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NSG 316 > LS-316 Quizlet > Flashcards

LS-316 Quizlet Flashcards

1
Q

subjective data

A

what the person says about himself or herself during history taking

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2
Q

objective data

A

observed when inspecting, palpating, percussing, and auscultating during physical exam

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3
Q

Episodic or problem-centered database

A

For limited or short-term problems
Collect “mini” database, smaller scope and more focused than complete database
Concerns mainly one problem, one cue complex, or one body system
History and examination follow direction of presenting concern

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4
Q

follow up database

A

The status of any identified problems should be evaluated at regular and appropriate intervals.

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5
Q

emergency database

A

rapid collection of the database, often compiled concurrently with lifesaving measures

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6
Q

What does ADPIE stand for in the nursing process?

A

A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation

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7
Q

priority problem levels

A

1st level of priority
- emergency/life threatening, immediate
2nd level of priority
-next in urgency, requires attention
3rd level of priority
-important to health, but can be addressed after the more urgent problems are addressed

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8
Q

collaborative problems require what type of approach

A

treatment requires multiple disciplinaries

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9
Q

randomized clinical trials

A

-current and best clinical practice based research
-standards focus on systemic reviews

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10
Q

evidence-based practice

A

clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences

GOLD STANDARD of practice

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11
Q

Age-specific charts

A

focus on major risk factors specific for each age group based on lifestyle, health needs, and problems

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12
Q

General Survey

A

study of the whole person, covering the general health state and any obvious physical characteristics

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13
Q

ABCs

A

airway, breathing, circulation

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14
Q

HIPAA

A

Health Insurance Portability and Accountability Act of 1996
-protects clients medical records

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15
Q

comprehensive assessment

A

health history and complete physical examination, usually conducted when a patient first enters a health care setting; provides a baseline for comparing later assessment

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16
Q

Focused assessment

A

-identifies limited or short term problems
concerns mainly one person
performed in all settings

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17
Q

goals of cultural competence

A

-culturally appropriate, sensitive, competent, care

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18
Q

4 basic concepts of culture

A

learned, shared, adapted, dynamic

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19
Q

health related behaviors affected by religion

A

meditating
Exercising/physical fitness
Sleep habits
Vaccinations
Willingness to undergo physical examination
Pilgrimage
Truthfulness about how patient feels
Maintenance of family viability
Hoping for recovery
Coping with stress
Genetic screening and counseling
Living with a disability
Caring for children

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20
Q

culture

A

the enduring behaviors, ideas, attitudes, values, and traditions shared by a group of people and transmitted from one generation to the next

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21
Q

Transcultural expression of pain

A

-Expectations, manifestations, and management of pain are all embedded in a cultural context
-Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person
-Silent suffering has been identified as the most valued response to pain by health care professionals

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22
Q

the interview consist of

A

-subjective data collection
-patient perception of health
-first step in therapeutic relationship

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23
Q

rapport

A

A positive relationship

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24
Q

open-ended questions

A

questions that allow respondents to answer however they want

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25
Q

close ended

A

yes or no questions

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26
Q

Elements of the Interview Process

A
  • Nonverbal
  • Physical appearance
  • posture
  • gestures
  • facial expression
    -eye contact
  • voice
  • touch
  • closing the interview
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27
Q

external factors in an interview

A

-ensure privacy
-refuse interruptions
-physical environment
-dress
-tape and video recording

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28
Q

types of verbal responses

A

-empathy
-clarification
-confrontation
-interpretation
-explanation
-summary

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29
Q

IPPA

A

Inspection
Palpation
Percussion
Auscultation

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30
Q

Health History Sequence

A
  1. Biographic data
  2. Reason for seeking care
  3. Present health or history of present illness
  4. Past history
  5. Medication reconciliation
  6. Family history
  7. Review of systems
  8. Functional assessment or activities of daily living (ADLs)
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31
Q

characteristic of a reliable person

A

a reliable person always gives the same response when questions are rephrased or repeated later in the interview

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32
Q

PQRSTU

A

P: Provocative or palliative
Q: Quality or quantity
R: Region or radiation
S: Severity scale
T: Timing
U: Understand patient’s perception

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33
Q

past medical history

A

-Childhood illness
-Accidents or injuries
-Serious or chronic illnesses
-Hospitalizations
-Operations
-Obstetric history
-Immunizations
-Last examination date
-Allergies
-Current medications

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34
Q

Family History

A

-Age and health or cause of death of relatives
-Health of close family members
-Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and tuberculosis
-Family tree (genogram) to show this information clearly and concisely

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35
Q

Review of Systems (ROS)

A

-to evaluate the past and present health state of each body system
-to double-check in case any significant data were omitted in the present illness section
-and to evaluate health promotion practices.

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36
Q

ADLs

A

Activities of daily living such as eating, bathing, grooming, walking, and toileting

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37
Q

AADLs

A

Advanced Activities of Daily Living: Activities older adults perform as family member, member of society and community, including occupational and recreational activities

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38
Q

IADLs

A

Instrumental Activities of Daily Living, which define a patient’s functional independence; shopping, meal prep, laundry, finances, medication regimen

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39
Q

CAGE test

A

felt the need to Cut down on drinking?
Annoyed by people criticizing your drinking?
felt Guilty about your drinking?
need an Eye-opener in the morning?

you should know what each score does

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40
Q

functional status

A

a person’s actual performance of activities and tasks associated with current life roles

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41
Q

ADL instruments

A

Katz Index of Independence in ADL
Barthel Index
Functional Independence Measure (FIM)
Rapid Disability Rating Scale-2 (RDS-2)

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42
Q

IADLs instruments

A

-Lawtons instrumental activities of daily living
-OARS-IADL older American resources and services multidimensional functional assessment
-Direct assessment of functional abilities (DAFA)

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43
Q

AADLs instruments

A

Physical Performance Test (PPT)
Performance Activities of Daily Living (PADL)
Up and Go Test

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44
Q

altered cognition in older adults attributed to

A

-dementia
-delerium
-depression

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45
Q

Delerium

A

A state of temporary but acute mental confusion

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46
Q

Dementia

A

a slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes

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47
Q

Informal support

A

-Includes family and close long-time friends, and is usually provided free of charge
-Services provided include tasks such as shopping, bathing, feeding, and paying bills

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48
Q

formal support

A
  • Social service and health care delivery agencies such as home health care
  • Several studies conclude that presence of a caregiver is most important factor in discharge plan of older adults from an acute care hospital
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49
Q

what should all caregivers be screened for?

A

caregiver burden

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50
Q

signs of caregiver burnout

A

-multiple somatic complaints
-increased stress and anxiety
-social isolation
-depression
-weight loss

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51
Q

8 components of health history

A
  1. biological data
  2. source of history
  3. reason for seeking care
  4. present health or history of present illness
  5. Past health
  6. Family history
  7. review of systems
  8. Functional assessment including ADLs
52
Q

What senses will the examiner use to gather data during the physical examination?

A

sight, smell, touch, hearing

53
Q

inspection

A

general observation of the patient as a whole, progressing to specific body areas

54
Q

What does inspection require?

A

-good lighting
-adequate exposure
-occasional use of instruments

55
Q

Palpation

A

an examination technique in which the examiner’s hands are used to feel the texture, size, consistency, and location of certain body parts

56
Q

Different parts of hands used for assessing different factors

A

-Fingertips
best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps
-Fingers and thumbs
detection of position, shape, and consistency of an organ or mass
-Dorsa of hands and fingertips
best for determining temp because skin is thinner on palms
-Base of finger or ulnar surface of hand
best for vibration

57
Q

Do nurses ever do deep palpation?

A

No, the provider will perform when needed

58
Q

Percussion

A

tapping the person’s skin with short, sharp strokes to assess underlying structures

59
Q

Two methods of percussion

A

Direct, sometimes called immediate, the striking hand directly contacts body wall

Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on person’s skin

60
Q

Auscultation

A

Listening with a stethoscope

61
Q

Nociceptors

A

specialized nerve endings that detect painful sensations (CNS)

62
Q

somatic pain

A

Pain that originates from skeletal muscles, ligaments, or joints.

63
Q

breakthrough pain

A

pain restarts or escalates before next scheduled analgesic dose

64
Q

visceral pain

A

pain that originates from organs or smooth muscles

65
Q

deep somatic pain

A

comes from sources such as blood vessels, joints, tendons, muscles, and bone

66
Q

cutaneous pain

A

superficial pain usually involving the skin or subcutaneous tissue

67
Q

referred pain

A

the sensation of pain is experienced at a site other than the injured or diseased tissue

68
Q

4 phases of nociception

A
  1. Transduction
  2. Transmission
  3. Perception
  4. Modulation
69
Q

neuropathic pain

A

Indicates type of pain that does not adhere to typical phases inherent in nociceptive pain
ex. throbbing, burning, shooting, numb, electric shock like
stabbing, pines and needles

70
Q

chronic pain

A

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

71
Q

acute pain

A

short-term, self-limiting, often predictable trajectory; stops after injury heals

72
Q

types of chronic pain

A

Malignant (cancer-related) & nonmalignant (arthritis, low back pain, fibromyalgia)

73
Q

what does neuropathic pain indicate?

A

an abnormal processing of pain

74
Q

Do older adults feel less pain?

A

No, no evidence exist to suggest that older individuals perceive pain to a lesser degree or sensitivity is diminished

75
Q

the most common pain producing conditions for aging adults

A

-arthritis, osteoarthritis, osteoporosis
-peripheral vascular disease, peripheral neuropathies
-angina, chronic constipation, cancer

76
Q

What type of data is pain

A

subjective data, and the most reliable indicator of pain

77
Q

Initial Pain Assessment

A

asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors

78
Q

types of pain scales

A

1.Numerical
-rate pain on scale of 1-10
2.Verbal
-verbal descriptor of pain
3.Visual Analogue
mark intensity of pain on a horizontal scale from no pain to worst pain

79
Q

Nonverbal Behaviors of Pain

A

-When individual cannot verbally communicate pain, you can (to a limited extent) identify pain using behavioral cues
-Recall that individuals react to painful stimuli with a wide variety of behaviors
-Behaviors are influenced by a wide variety of factors, including nature of pain (acute versus chronic), age, and cultural and gender expectations

80
Q

nonverbal behaviors of acute pain`

A
  • guarding
  • grimacing
  • vocalizations (moaning)
  • agitation, restlessness
  • stillness
  • diaphoresis
  • change in vital signs
81
Q

nonverbal behaviors of chronic pain

A
  • bracing
  • rubbing
  • diminished activity
  • sighing
  • change in appetite
82
Q

Is pain a normal part of aging?

A

No, older people often suffer from chronic conditions such as arthritis, cancer, and bone fractures that are associated with pain

Pain in the older adult is prevalent however

83
Q

Two layers of skin

A

epidermis and dermis

84
Q

Epidermis

A

-outer highly differentiated layer
-basal cell layer forms new skin cells
-outer horny cell layer of dead keratinized cells

85
Q

Dermis

A

-Inner supportive layer
-elastic tissue

86
Q

What is under the epidermis and dermis?

A

subcutaneous layer of adipose tissue

87
Q

sweat glands

A

important for fluid balance and thermoregulation
-eccrine glands
-apocrine glands

88
Q

Skin functions

A

Protection from environment
Prevents penetration
Perception
Temperature regulation
Identification
Communication
Wound repair
Absorption and excretion
Production of vitamin D

89
Q

Skin elasticity in aging adult

A

looses elasticity, skin folds and sags

90
Q

Sweat and sebaceous glands in the aging adult

A

Decrease in number and function, leaving skin dry

91
Q

senile purpura

A

discoloration due to increasing capillary fragility (occur in aging adult)

92
Q

Factor that affect wound healing in aging adults

A

cell replacement is slower and wound healing is delayed

93
Q

hair matrix in the aging adult

A

Functioning melanocytes decrease, leading to gray fine hair

94
Q

Subjective Data Health History Questions

A

Past history of skin disease, allergies, hives, psoriasis, or eczema?
Change in pigmentation or color, size, shape, tenderness?
Excessive dryness or moisture?
Pruritus or skin itching?
Excessive bruising?
Rash or lesions?
Medications: prescription and over-the-counter?
Hair loss?
Change in nails’ shape, color, or brittleness?
Environmental or occupational hazards?
Self-care behaviors?

95
Q

complete physical examination

A

-Skin assessment integrated throughout examination
-Scrutinize the outer skin surface first before you concentrate on underlying structures
-Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly
-These areas are dark, warm, and moist and provide perfect conditions for irritation or infection
-Always inspect feet, toenails, and between toes

96
Q

what does warm skin suggest?

A

normal circulatory status

97
Q

diaphoresis

A

excessive sweating

98
Q

what is a bruise?

A

A rupture of blood vessels cells

99
Q

What is the concern with multiple bruises at different stages of healing?

A

Abuse

100
Q

edema

A

Abnormal accumulation of fluid in interstitial spaces of tissues.

101
Q

Scale to Grade Pitting Edema

A

-1+ mild pitting, slight indentation, no
perceptible swelling in the leg
-2+ moderate pitting, indentation subsides
rapidly
-3+ deep pitting, indention remains for a
short time, leg looks swollen
-4+ very deep pitting, indentation lasts a
long time, leg is grossly swollen and distorted

102
Q

Lesions

A

areas of tissue that have been pathologically altered by injury, wound, or infection

103
Q

What to note with lesions

A

-color
-elevation
-pattern or shape
-size
-location and distribution on body
-any exudate (note color and odor)

104
Q

Woodlight examination

A
  • use of a light (ultraviolet light filtered through special glass) to detect fluorescing lesions
105
Q

what to inspect with hair

A

color
texture
distribution
lesions

106
Q

what angle should finger nails be at

A

roughly 160 degrees

107
Q

clubbing of nails

A

deformity of fingers and fingernails associated with
underlying medical conditions or diseases that cause the finger tissue to increase and nails to curve downward (hypoxia)

108
Q

capillary refill

A

depress the nail edge to blanch and then release, noting the return of color in 1-2 seconds

109
Q

What does capillary refill indicate?

A

status of peripheral circulation

110
Q

ABCDEF skin assessment

A

A: asymmetry
B: border irregularity
C: color variations
D: diameter greater than 6 mm
E: elevation or evolution
F: funny looking—”ugly duckling” —different from others

111
Q

jaundice

A

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood

112
Q

rubor

A

redness

113
Q

flushing

A

reddening of the face and neck as a result of increased bood flow

114
Q

cyanosis

A

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

115
Q

Types of lesions

A

primary, secondary, vascular

116
Q

types of debris on skin surface

A

crust
scales

117
Q

hemangiomas

A

Port-wine stain (nevus flammeus)
Strawberry mark (immature hemangioma)
Cavernous hemangioma (mature)

118
Q

Telangiectasia

A

Spider or star angioma
Venous lake

119
Q

purpuric lesions

A

petechiae and purpura

120
Q

Lesions caused by trauma or abuse

A

Pattern injury
Hematoma
Contusion (bruise)

121
Q

pressure ulcer

A

any lesion caused by unrelieved pressure that results in damage to underlying tissue

122
Q

stethoscope uses

A

Bell: is typically used for detecting low-frequency sounds, such as certain types of murmurs or vascular sounds
Diaphragm: is suitable for detecting high-frequency sounds, including normal heart sounds, lung sounds, and bowel sounds.

123
Q

when should you assess painful areas?

A

last

124
Q

SBAR

A

Situation
Background
Assessment
Recommendation

Usually used in a hand-off report between shifts and when speaking with the provider

125
Q

SOAP

A

Subjective
Objective
Assessment
Plan

NSG 316 (9 decks)

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