History taking/Interview/Hand Washing/Vital Signs Lecture (unit 1) Flashcards
health
- absence of disease
- having good quality of life
- disease prevention
biomedical model of health
•absence of disease
wellness model of health
- dynamic process
* move toward optimal functioning
holistic health
•mind, body, spirit, and environment interdependent
health history
- asking pt/family ???
* past medical records
physical assessment
•using systematic, organized head-toe exam
components of health assessment
•health history
•physical assessment
•collecting data
*basis for developing a nursing plan of care for pt
nursing process in HA
- assessment
- nursing diagnosis
- planning/intervention
- evaluation
assessment
•collect pt data and think critically
nursing diagnosis
•name/prioritize issues
planning/intervention
•develop a plan for each issue
evaluation
•reassess effectiveness of interventions
health history interview
- gives subjective data- what pt says
* first and most important part of HA
phases of interview
- ) pre-interview
- ) introduction
- ) working phase
- ) termination
pre-interview
- review pt record/bedside report
- adjust environment for pt comfort (privacy)
- assessment of your own behavior/appearance
introduction
- greet patient/establish rapport
* establish agenda- purpose for visit
working phase
- invite patient’s story- listen
- identify/respond to pt emotional cues
- expand/clarify pt story
termination
- summarize important points
* discuss plan
establishing agenda
- ask about chief complaints
* use open-ended questions
expanding/clarifying story
- guide pt to focus on chief issue
- have pt elaborate on significant issues
- use 7 attributes of a symptom
therapeutic communication
- exchange of info that conveys meaning
- listen w/o interrupting
- show empathy
- eye contact
- take brief notes- keep attention on pt
interviewing acutely ill
- ask abbreviated ??? (what hurts?)
- determine cause of visit
- prioritize
interviewing someone under the influence
- simple direct ???s
- avoid confrontation
- determine last use of drug
- get full history when sober
interviewing sexually aggressive pts
- make clear that you are health care professional
* be assertive and don’t tolerate inappropriate behaviors
how to avoid personal questions
- provide brief info if appropriate
* direct ??? back to pt
interviewing angry pts
- don’t personalize the anger
* address the pts anger first with open ended ???s
interviewing pts with anxiety
- normal response to illness
* be empathetic and compassionate
interviewing hearing impaired
- ask preferred method of comm.
* get interpreter if necessary
interviewing crying person
- let them express feelings
- offer tissue
- wait for crying to subside to talk
interviewing elderly
- always use last name- Mr. last name
- don’t rush them
- give longer response time
- consider physical limitations
- touch is very important
responses to open ended question response
- facilitation
- silence
- reflection
- empathy
- clarification
- confrontation
- interpretation- inference
- explanation- facts
- summary
facilitation
- encourages person to say more
- nodding
- “yes”, “go on”
reflection
•echoing pts words
empathy
•recognize feeling and put it in words
clarification
•”tell me what you mean by that”
confrontation
•”you tell me you don’t hurt, but when I touch here, you flinch”
traps of interviewing (10)
- ) false assurance/reassurance
- ) giving unwanted advice
- ) using authority
- ) using avoidance language
- ) engaging in distancing
- ) using professional jargon
- ) using leading/biased ???s
- ) talking too much
- ) interrupting
- ) asking “why” ???s
avoiding false reassurance
- “you seem worried about ___”
* offer to listen to anxieties/sit for moment
avoiding using authority
- don’t say dr. knows best
- state there are risks/benefits
- remide pt that decision is ultimately theirs
avoiding using avoidance language
- don’t step around the truth
* state facts
aspects of nonverbal communication
- appearance
- gestures
- posture
- facial expressions
- eye contact
- voice
- touch
health history
- pt provides subjective info about their past/present health
- primary data source
- key is reliability- pt give same responses later?
secondary data source
- charts
* family
categories of health history
- biographical data
- reason for seeking care
- history of present condition
- past history
- family history
- review of symptoms
- health patterns
biographical data
•name, age, occupation, DOB, phone #, religion, ethnicity, etc
reason for seeking care
- describes reason for visit
- record 1-2 symptoms and duration
- use quotes
sign
•objective
symptom
- subjective
* written in “”
history for present illness
•complete description of present illness
OLD CART
Onset Location Duration Characteristic symptoms Associated manifestations Relieving/exacerbating factors Treatments
provocative/palliative
- what brings it on
* what makes it better
quality
•how intense
region
- where
* does it spread
severity
•pain skill
past history
- allergies/what happens?
- medication (rx and over counter)
- childhood/adult documented illness
- surgeries
- OB history
- health maintenance behaviors
health maintenance behaviors
- immunizations
- screenings
- safety measures
- risk factors
review of symptoms
- history of each symptom from head to toe
- record symptoms as present/absent/”denies”
- only subjective data
- recorded in medical terminology (denies frequency, nocturia, dysuria)
health patterns
- values/beliefs
- sleep
- exercise
- nutrition
- relationships
- stress
- family violence
- sensitive topics
functional assessment
•measures self care ability related to
- activities of daily living (ADLs)
- activities needed for independent living
- personal habits (drugs/alcohol-ETOH/tobacco-PPD/exercise)
activities of daily living (ADLs)
- bathing
- dressing
- eating
- walking
activities needed for independent living
- housekeeping
- cooking/cleaning
- finances
standard precautions
•set of principles assuming that all blood, body fluids, secretions, excretions, non-intact skin, and mucus membranes can possibly transmit pathogens
most important way to prevent spread of infection
•hand washing
nosocomial infection
- infection that has been acquired in a health care setting
* HAI- hospital acquired infection
when to wash hands with soap
- if visibly soiled or exposed to C. diff
- before/after physical contact w/ pt
- after moving from contaminated to clean
- after removing gloves
- after contact w/ secretions, objects, and blood
- before/after entering pt rooms
when to perform physical assessment
- on admission
- ongoing basis
- accepting responsibility for pt
- pt status changes
- evaluating effectiveness of interventions
preparing for an exam (5)
- ) reflect on you approach
- ) adjust environment
- ) make pt comfortable
- ) gather equipment
- ) choose systematic head to toe sequence
reflecting on approach
- ID self as student
- remind them it may take you a little longer (learning)
- don’t interpret findings (if hear lung crackle, don’t assume it’s pneumonia)
- eye contact
adjust the environment
- avoid awkward positions- adjust bed height
- good lighting
- close curtain
- quiet (turn tv down)
make pt comfortable
- keep informed
- privacy
- draping to visualize one area at a time
- pay attention to facial expressions
order of examination (except abdomen)
- inspection
- palpation
- percussion
- auscultation
order of examination abdomen
- inspection
- auscultation
- percussion
- palpation
inspection
•concentrated watching
•always comes first
•look for symmetry
*most important part of exam
palpation
- touching pt to assess
* applying tactile pressure from palmar fingers to assess
palpation w/ fingertips
•texture, swelling, pulsation, masses
grasping palpation
•position, shape, consistency, attachment
dorsal surface of hand palpation
•temperature
ball of hand/base of fingers palpation
•vibrations
light palpation of abdomen
- slow
- systematic
- detects surface/muscle characteristics
- be gentle w/ warm hangings
deep (bimanual) palpation
- using both hands
- getting at deeper organs beneath muscle
- liver, kidney
perpendicular lighting
- light source directly over area
* light on bed over pt
tangental lighting
•lighting that comes from the side
•shows shadows that can tell abnormal elevation/indentation
•utilized when examining jugular vein
*best type of lighting
percussion
- Use of finger (third) to deliver rapid tap or blow against distal finger laid against a surface of chest or abdomen
- evokes a sound wave to determine location, size, density of organs
purpose of percussion
- helps determine if increased density of tissue
- helps determine increased/decreased air beneath surface
- helps detect air, fluid, or solid mass
how to percuss
- place middle finger on area w/ other fingers raised
* use middle finger of other hand to do a wrist-flick strike on stationary middle finger
more dense the organ
•the duller the sound
resonant sound
- air filled
* Ex: lungs
tympany
- hollow organ sound
* Ex: stomach
dull sound
- over denser organs
* Ex: liver
flat sound
- no air
* Ex: bone
auscultation
- Detect characteristics of heart, lung, bowel sounds, and turbulent blood flow
- don’t listen through clothing
- avoid touching tubing
- avoid friction/wet hair
diaphragm of stethoscope
- High pitched
- Breath, bowel, normal heart sounds
- Held firmly: leave a slight ring
bell of stethoscope
- Soft, low pitched sounds
- Extra heart sounds, murmurs
- Held lightly
using stethoscope
- keep tubing steady
- slope ear pieces toward nose
- make sure snug in ears- blocks extraneous noise
- make sure chest piece turned to bell/diaphragm side
head to toe sequence (10)
- ) general survey
- ) vital signs
- ) skin
- ) HEENT- head, neck, eyes, ears, nose, throat
- ) posterior/anterior thorax/lungs
- ) breasts, axillae
- ) cardiovascular
- ) abdomen
- ) lower extremities and circulation
- ) nervous and musculoskeletal
general survey
- objective observation of pt
* all data gathered at first encounter and continues throughout interaction
data you should gather through general survey (5)
- ) physical appearance
- ) state of health
- ) grooming
- ) mobility
- ) behavior
apparent state of health
- look age
- look ill
- skin color
- odor
- facial expressions
- posture
- speech
- mood
- symmetry
- motor activity
- signs of distress
level of consciousness
- LOC
* awake/alert
measurement during general survey
•weight and height
influences on temperature
*hypothalamus controls •diurnal cycle (highest 8pm-12am) •menstrual cycle •exercise •age •stress •illness
normal resting temp
- 37 C
* 98.6 F
normal rage of temp
- 35.8-37.3 C
* 96.4-99.1 F
oral temp
•under tongue on side in posterior pockets
•delay 10-15 min if just ate/drank/smoked
*most common
rectal temp
- insert 3-4 cm in anal canal toward umbilicus
* not used often b/c of health risks
tympanic temp
•less accurate measurement
apical pulse
- central pulse located over apex of heart
* reflects HR
peripheral pulse
- rhythmic expansion of an artery that is palpated
* reflects HR and adequacy of circulation to extremity
pulse deficit
- difference b/t apical and peripheral pulse rate
* apical-radial
stroke volume
- amount of blood that exits LV during each ctx
* pressure wave in arteries
cardiac output
- volume of blood pumped from heart in one min
* SVxHR
heart rate
- bpm
- decreases with age- newborn 120 bpm
- affected by age, gender, circadian rhythm, blood volume, body temp, exercise, stress, meds, etc
Tachycardia
•more than 100 bpm
Bradycardia
•less than 60 bpm
when to take apical pulse
- when you are measuring vital signs and you palpate radial pulse
- if radial pulse is irregular
- take apical for full min
- compare the two- find pulse deficit
heart rhythm
- regularity of beats
* how even is the tempo
Sinus arrhythmia
•during inspiration HR increases
hypervolemia
- high blood volume
- pulse full; bounding
- HR may increase
- Ex: too many fluids
hypovolemia
- low blood volume
- pulse weak or thready
- rade increases to transport more O2
- Ex: bleeding inside
HR increases when…
•blood volume decreases
0 force
•absent pulse
1+ force
•weak/thready pulse
2+ force
•normal pulse
3+/4+ force
•full; bounding
artery elasticity
•feels springy when taking pulse
taking pulse in child under 2
- take apical
* record for min
taking pulse in child > 2
•radial x 1 min
taking adult pulse
- radial x 30 sec (unless abnormal)
* if irregular, determine pulse deficit- RECORD FOR MIN
what to pay attention to when taking pulse (3)
- ) rate
- ) rhythm
- ) force/elasticity
recording respirations
- do secretly- finish counting pulse but pretend still counting while counting resp. rate
- count for 30 sec unless irregular
normal respiratory rate infant
•30-80 bpm
normal respiratory rate adult
•12-20 bpm
blood pressure
- force of blood against arterial wall
* normal is 120/80
systolic pressure
•max on ctx of L ventricle
diastolic (DP)
•pressure during resting phase of cardiac cycle
pulse pressure (PP)
- SP-DP
* tends to increase w/ age
mean arterial pressure
- pressure average in arteries
* pressure forcing blood into tissues
BP range
•90/60-139/89
physiologic factors controlling BP
- cardiac output
- peripheral vascular resistance
- vol. circulating blood
- viscosity
- elasticity
peripheral vascular resistance
- how much resistance heart has to push against during contraction
- BP = CO x PVR
- higher if have narrow arteries
what influences blood viscosity
- # RBCs
* glucose levels
sphygmomanometer measurement
- W = 40% arm circumference
* L = 80% arm circumference
using too small BP cuff
•false high reading
using too large BP cuff
•false low reading
positioning pt for BP reading
- allow rest 5 min to be relaxed
- put cuff on bare arm
- arm at heart level
- back against chair, feet flat on ground
- bladder of cuff centered over brachial art. 2.5 cm above antecubital crease
- secure cuff snugly
steps of taking BP
- ) palpate brachial artery and place bell over
- ) rapidly inflate until pulse is obliterated
- ) slowly deflate 2 mmHg/beat
- ) listen for Korotkoff’s sounds
- ) read gauge at first sound- systolic
- ) read gauge at last sound- diastolic
- ) document systolic/diastolic and position of pt
osculatory gap
• the period during which Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point
•responsible for errors made in recording falsely low systolic blood pressure
*to avoid estimate systolic first and if pump cuff 30 mmHg past normal
estimating systolic pressure
- ) palpate radial artery
- ) blow cuff until can’t palpate anymore
* blow cuff 20-30 mmHg higher than estimated systolic
Korotkoff sound I
•systolic pressure
Korotkoff IV sound
•muffling of sounds
Korotkoff V sound
•when sounds disappear
•diastolic pressure
*listen little longer to be sure
acute pain
- short term, sudden onset
* dissipates after injury heals
chronic pain
- continues for 6 months or longer
* doesn’t stop when injury heals
stomatic pain
- ligaments
* bones
cutaneous pain
•lacerations
visceral pain
- abdomen
* thorax
radiating pain
•left arm pain w/ heart attack
referred pain
- liver pain in shoulder
* same nerve
intractable pain
- severe, constant pain that is not curable by any known means and which causes a bed or house-bound state and early death if not adequately treated
- treated with opioids and/or interventional procedures
neuropathic pain
•PNS or CNS
phantom pain
•missing body part
what to observe when inspecting pain
- guarding
- facial grimacing
- restlessness
- changes in vital signs
guarding
•trying to protect area
what to look for when palpating pain
- crepitation
* swelling
