Health Assessment Exam I Flashcards
What were you doing when the pain started? What caused it? What makes it better and worse? What seems to trigger it? What relieves it? What aggravates it?
P=Provocation/Palliation
What does it feel like?
Use words to describe the pain, such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, or stretching.
Q= Quality/ Quantity
Where is the pain located?
Does it radiate?
Does it feel as if it travels/ moves around?
Did it start elsewhere and is now localized to one spot?
R= Region/Radiation
How severe is the pain on a scale of 0 to 10 with zero being no pain and 10 being the worst pain ever?
Does it interfere with activities?
How bad is it at its worst?
Does it force you to sit down, lie down, slow down?
How long does the episode last?
S=Severity Scale
When/ at what time did the pain start?
How long did it last?
How often does it occur: hourly, daily, weekly, monthly? Is it sudden or gradual?
What were you doing when you first experienced it?
When do you usually experience it: daytime, night, early morning?
Are you ever awakened by it?
Does it lead to anything else?
Is it accompanied by other signs and symptoms?
Does it ever occur before, during or after meals?
Does it occur seasonally?
T=Timing
Emergent, life-threatening, and immediate-ABCs
First level priority
Next in urgency, requiring attention so as to avoid further deterioration-Pain, mental status changes, infection risk, abnormal lab value, elimination problems
Second level priority
Important to patient’s health but can be addressed after more urgent problems are addressed.-Lack of knowledge, mobility problems, family coping
Third level priority
The approach to treatment involves multiple disciplines
Collaborative problems
What must the nurse assess first when providing culturally competent health care to an Asian American patient?
The tradition of the Asian American culture and the health care practices r/t health and wellness
The nurse’s heritage-based cultural values, beliefs, attitudes, and practices
Any differences between the nurse’s culture and the Asian American culture
The attitudes of Asian American cultures to the health care system in the United States
The correct answer is 2.
The nurse first needs to be able to determine what biases or differences exist prior to rendering care to any other culture.
Options 1, 3, and 4 are also important aspects of providing culturally component care; however the nurse must begin with his or her own beliefs.
Social group with shared traits
Ethnicity
Process of adopting culture and behavior of the majority culture
Acculturation:
Unidirectional in a linear fashion
Assimilation
Provide a brief description of pertinent patient variables,
demographics, clinical diagnosis, and location
Situation-SBAR
Provide pertinent history as it directly relates to the patient’s current health status
Background- SBAR
State pertinent assessment findings obtained with an interpretation of data
Assessment-SBAR
State what you need or want for the patient in terms of medical treatment and/or assistance
Recommendation or Request-SBAR
subjective sensation person feels from disorder documented in quotes
Symptom
objective abnormality that can be detected on physical examination or in laboratory reports
Sign
a gradual progressive process—causing decreased cognitive function even though the person is fully conscious and awake—and is not reversible.
dementia
an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
Delirium
AIDET
Acknowledge Introduction Duration Explanation Thank you
Appearance
Behavior
Cognition function
Thought process
Mental Status Assessment
implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing.
Culturally sensitive
implies that caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care
Culturally appropriate
Implies that the caregivers understand and attend to the total context of the invididuals’ situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences
Culturally competent
Senses in order
Inspection
Palpation
Percussion
Auscultation
applies sense of touch to assess the following:
Texture, temperature and moisture
Organ location and size
Swelling, vibration, pulsation or crepitation
Rigidity or spasticity
Presence of lumps or masses
Presence of tenderness or pain
Should be performed slow and systematic
Start with light and proceed to deep.
Bimanual palpation is used for certain body parts or organs.
Palpation
Close, careful scrutiny, first of individual as a whole and then of each body system
Begins when you first meet person with a general survey
As you proceed through examination, start assessment of each body system
always comes first.
requires
good lighting.
adequate exposure.
occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view.
Inspection
Different parts of hands are best suited for assessing different factors:
Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps
Fingers and thumb: detection of position, shape, and consistency of an organ or mass
Dorsa of hands and fingers: best for determining temperature because skin here is thinner than on palms
Base of fingers or ulnar surface of hand: best for vibration
Palpation Techniques
Tapping person’s skin with short, sharp strokes to assess underlying structures
has following uses:
Mapping location and size of organs
Signaling density of a structure by a characteristic note
Detecting a superficial abnormal mass
vibrations penetrate about 5 cm deep.
Deeper mass would give no change in percussion.
Eliciting pain if underlying structure is inflamed
Eliciting deep tendon reflex using percussion hammer
Technique should be practiced to achieve competence.
Stationary hand: Pleximeter—middle finger hyperextension
Striking hand: Plexor—striking finger
Percussion
practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition.
Body mass index
pressure forcing blood into tissues, averaged over cardiac cycle
Mean arterial pressure (MAP
is force of blood pushing against side of its container, vessel wall.
Blood pressure (BP)
elastic recoil, or resting, pressure that blood exerts constantly between each contraction
Diastolic pressure
maximum pressure felt on artery during left ventricular contraction or systole
Systolic pressure
Short-term and self-limiting:
Often follows a predictable trajectory, and dissipates after an injury heals
Self-protective purpose
Acute pain
can be further divided into malignant (cancer related) and nonmalignant.
In contrast, chronic (or persistent) pain is diagnosed when pain continues for 6 months or longer.
Chronic pain
Transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome
Can result from:
End of dose medication failure
Result of incident or episodic pain
Treatment:
Shorten interval dosing and/or increase medication
Experience of pain is a complex biopsychosocial mechanism.
More clinical research is needed.
Rely on patient report as best indicator of pain
Breakthrough pain
reflects average blood glucose levels for the prior 2 to 3 months.
range from 5% to 7%.-normal
Glycosylated Hb, also known as HbA1c
format uses numbers to identify a response.
Three domains: alcohol consumption, drinking behavior or dependence, and adverse consequences (Maximum score: 40)
Useful in primary care with adolescents and older adults
Relatively free of gender and cultural bias
AUDIT-C: shorter form for acute and critical care units (maximum score: 12)
The AUDIT will help detect less severe alcohol problems (hazardous and harmful drinking) as well as alcohol abuse and dependence disorders.
Helpful with emergency department (ED) and trauma patients because it is sensitive to current as opposed to past alcohol problems.
AUDIT-Alcohol Use Disorders Identification Tests Questionnaire
