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Health Assessment > History taking/Interview/Hand Washing/Vital Signs Lecture (unit 1) > Flashcards

History taking/Interview/Hand Washing/Vital Signs Lecture (unit 1) Flashcards

1
Q

health

A
  • absence of disease
  • having good quality of life
  • disease prevention
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2
Q

biomedical model of health

A

•absence of disease

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3
Q

wellness model of health

A
  • dynamic process

* move toward optimal functioning

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4
Q

holistic health

A

•mind, body, spirit, and environment interdependent

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5
Q

health history

A
  • asking pt/family ???

* past medical records

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6
Q

physical assessment

A

•using systematic, organized head-toe exam

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7
Q

components of health assessment

A

•health history
•physical assessment
•collecting data
*basis for developing a nursing plan of care for pt

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8
Q

nursing process in HA

A
  • assessment
  • nursing diagnosis
  • planning/intervention
  • evaluation
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9
Q

assessment

A

•collect pt data and think critically

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10
Q

nursing diagnosis

A

•name/prioritize issues

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11
Q

planning/intervention

A

•develop a plan for each issue

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12
Q

evaluation

A

•reassess effectiveness of interventions

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13
Q

health history interview

A
  • gives subjective data- what pt says

* first and most important part of HA

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14
Q

phases of interview

A
  1. ) pre-interview
  2. ) introduction
  3. ) working phase
  4. ) termination
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15
Q

pre-interview

A
  • review pt record/bedside report
  • adjust environment for pt comfort (privacy)
  • assessment of your own behavior/appearance
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16
Q

introduction

A
  • greet patient/establish rapport

* establish agenda- purpose for visit

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17
Q

working phase

A
  • invite patient’s story- listen
  • identify/respond to pt emotional cues
  • expand/clarify pt story
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18
Q

termination

A
  • summarize important points

* discuss plan

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19
Q

establishing agenda

A
  • ask about chief complaints

* use open-ended questions

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20
Q

expanding/clarifying story

A
  • guide pt to focus on chief issue
  • have pt elaborate on significant issues
  • use 7 attributes of a symptom
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21
Q

therapeutic communication

A
  • exchange of info that conveys meaning
  • listen w/o interrupting
  • show empathy
  • eye contact
  • take brief notes- keep attention on pt
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22
Q

interviewing acutely ill

A
  • ask abbreviated ??? (what hurts?)
  • determine cause of visit
  • prioritize
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23
Q

interviewing someone under the influence

A
  • simple direct ???s
  • avoid confrontation
  • determine last use of drug
  • get full history when sober
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24
Q

interviewing sexually aggressive pts

A
  • make clear that you are health care professional

* be assertive and don’t tolerate inappropriate behaviors

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25
Q

how to avoid personal questions

A
  • provide brief info if appropriate

* direct ??? back to pt

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26
Q

interviewing angry pts

A
  • don’t personalize the anger

* address the pts anger first with open ended ???s

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27
Q

interviewing pts with anxiety

A
  • normal response to illness

* be empathetic and compassionate

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28
Q

interviewing hearing impaired

A
  • ask preferred method of comm.

* get interpreter if necessary

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29
Q

interviewing crying person

A
  • let them express feelings
  • offer tissue
  • wait for crying to subside to talk
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30
Q

interviewing elderly

A
  • always use last name- Mr. last name
  • don’t rush them
  • give longer response time
  • consider physical limitations
  • touch is very important
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31
Q

responses to open ended question response

A
  • facilitation
  • silence
  • reflection
  • empathy
  • clarification
  • confrontation
  • interpretation- inference
  • explanation- facts
  • summary
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32
Q

facilitation

A
  • encourages person to say more
  • nodding
  • “yes”, “go on”
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33
Q

reflection

A

•echoing pts words

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34
Q

empathy

A

•recognize feeling and put it in words

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35
Q

clarification

A

•”tell me what you mean by that”

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36
Q

confrontation

A

•”you tell me you don’t hurt, but when I touch here, you flinch”

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37
Q

traps of interviewing (10)

A
  1. ) false assurance/reassurance
  2. ) giving unwanted advice
  3. ) using authority
  4. ) using avoidance language
  5. ) engaging in distancing
  6. ) using professional jargon
  7. ) using leading/biased ???s
  8. ) talking too much
  9. ) interrupting
  10. ) asking “why” ???s
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38
Q

avoiding false reassurance

A
  • “you seem worried about ___”

* offer to listen to anxieties/sit for moment

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39
Q

avoiding using authority

A
  • don’t say dr. knows best
  • state there are risks/benefits
  • remide pt that decision is ultimately theirs
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40
Q

avoiding using avoidance language

A
  • don’t step around the truth

* state facts

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41
Q

aspects of nonverbal communication

A
  • appearance
  • gestures
  • posture
  • facial expressions
  • eye contact
  • voice
  • touch
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42
Q

health history

A
  • pt provides subjective info about their past/present health
  • primary data source
  • key is reliability- pt give same responses later?
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43
Q

secondary data source

A
  • charts

* family

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44
Q

categories of health history

A
  • biographical data
  • reason for seeking care
  • history of present condition
  • past history
  • family history
  • review of symptoms
  • health patterns
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45
Q

biographical data

A

•name, age, occupation, DOB, phone #, religion, ethnicity, etc

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46
Q

reason for seeking care

A
  • describes reason for visit
  • record 1-2 symptoms and duration
  • use quotes
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47
Q

sign

A

•objective

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48
Q

symptom

A
  • subjective

* written in “”

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49
Q

history for present illness

A

•complete description of present illness

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50
Q

OLD CART

A 
Onset
Location
Duration
Characteristic symptoms
Associated manifestations
Relieving/exacerbating factors
Treatments
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51
Q

provocative/palliative

A
  • what brings it on

* what makes it better

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52
Q

quality

A

•how intense

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53
Q

region

A
  • where

* does it spread

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54
Q

severity

A

•pain skill

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55
Q

past history

A
  • allergies/what happens?
  • medication (rx and over counter)
  • childhood/adult documented illness
  • surgeries
  • OB history
  • health maintenance behaviors
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56
Q

health maintenance behaviors

A
  • immunizations
  • screenings
  • safety measures
  • risk factors
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57
Q

review of symptoms

A
  • 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)
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58
Q

health patterns

A
  • values/beliefs
  • sleep
  • exercise
  • nutrition
  • relationships
  • stress
  • family violence
  • sensitive topics
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59
Q

functional assessment

A

•measures self care ability related to

  • activities of daily living (ADLs)
  • activities needed for independent living
  • personal habits (drugs/alcohol-ETOH/tobacco-PPD/exercise)
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60
Q

activities of daily living (ADLs)

A
  • bathing
  • dressing
  • eating
  • walking
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61
Q

activities needed for independent living

A
  • housekeeping
  • cooking/cleaning
  • finances
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62
Q

standard precautions

A

•set of principles assuming that all blood, body fluids, secretions, excretions, non-intact skin, and mucus membranes can possibly transmit pathogens

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63
Q

most important way to prevent spread of infection

A

•hand washing

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64
Q

nosocomial infection

A
  • infection that has been acquired in a health care setting

* HAI- hospital acquired infection

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65
Q

when to wash hands with soap

A
  • 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
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66
Q

when to perform physical assessment

A
  • on admission
  • ongoing basis
  • accepting responsibility for pt
  • pt status changes
  • evaluating effectiveness of interventions
67
Q

preparing for an exam (5)

A
  1. ) reflect on you approach
  2. ) adjust environment
  3. ) make pt comfortable
  4. ) gather equipment
  5. ) choose systematic head to toe sequence
68
Q

reflecting on approach

A
  • 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
69
Q

adjust the environment

A
  • avoid awkward positions- adjust bed height
  • good lighting
  • close curtain
  • quiet (turn tv down)
70
Q

make pt comfortable

A
  • keep informed
  • privacy
  • draping to visualize one area at a time
  • pay attention to facial expressions
71
Q

order of examination (except abdomen)

A
  • inspection
  • palpation
  • percussion
  • auscultation
72
Q

order of examination abdomen

A
  • inspection
  • auscultation
  • percussion
  • palpation
73
Q

inspection

A

•concentrated watching
•always comes first
•look for symmetry
*most important part of exam

74
Q

palpation

A
  • touching pt to assess

* applying tactile pressure from palmar fingers to assess

75
Q

palpation w/ fingertips

A

•texture, swelling, pulsation, masses

76
Q

grasping palpation

A

•position, shape, consistency, attachment

77
Q

dorsal surface of hand palpation

A

•temperature

78
Q

ball of hand/base of fingers palpation

A

•vibrations

79
Q

light palpation of abdomen

A
  • slow
  • systematic
  • detects surface/muscle characteristics
  • be gentle w/ warm hangings
80
Q

deep (bimanual) palpation

A
  • using both hands
  • getting at deeper organs beneath muscle
  • liver, kidney
81
Q

perpendicular lighting

A
  • light source directly over area

* light on bed over pt

82
Q

tangental lighting

A

•lighting that comes from the side
•shows shadows that can tell abnormal elevation/indentation
•utilized when examining jugular vein
*best type of lighting

83
Q

percussion

A
  • 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
84
Q

purpose of percussion

A
  • helps determine if increased density of tissue
  • helps determine increased/decreased air beneath surface
  • helps detect air, fluid, or solid mass
85
Q

how to percuss

A
  • 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

86
Q

more dense the organ

A

•the duller the sound

87
Q

resonant sound

A
  • air filled

* Ex: lungs

88
Q

tympany

A
  • hollow organ sound

* Ex: stomach

89
Q

dull sound

A
  • over denser organs

* Ex: liver

90
Q

flat sound

A
  • no air

* Ex: bone

91
Q

auscultation

A
  • Detect characteristics of heart, lung, bowel sounds, and turbulent blood flow
  • don’t listen through clothing
  • avoid touching tubing
  • avoid friction/wet hair
92
Q

diaphragm of stethoscope

A
  • High pitched
  • Breath, bowel, normal heart sounds
  • Held firmly: leave a slight ring
93
Q

bell of stethoscope

A
  • Soft, low pitched sounds
  • Extra heart sounds, murmurs
  • Held lightly
94
Q

using stethoscope

A
  • 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
95
Q

head to toe sequence (10)

A
  1. ) general survey
  2. ) vital signs
  3. ) skin
  4. ) HEENT- head, neck, eyes, ears, nose, throat
  5. ) posterior/anterior thorax/lungs
  6. ) breasts, axillae
  7. ) cardiovascular
  8. ) abdomen
  9. ) lower extremities and circulation
  10. ) nervous and musculoskeletal
96
Q

general survey

A
  • objective observation of pt

* all data gathered at first encounter and continues throughout interaction

97
Q

data you should gather through general survey (5)

A
  1. ) physical appearance
  2. ) state of health
  3. ) grooming
  4. ) mobility
  5. ) behavior
98
Q

apparent state of health

A
  • look age
  • look ill
  • skin color
  • odor
  • facial expressions
  • posture
  • speech
  • mood
  • symmetry
  • motor activity
  • signs of distress
99
Q

level of consciousness

A
  • LOC

* awake/alert

100
Q

measurement during general survey

A

•weight and height

101
Q

influences on temperature

A 
*hypothalamus controls
•diurnal cycle (highest 8pm-12am)
•menstrual cycle
•exercise
•age
•stress
•illness
102
Q

normal resting temp

A
  • 37 C

* 98.6 F

103
Q

normal rage of temp

A
  • 35.8-37.3 C

* 96.4-99.1 F

104
Q

oral temp

A

•under tongue on side in posterior pockets
•delay 10-15 min if just ate/drank/smoked
*most common

105
Q

rectal temp

A
  • insert 3-4 cm in anal canal toward umbilicus

* not used often b/c of health risks

106
Q

tympanic temp

A

•less accurate measurement

107
Q

apical pulse

A
  • central pulse located over apex of heart

* reflects HR

108
Q

peripheral pulse

A
  • rhythmic expansion of an artery that is palpated

* reflects HR and adequacy of circulation to extremity

109
Q

pulse deficit

A
  • difference b/t apical and peripheral pulse rate

* apical-radial

110
Q

stroke volume

A
  • amount of blood that exits LV during each ctx

* pressure wave in arteries

111
Q

cardiac output

A
  • volume of blood pumped from heart in one min

* SVxHR

112
Q

heart rate

A
  • bpm
  • decreases with age- newborn 120 bpm
  • affected by age, gender, circadian rhythm, blood volume, body temp, exercise, stress, meds, etc
113
Q

Tachycardia

A

•more than 100 bpm

114
Q

Bradycardia

A

•less than 60 bpm

115
Q

when to take apical pulse

A
  • 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
116
Q

heart rhythm

A
  • regularity of beats

* how even is the tempo

117
Q

Sinus arrhythmia

A

•during inspiration HR increases

118
Q

hypervolemia

A
  • high blood volume
  • pulse full; bounding
  • HR may increase
  • Ex: too many fluids
119
Q

hypovolemia

A
  • low blood volume
  • pulse weak or thready
  • rade increases to transport more O2
  • Ex: bleeding inside
120
Q

HR increases when…

A

•blood volume decreases

121
Q

0 force

A

•absent pulse

122
Q

1+ force

A

•weak/thready pulse

123
Q

2+ force

A

•normal pulse

124
Q

3+/4+ force

A

•full; bounding

125
Q

artery elasticity

A

•feels springy when taking pulse

126
Q

taking pulse in child under 2

A
  • take apical

* record for min

127
Q

taking pulse in child > 2

A

•radial x 1 min

128
Q

taking adult pulse

A
  • radial x 30 sec (unless abnormal)

* if irregular, determine pulse deficit- RECORD FOR MIN

129
Q

what to pay attention to when taking pulse (3)

A
  1. ) rate
  2. ) rhythm
  3. ) force/elasticity
130
Q

recording respirations

A
  • do secretly- finish counting pulse but pretend still counting while counting resp. rate
  • count for 30 sec unless irregular
131
Q

normal respiratory rate infant

A

•30-80 bpm

132
Q

normal respiratory rate adult

A

•12-20 bpm

133
Q

blood pressure

A
  • force of blood against arterial wall

* normal is 120/80

134
Q

systolic pressure

A

•max on ctx of L ventricle

135
Q

diastolic (DP)

A

•pressure during resting phase of cardiac cycle

136
Q

pulse pressure (PP)

A
  • SP-DP

* tends to increase w/ age

137
Q

mean arterial pressure

A
  • pressure average in arteries

* pressure forcing blood into tissues

138
Q

BP range

A

•90/60-139/89

139
Q

physiologic factors controlling BP

A
  • cardiac output
  • peripheral vascular resistance
  • vol. circulating blood
  • viscosity
  • elasticity
140
Q

peripheral vascular resistance

A
  • how much resistance heart has to push against during contraction
  • BP = CO x PVR
  • higher if have narrow arteries
141
Q

what influences blood viscosity

A
  • # RBCs

* glucose levels

142
Q

sphygmomanometer measurement

A
  • W = 40% arm circumference

* L = 80% arm circumference

143
Q

using too small BP cuff

A

•false high reading

144
Q

using too large BP cuff

A

•false low reading

145
Q

positioning pt for BP reading

A
  • 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
146
Q

steps of taking BP

A
  1. ) palpate brachial artery and place bell over
  2. ) rapidly inflate until pulse is obliterated
  3. ) slowly deflate 2 mmHg/beat
  4. ) listen for Korotkoff’s sounds
  5. ) read gauge at first sound- systolic
  6. ) read gauge at last sound- diastolic
  7. ) document systolic/diastolic and position of pt
147
Q

osculatory gap

A

• 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

148
Q

estimating systolic pressure

A
  1. ) palpate radial artery
  2. ) blow cuff until can’t palpate anymore
    * blow cuff 20-30 mmHg higher than estimated systolic
149
Q

Korotkoff sound I

A

•systolic pressure

150
Q

Korotkoff IV sound

A

•muffling of sounds

151
Q

Korotkoff V sound

A

•when sounds disappear
•diastolic pressure
*listen little longer to be sure

152
Q

acute pain

A
  • short term, sudden onset

* dissipates after injury heals

153
Q

chronic pain

A
  • continues for 6 months or longer

* doesn’t stop when injury heals

154
Q

stomatic pain

A
  • ligaments

* bones

155
Q

cutaneous pain

A

•lacerations

156
Q

visceral pain

A
  • abdomen

* thorax

157
Q

radiating pain

A

•left arm pain w/ heart attack

158
Q

referred pain

A
  • liver pain in shoulder

* same nerve

159
Q

intractable pain

A
  • 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
160
Q

neuropathic pain

A

•PNS or CNS

161
Q

phantom pain

A

•missing body part

162
Q

what to observe when inspecting pain

A
  • guarding
  • facial grimacing
  • restlessness
  • changes in vital signs
163
Q

guarding

A

•trying to protect area

164
Q

what to look for when palpating pain

A
  • crepitation

* swelling

Health Assessment (8 decks)

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