LS-316 Quizlet Flashcards
subjective data
what the person says about himself or herself during history taking
objective data
observed when inspecting, palpating, percussing, and auscultating during physical exam
Episodic or problem-centered database
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
follow up database
The status of any identified problems should be evaluated at regular and appropriate intervals.
emergency database
rapid collection of the database, often compiled concurrently with lifesaving measures
What does ADPIE stand for in the nursing process?
A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
priority problem levels
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
collaborative problems require what type of approach
treatment requires multiple disciplinaries
randomized clinical trials
-current and best clinical practice based research
-standards focus on systemic reviews
evidence-based practice
clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences
GOLD STANDARD of practice
Age-specific charts
focus on major risk factors specific for each age group based on lifestyle, health needs, and problems
General Survey
study of the whole person, covering the general health state and any obvious physical characteristics
ABCs
airway, breathing, circulation
HIPAA
Health Insurance Portability and Accountability Act of 1996
-protects clients medical records
comprehensive assessment
health history and complete physical examination, usually conducted when a patient first enters a health care setting; provides a baseline for comparing later assessment
Focused assessment
-identifies limited or short term problems
concerns mainly one person
performed in all settings
goals of cultural competence
-culturally appropriate, sensitive, competent, care
4 basic concepts of culture
learned, shared, adapted, dynamic
health related behaviors affected by religion
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
culture
the enduring behaviors, ideas, attitudes, values, and traditions shared by a group of people and transmitted from one generation to the next
Transcultural expression of pain
-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
the interview consist of
-subjective data collection
-patient perception of health
-first step in therapeutic relationship
rapport
A positive relationship
open-ended questions
questions that allow respondents to answer however they want
close ended
yes or no questions
Elements of the Interview Process
- Nonverbal
- Physical appearance
- posture
- gestures
- facial expression
-eye contact - voice
- touch
- closing the interview
external factors in an interview
-ensure privacy
-refuse interruptions
-physical environment
-dress
-tape and video recording
types of verbal responses
-empathy
-clarification
-confrontation
-interpretation
-explanation
-summary
IPPA
Inspection
Palpation
Percussion
Auscultation
Health History Sequence
- Biographic data
- Reason for seeking care
- Present health or history of present illness
- Past history
- Medication reconciliation
- Family history
- Review of systems
- Functional assessment or activities of daily living (ADLs)
characteristic of a reliable person
a reliable person always gives the same response when questions are rephrased or repeated later in the interview
PQRSTU
P: Provocative or palliative
Q: Quality or quantity
R: Region or radiation
S: Severity scale
T: Timing
U: Understand patient’s perception
past medical history
-Childhood illness
-Accidents or injuries
-Serious or chronic illnesses
-Hospitalizations
-Operations
-Obstetric history
-Immunizations
-Last examination date
-Allergies
-Current medications
Family History
-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
Review of Systems (ROS)
-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.
ADLs
Activities of daily living such as eating, bathing, grooming, walking, and toileting
AADLs
Advanced Activities of Daily Living: Activities older adults perform as family member, member of society and community, including occupational and recreational activities
IADLs
Instrumental Activities of Daily Living, which define a patient’s functional independence; shopping, meal prep, laundry, finances, medication regimen
CAGE test
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
functional status
a person’s actual performance of activities and tasks associated with current life roles
ADL instruments
Katz Index of Independence in ADL
Barthel Index
Functional Independence Measure (FIM)
Rapid Disability Rating Scale-2 (RDS-2)
IADLs instruments
-Lawtons instrumental activities of daily living
-OARS-IADL older American resources and services multidimensional functional assessment
-Direct assessment of functional abilities (DAFA)
AADLs instruments
Physical Performance Test (PPT)
Performance Activities of Daily Living (PADL)
Up and Go Test
altered cognition in older adults attributed to
-dementia
-delerium
-depression
Delerium
A state of temporary but acute mental confusion
Dementia
a slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes
Informal support
-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
formal support
- 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
what should all caregivers be screened for?
caregiver burden
signs of caregiver burnout
-multiple somatic complaints
-increased stress and anxiety
-social isolation
-depression
-weight loss
8 components of health history
- biological data
- source of history
- reason for seeking care
- present health or history of present illness
- Past health
- Family history
- review of systems
- Functional assessment including ADLs
What senses will the examiner use to gather data during the physical examination?
sight, smell, touch, hearing
inspection
general observation of the patient as a whole, progressing to specific body areas
What does inspection require?
-good lighting
-adequate exposure
-occasional use of instruments
Palpation
an examination technique in which the examiner’s hands are used to feel the texture, size, consistency, and location of certain body parts
Different parts of hands used for assessing different factors
-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
Do nurses ever do deep palpation?
No, the provider will perform when needed
Percussion
tapping the person’s skin with short, sharp strokes to assess underlying structures
Two methods of percussion
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
Auscultation
Listening with a stethoscope
Nociceptors
specialized nerve endings that detect painful sensations (CNS)
somatic pain
Pain that originates from skeletal muscles, ligaments, or joints.
breakthrough pain
pain restarts or escalates before next scheduled analgesic dose
visceral pain
pain that originates from organs or smooth muscles
deep somatic pain
comes from sources such as blood vessels, joints, tendons, muscles, and bone
cutaneous pain
superficial pain usually involving the skin or subcutaneous tissue
referred pain
the sensation of pain is experienced at a site other than the injured or diseased tissue
4 phases of nociception
- Transduction
- Transmission
- Perception
- Modulation
neuropathic pain
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
chronic pain
episode of pain that lasts for 6 months or longer; may be intermittent or continuous
acute pain
short-term, self-limiting, often predictable trajectory; stops after injury heals
types of chronic pain
Malignant (cancer-related) & nonmalignant (arthritis, low back pain, fibromyalgia)
what does neuropathic pain indicate?
an abnormal processing of pain
Do older adults feel less pain?
No, no evidence exist to suggest that older individuals perceive pain to a lesser degree or sensitivity is diminished
the most common pain producing conditions for aging adults
-arthritis, osteoarthritis, osteoporosis
-peripheral vascular disease, peripheral neuropathies
-angina, chronic constipation, cancer
What type of data is pain
subjective data, and the most reliable indicator of pain
Initial Pain Assessment
asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors
types of pain scales
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
Nonverbal Behaviors of Pain
-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
nonverbal behaviors of acute pain`
- guarding
- grimacing
- vocalizations (moaning)
- agitation, restlessness
- stillness
- diaphoresis
- change in vital signs
nonverbal behaviors of chronic pain
- bracing
- rubbing
- diminished activity
- sighing
- change in appetite
Is pain a normal part of aging?
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
Two layers of skin
epidermis and dermis
Epidermis
-outer highly differentiated layer
-basal cell layer forms new skin cells
-outer horny cell layer of dead keratinized cells
Dermis
-Inner supportive layer
-elastic tissue
What is under the epidermis and dermis?
subcutaneous layer of adipose tissue
sweat glands
important for fluid balance and thermoregulation
-eccrine glands
-apocrine glands
Skin functions
Protection from environment
Prevents penetration
Perception
Temperature regulation
Identification
Communication
Wound repair
Absorption and excretion
Production of vitamin D
Skin elasticity in aging adult
looses elasticity, skin folds and sags
Sweat and sebaceous glands in the aging adult
Decrease in number and function, leaving skin dry
senile purpura
discoloration due to increasing capillary fragility (occur in aging adult)
Factor that affect wound healing in aging adults
cell replacement is slower and wound healing is delayed
hair matrix in the aging adult
Functioning melanocytes decrease, leading to gray fine hair
Subjective Data Health History Questions
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?
complete physical examination
-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
what does warm skin suggest?
normal circulatory status
diaphoresis
excessive sweating
what is a bruise?
A rupture of blood vessels cells
What is the concern with multiple bruises at different stages of healing?
Abuse
edema
Abnormal accumulation of fluid in interstitial spaces of tissues.
Scale to Grade Pitting Edema
-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
Lesions
areas of tissue that have been pathologically altered by injury, wound, or infection
What to note with lesions
-color
-elevation
-pattern or shape
-size
-location and distribution on body
-any exudate (note color and odor)
Woodlight examination
- use of a light (ultraviolet light filtered through special glass) to detect fluorescing lesions
what to inspect with hair
color
texture
distribution
lesions
what angle should finger nails be at
roughly 160 degrees
clubbing of nails
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)
capillary refill
depress the nail edge to blanch and then release, noting the return of color in 1-2 seconds
What does capillary refill indicate?
status of peripheral circulation
ABCDEF skin assessment
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
jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood
rubor
redness
flushing
reddening of the face and neck as a result of increased bood flow
cyanosis
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
Types of lesions
primary, secondary, vascular
types of debris on skin surface
crust
scales
hemangiomas
Port-wine stain (nevus flammeus)
Strawberry mark (immature hemangioma)
Cavernous hemangioma (mature)
Telangiectasia
Spider or star angioma
Venous lake
purpuric lesions
petechiae and purpura
Lesions caused by trauma or abuse
Pattern injury
Hematoma
Contusion (bruise)
pressure ulcer
any lesion caused by unrelieved pressure that results in damage to underlying tissue
stethoscope uses
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.
when should you assess painful areas?
last
SBAR
Situation
Background
Assessment
Recommendation
Usually used in a hand-off report between shifts and when speaking with the provider
SOAP
Subjective
Objective
Assessment
Plan
