rapid twitching of a muscle at rest
fasciculation
__________ is alteration in muscle movement that is seen as a sudden jerking of the arm or leg when falling asleep
myoclonus
__________ is alteration in muscle movement characterized by involuntary, repetitive movement of a muscle group related to a neurological or psychogenic cause.
Tic
grimaces, winks, shoulder shrugs
____________ is alteration in muscle movement by opposing muscle groups that result in a rhythmic movement of one or more joints, can occur at rest or when attempting voluntary and purposeful movement
tremors
Unintentional weight gain ( 5 lb in a day) could indicate ___________
fluid retention could lead to heart failure
Unintentional weight loss (5% of body weight in a month or 10% in 6 months) could indicate ______________
disease process such as:
fever
infection
malignancy
endocrine disease
Older adults see a decrease in their heights when they reach ___________
80
Why do older adults see a reduce in their heights?
thinning in the vertebral disk
shortening of the vertebrae
kyphosis
mild flexion of the knees and hips
____________ is excessive outward curvature of the spine, causing hunching of the back.an
kyphosis
Why do older adults see a decrease in body weight?
loss of muscle mass & subcutaneous fat
_____________ hypothalamus is responsible for heat loss
anterior
__________ hypothalamus is responsible for heat production and conservation
posterior
________ occurs to decrease blood flow to the extremities and skin
vasoconstriction
____________ conserves the core temperature and prevent heat loss
vasoconstriction
Vasodilation causes ____________
evaporation
radiation
conduction
convection
Body temperature is at its lowest in ___________
morning (1-4 am)
When does body temperature peak?
4 pm
A diminished pulse could indicate ______________
weekend heart muscle
hemorrhaging
poor vascular flow to pulse site
A strong bounding pulse could indicate?
anxiety
increased activity
abnormal condition causing the heart contractility to increase blood pressure
How is pulse strength measured?
0 = absent 1+ = weak, thready, diminished pulse 2+ = normal, brisk pulse (expected) 3+ = increased, strong pulse 4+ = bounding, full volume pulse
Where can you apply a oximeter?
finger
nose
forehead
earlobe
foot
__________ and _________ placement of the oximeter have shown to provide faster and more reliable results if the client has poor peripheral blood flow
earlobe
forehead
What could negatively affect a pulse oximetry reading?
- carbon dioxide poisoning, jaundice, painted finger nails, recent injection of dyes in the circulatory system, dark skin tone
- clients movements during testing
- clients who have impaired circulation (peripheral vascular disease, hypothermia, vasoconstriction, hypotension, peripheral edema)
__________ is oxygen saturation level less than 90%
hypoxia
Anxiety can make a client’s breathing rate ____________ due to the stimulation of the sympathetic nervous system
increase
Smoking tobacco changes the lining of the airways in the lungs, inhibiting airflow and making clients breathe _____________
faster
Less hemoglobin means less oxygen and causes ____________ breathing
faster
Sickled blood cells are malformations that reduce the oxygen-carrying ability of hemoglobin to the cells. This will cause an ___________ in respiratory rate and depth
increase
Electronic monitoring of the blood pressure should not be used in what type of patient?
hypertension
hypotension with systolic less than 90 mm Hg
dysrhythmias
seizures
experienced trauma because the readings will not be accurate
Smoking causes the blood vessels to constrict which will cause __________ blood pressure
high
__________ blood pressure is a test involves taking multiple blood pressure readings in supine, standing, and sitting positions. Allow the patient to rest for 3 minutes after positioning them
orthostatic
During orthostatic blood pressure test if the patient’s systolic pressure drop 20 mm Hg or decrease of 10 mm Hg in diastolic pressure between positions this indicates _____________
orthostatic hypotension
Which of the following are researched-validated reasons to conduct a health history using an interpreter? (select all that apply)
A. to increase the self-esteem of the client
B. to increase the accuracy of the communication
C. to decrease the cost of care
D. to increase the client’s satisfaction with care
B
D
What is the order for the head to toe assessment of the systems?
A. eyes
B. nose
C. neck
D. head
E. ears
F. mouth
D. head
A. eyes
E. ears
B. nose
F. mouth
C. neck
A nurse is collecting data during a review of systems and asks the client how many pillows are required to sleep comfortably at night. This question involves assessment of which of the following systems?
A. musculoskeletal
B. cardiovascular
C. neurological
D. endocrine
B
Which of the following factors are included in health literacy? (select all that apply)
A. basic reading skills
B. basic writing skills
C. competency using numbers
D. understanding how to use literacy
E. ability to follow verbal instructions
F. ability to use a computer
A
C
E
What does FICA stand for when exploring a patient’s spirituality?
Faith
Influence
Community
Address
What are the systems that are involved in the while-body systems?
musculoskeletal
neurologic
hematologic
endocrine
Order of the full body assessment?
Overall health
skin
head and neck
breast and lymphatics
respiratory system
cardiac and peripheral vascular system
gastrointestinal
genitourinary
whole body systems
Conditions that may have a genetic component?
- blood disorders (sickle cell anemia)
- obesity
- kidney disease
- cancer (breast, ovarian, colon, prostate)
- behavioral health (suicide, depression, bipolar, schizophrenia)
- stroke
- substance use disorder
- seizure disorder
- dementia / alzheimer’s
- heart disease ( myocardial infarction, hypertension, hyperlipidemia)
- diabetes (type 1 & 2)
- thyroid ( hyperthyroid, hypothyroid)
- arthritis
- tuberculosis
- asthma
- food allergies
- medication allergies
What does OLD CARTS stand for when collecting details about a presenting problem?
onset
location
duration
characteristics
aggravating or alleviating factors
related symptoms
treatment
severity
A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is “in the stomach and is a crampy, dull ache”. Which type of pain should the nurse identify this client is experiencing?
A. Neuropathic
B. somatic
C. visceral
D. referred
C
A nurse is reviewing the vital signs for a client who’s admitted with shortness of breath. The nurse notes the client’s respiratory rate is 24/min. The nurse should use which of the following items when documenting this finding?
A. hypoventilation
B. apnea
C. tachypnea
D Chryne-stokes respirations
D labored
_________ pain begins in the larger internal organs
visceral
__________ pain is often described as cramping, squeezing, dull pain
visceral
What are some examples of visceral pain?
ureteral colic
acute appendicitis
ulcer pain
colitis (inflammation of the colon)
cholecystitis (inflammation of the gallbladder)
_________- pain travels along the autonomic nervous system
visceral
__________ pain is associated with sweating, nausea, and vomiting
visceral
__________ pain is often associated with musculoskeletal system
somatic
Deep _________ pain originates in ,muscles, bones, tendons, ligaments, and blood vessels
somatic
__________ pain is often described as throbbing pain or deep achy feeling
somatic
___________ pain is associated with sweating, nausea, and tachycardia from an ANS response
somatic
which tools and techniques to perform assessment of chest
inspect
ausculate
stethoscope
9 types of nursing documentation errors
- sloppy/illegible handwriting
- failure to date/time/sign medical entry
- lack of documentation for omitted meds/treatments
- incomplete of missing documentation
- adding entries later on
- documenting subjective data
- not questioning incomprehensible orders
- using the wrong abbreviations
- entering info in wrong chart
