MIDTERM Flashcards
1
Q
OPQRSTUV
A
Onset
Palliative (What helps and aggrevates)
Quality (How would you describe the pain)
Region: Where would you describe the pain to be
Severity: How would you rate this pain?
Treatment: What has worked in the past?
Understanding: Is the pain acceptable, intolerable
Values: Any more pain, emotional, spiritual etc.
2
Q
SBAR
A
Situation
Background
Assessment
Recommendations
3
Q
3 types of clinical reasoning modules
A
Diagnostic reasoning
Nursing process
Critical thinking
4
Q
Cue
A
a piece of information, sign or symptom, or lab data.
5
Q
diagnosis of health problems iswho’s job
A
in the realm of advance practice
NPs and physicians
6
Q
Nursing process
A
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
7
Q
First-level priority problems
A
emergent, life threatening, immediate respnose required
ABCDEF assessment
8
Q
Second level priority problems
A
Urgent, necessitating prompt intervention
Acute pain, abnormal results, mental status change
9
Q
Third level priority problems
A
Important, addressed after more urgent problems
Lack of knowledge, family coping, lack of activiity, rest
10
Q
What is a collaborative problem
A
Treatment invlovles multiple disciplines
11
Q
Relational approach to health assessment allows professionsal to approach nursing situations from waht perspective
A
A perspective of inquiry
12
Q
DARP charting stands for:
A
Data
Action
Response
Plan
13
Q
Communication skills
A
Unconditional positive regard
Empathy
Active listening
14
Q
Traps of interviewing
A
Providing false assurance or false reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Overusing professional jargon or casual language
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions
15
Q
Are notes a good idea during interview?
A
Impedes eye contact
Shifts attention away from patient
Interrupts patient’s narrative flow
Impedes observation of nonverbal behaviour
Can be threatening during discussion of sensitive issues
16
Q
LOTTAARRPP
A
Location
Onset
Type
Timing
Aggravating
Alleviating
Radiating
Related symptoms
Personal perception
Precipitating event
17
Q
Purpose of LOTTAARRPP
A
Describe any symptoms reported by an individual
18
Q
Health history questions
A
Childhood illnesses
Accidents or injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetrical history
Immunizations
Most recent examination date
Allergies
Current medications
Age and health or cause of death of blood relatives
Health of close family members
19
Q
Difference bw ADLS and IADLS
A
ADLS a patient’s self-care abilities in the area of bathing, dressing, toileting, eating, and walking
Instrumental activities of daily living: assess ability for independent living, such as housekeeping, shopping, cooking, doing laundry, using the phone, managing finances, nutrition, social relationships, self-concept, coping, and home environment.
20
Q
Skills of physical examination
A
inspection,
palpation,
percussion
auscultation
21
Q
What is the exception to the order of the physical examinatoini assessment
A
Abdominal assessment
22
Q
Which part of body is best for feeling temperature of patient
A
Back of hand
23
Q
Best part of body with which to discern vibration
A
Tip of fingers
24
Q
Purpose of percussion
A
Assess underlying structures
A trained ear can detect sounds that are characteristic of a solid or hollow structure and can be used to detect the location, size, and density of an underlying organ.
25
Percussion sound descriptions
Resonant
Hyperresonant
Tympany
Dull
Flat
26
What sort of things are observed in a general survey
Physical appearance
Body structure
Mobility
Behaviour (Dress, heigiene etc.)
27
Narrative Charting
charting reads like a story, may include assessments, interventions, and outcomes in chronological order. Often referred to as progress notes.
28
What does focus charting using DARP concerned abt?
centers on a patient’s concern, behavior, change in status, significant event. It includes data, analysis/action, response, plan
29
purpose of ISBARR
to prevent miscommunication and adverse patient events. This is used to organize information/data for verbal communication within the health care team (ie. Calls to physicians, nursing shift reports, patient transfers to other units). Critical assessment findings communicated in a structured manner ensure that team members are well aware of the patient status that requires an action response.
extra I is identify self and client
Extra R is repeat back for clarity
30
ABC
Appearance: what are they doing, behavior, posture/positioning, level of consciousness, ability to interact
Work of Breathing: listen for obvious sounds of abnormal breathing (those heard without a stethoscope) and look at their body position.
Circulation (colour): skin color, obvious bleeding.
DO NOT proceed with assessment if any abnormal findings within ABC assessment
31
ABCDE
Airway
Breathing
Circulation
Disability
Exposure
32
What is the focused examination?
performed after both the initial assessment and primary survey reveal the patient is stable enough for you to proceed with a thorough review of body systems
33
What is included in the initial assessment
Appearance
Work of Breathing
Circulation (color)
34
What is included in the primary survey (safety check)
A-B-C-D-E-F
Vital Signs
35
What is included in the focused physical examination
Body System(s)
Subjective & Objective Data
36
What is the order of assessments?
Initial Assessment
Primary survey
Focused Physical examination
Do not progress if anything is abnormal in any of the first assessments
37
Number one priority in ABCDE
A clear airway
38
Examples of airway interventions
Reposition – head tilt/chin lift or jaw thrust
Suction – secretions, emesis
Airway – adjunct, endotracheal intubation
39
What would be a concerning number of respirations?
>20 Respirations per minute
<12 Respirations per minute
40
Apnea
Not breathing for 20 seconds or more
41
SBO2 Sat should be
96 or higher on room air
42
Breathing interventions
Elevate head of bed or position of comfort
Apply oxygen – nasal prongs, face mask
Assist ventilation – bag-valve mask
43
Things to assess for circulation
Heart rate and rhythm
Quality of pulses
Skin color, temperature, capillary refill
Blood pressure
Signs of bleeding
Intravenous access
Urine output
44
Abnormal signs for circulation
HR <50 or >90
Absent or poor quality pulses
Skin pale, cyanotic, grey
Cap refill >3 sec
BP less than 90 systolic
Hemmorhage
Urine output <0.5 ml/kg/hr
45
circulation interventions
Chest compressions
Control of bleeding
IV access
Fluids, medications, blood transfusion
46
What is assessed regarding disability
AVPU/GCS
Pupil response
Blood glucose/dextrose
Pain
47
3 elements of a disability assessment
: level of consciousness, pain, and blood sugar level (dextrose) .
48
AVPU
is the patient alert,
or responds only to verbal stimulus,
painful stimulus,
or is unresponsive
49
GCS
Glasgow Coma Scale is a more detailed assessment and scoring of how your patient responds in these three categories: eye opening, motor response, verbal response. Score out of 15
50
Warning signs of a disability problem
Any decrease in level of consciousness
Change in pupil response – sluggish, non-reacting, unequal
Blood glucose < 4 mmol/L
Sudden or uncontrolled pain
51
What level of blood glucose is considered hypoglycemic
glucose less than 4 mmol/l is considered hypoglycemia and needs to be treated rapidly
52
Fastest way to check glucose levels
glucometer
53
dextrose
Low glucose levels
common cause of decreased LOC
54
Disability interventions
Attempt to elicit a response – verbal, then painful stimulus
If unresponsive, obtain help and check breathing and pulses, repeat vital signs
Administer glucose
Treat pain
55
What is often referred to as the 5th vital sign
Pain
56
What is entailed in the exposure assessment
Face and head
Torso (front and back)
Extremities
Skin
Temperature
Incontinence
57
Exposure abnormalities
Bleeding, burns, unusual markings
Petechiae, purpura
Temperature less than 36.1 or greater than 38.0 degrees
58
Petechiae and purpura
non-blanchable red or purplish rashes that may signal internal bleeding or a bleeding disorder
59
Exposure interventions
Control bleeding, investigate signs of abuse, maintain a normal temperature.
60
Full set of vital signs includes:
HR
BP
RR
SBO2
Temp
61
Abnormal vital signs
HR < 50 or >90
RR <8
BP systolic <90 or >180
Temp <36.0 or >38.0
O2 Sat <95%
62
Functions of the skin
Protection – waterproof, resilient; protection from physical, chemical, thermal, light wave injury.
Prevention of penetration – a barrier that keeps out micro-organisms, prevents loss of water and electrolytes.
Perception – sensory end organs for touch, pain, temperature, and pressure all reside in the skin.
Temperature regulation – sweat glands and subcutaneous insulation for heat dissipation and storage.
Identification – unique facial characteristics, hair, skin color, fingerprints.
Communication – face and body posture signal emotional states (ie. Blushing).
Wound repair – allows for cell replacement.
Absorption and excretion – some excretion of metabolic wastes (ie. Minerals, sugars, amino acids, cholesterol, uric acid, urea).
Production of vitamin D – UV light converts cholesterol into vitamin D on the surface of the skin.
63
Pruritis
= itching; the most common skin symptoms
64
Seborrhea
Oily
65
Xerosis
Dry
66
How does the aging process effect skin
Epidermis Flattens, thins (easier entry of microorganisms)
dermis experiences a loss of connective tissue (collagen) = risk of shearing and tearing.
- the subcutaneous layer decreases = less cushioning from physical injury
- decrease in amount of sweat and sebaceous glands = skin is dry, less thermoregulatory response.
- psychological impact of a loss of youthful appearance, linked to self-esteem
67
What aspects of skin are you palpating for
Thickness
Texture
Edema
Mobility and Turgor
Vascularity
Temperature
Moisture
68
When does clubbing of the nails occur
Nails can be a source of information on self-care ability/habits, and certain diseases. For example, clubbing of nails occurs with
69
ABCDE. rule for skin lesion examination
A: asymmetry
B: border irregularity
C: colour variation
D: diameter
E: elevation and enlargement
70
Stages of pressure ulcer
Stage 1 – intact skin appears red, but unbroken. Localized erythema, blanchable (turns light with pressure, then back to skin color).
Stage 2 – partial thickness, loss of epidermis +/- dermis. Looks like an abrasion or open blister.
Stage 3 – full-thickness, extends into the subcutaneous tissue. Looks like a crater, may see subcutaneous tissue.
Stage 4 – full-thickness, involves all skin layers and extends into supporting tissue; muscle, tendon, bone may be exposed, black or brown necrotic tissue (eschar).
71
What do non-blanchable rashes indicate?
may signal a bleeding disorder, such as thrombocytopenia (abnormal clotting) or septicemias (infection in the blood stream
72
Braden risk scale assesses
moisture, activity, mobility, nutrition, frictino and shear
low score is higher risk
73
Four phases of nociception
Transduction – a noxious stimuli is inflicted upon the individual.
Transmission – the impulse moves along the spinal cord to the brain, if not interrupted by the opioid receptors.
Perception – the noxious stimuli is interpreted as pain.
Modulation – the pain impulse may be slowed down by neurotransmitters that act like analgesia (ie. Serotonin, norepinephrine, endorphins, etc).
74
3 types of pain
Somatic = may be superficial (ie. Skin) or deep (ie. Muscles, tendons).
Visceral = internal organs (ie. Gallbladder, kidney, intestine, pancreas).
Neuropathic = caused by damage or disease of the somatosensory nervous system (ie. Spinal cord injury, infectious or metabolic diseases, medication-induced).
75
A consideration when assessing pain in children
children experience pain in the same way as adults but are not able to describe it in the same way
76
Most reliable indicator of a persons pain
self report
77
Initial pain assessment
Onset: When did the pain start?
Provocative or palliative: What makes your pain worse? Does anything make it better/relieved?
Quality of pain: Words to describe pain?
Region of body: Where? Does it radiate or move to other areas?
Severity: How do you rate the pain on an intensity scale?
Treatment and Timing of pain: What treatments have worked for you? Is it a constant, dull, or intermittent pain? Pain-free periods or changed over time?
Understanding of pain: What do you believe is causing the pain? Goal for comfort?
Values. Acceptable level of pain? Any other stressors or spiritual pain?
78
NVPS
Adult NonVerbal Pain Scale
judged on:
Face
Activity
Guarding
Phsyiology (VS)
Respiratory
0 - 2 (0 being normal, 2 being excessively abnormal)
79
Signs of an unconuscious patient being in pain
Grimacing, wincing, moaning, rigidity, arching, restlessness, shaking, pushing to indicate pain
Critical-Care Pain Observation Tool
80
Major two muscles of the neck
Sternomastoid – for head rotation and flexion
- Trapezius – moves the shoulders and extends/turns the head.
81
Thyroid Gland
important endocrine gland with a rich blood supply on either side of the trachea
responsible for cellular metabolism; normally not palpable behind the trachea.
82
Subjective data for the head
dizziness, headache, head injury, history
83
normocephalic
Normal size and shape of the head
84
Temporal artery may be palpated
Bw cheek bone and eye
85
What neck artery and how do you assess it?
Auscultate carotid artery before palpation (so not to dislodge plaque). Listen for a bruit (blowing, swishing sound) on both sides. Could indicate narrowed arteries
Do not assess both at same time
86
If trachea is not midline
May have an airway problem, intervene immediately
87
How many muscle attatch to eye
6
88
What tool do advanced nurses use to examine the ey?
opthalmoscope
89
Subjective data regarding eyes
Vision difficulty
Pain
Crossed eyes (When does this occur)
Redness or swelling
Watery Discharge
Ocular problems
Glasses or Contacts
Self Care behaviours
Medication
Vision Loss
90
Diplopia
Crossed eyes
91
Sudden onset of eye pain, blurred vision, floarers in visual field or loss of peripheral vision is what?
a medical emergency
92
PERRLA
Common eye exam performed by nurses in acute care settings
pupils are equal, round, react to light and accommodation
93
Normal Pupil size
3-5mm
94
Diopter
Unit of strength in the lenses of an ophthalmoscope
95
Some normal findings of the ocular fundus
- optic disc
- retinal vessels
- general background
- macula
96
How many posiitions of gaze must be checked to reveal any ocular muscle weaknesses?
6
97
Nystagmus
a fine oscillating movement around the iris, may indicate weakness or disease
98
Ptosis
drooping upper lid
99
Miosis
constriction of pupi
100
Mydriasis
dilation of pupil
101
Vertigo
inflammation of the semicircular canals of the inner ear that result in a spinning, whirling sensation.
102
What is the external ear also called
auricle or pinna
103
Subjective data for ears
Earaches
Infections
Discharge
Hearing loss
Enbironmental noise
Vertigo
Self care behaviours
104
What determines whether you have dry or wet ceremun
Genetics
105
Most common chronic condition in older adults - normal part of agin
Hearing loss
106
Cues of possible hearing loss
Frowning or straining to hear
Acting irritable or starteld when u raise your voice
Inappropriately loud voice
Flat monotonous tone
Garbelled. speech
107
60 60 rule reccomendation
No more than 60 minutes of listening at no more than 60% maximum volume in earbuds to prevent hearing damage
108
Position of ear during ear exam
Pull pinna up and back on adults or older children (pull pinna down on infants and < 3yrs of age).
109
Watery drainage out of ear canal following head trauma could indicate
CSF and therefore a skull fracture
110
Subjective questions regarding mouth and throat
Discharge, colds, sinus pain, trauma, allergies, altered smell, sores or lesions
sore throat, bleeding gums, toothaches, hoarseness, dysphagia
111
Epistaxis
Nosebleeds for >20 minutes is a medical emergency
112
Strategies for dealing with dysphagia
sitting in high fowler’s, remain upright for 30 min following meals, perform good oral hygiene, thickened fluids, take time to assist with feed, lessen distractions
113
Indicators of brain disfunctions
Partial or complete paralysis.
Muscle weakness.
Partial or complete loss of sensation.
Seizures.
Difficulty reading and writing.
Poor cognitive abilities.
Unexplained pain.
Decreased alertness.
Head injuries (falls)
Headaches
Dizziness/vertigo/fainting
Tremors
Weakness (usually one-sided)/paralysis
Incoordination
Numbness/tingling sensation
Dysphagia
Aphasia
Falling
Confusion
Visual disturbances
114
What does aging cause in relation to the brain?
Atrophe
115
Syncope
Temporary LOC
(Fainting)
116
Sizures
involuntary movements with altered consciousness.
117
Tremors
Tremors = involuntary movements (shaking, vibrating, trembling) while conscious.
118
Subjective brain quesitons
Incoordination
Numbness or Tingling Sensation
Difficulty Speaking or swallowing
Significant Past History
Environmental or Occupational Hazards
Head ache
Head Injury
Dizziness or Vertigo
Seizures
Tremors
Weakness
119
type of neuro assessment depends on ?
Your role and the sympotms being displayed by the patient
Screening neuro exam – health history in otherwise healthy patient
Complete neuro exam – neuro concerns, most detailed and thorough exam
Neuro re-check - those with deficits and require frequent rechecks
120
A change in ____ is the earliest and most sensitive index of change in neuro status
LOC
121
3 questions we ask patients to determine whether they ar ealert and oriented
Person (first, last name, DOB, occupation, names of others)
Place (building, city, province, country)
Time (date, month, year, day of week, season)
122
Increasing stimulus for impair LOC least to greatest
Calling of name
Light touch on patient’s arm
Vigorous shake of patient's shoulder
Pain applied (pinch nail bed, squeeze trapezius muscle, sternal rub)
123
Levles of consciousness
Alert
Lethargic: More than sleepy, multiple tries to wake up or loud verbal stimuli
Obtunded – severe drowsiness, may rouse for brief periods with repeated painful stimuli
Stupor – mostly unresponsive, will only rouse with vigorous repeated painful stimuli and will immediately lapse back into unresponsiveness
Coma – unresponsive, cannot be roused with any stimuli, eyes remain closed
Acute delirium – a fast-developing type of confusion, often caused by an illness or environmental factors that disrupt brain function
124
PERRL vs PERRLA
PERRL is routinely documented on all patients in the acute care setting as an indicator of neurological status. Does not always include “A” = accommodation (test for ability of eyes to focus more of an eye exam). So important to know your patient’s baseline status in case something changes.
125
Sudden, unilateral dilation and non-reactivity (pupil is “blown”) is a sign of
A rise in intercranial pressure
126
Motor movement of the face is assessed
bilaterally
127
Acronym for identifying a storke
Face
Arms
Slurred or jumbled speech
Time to call 911
128
Who is at risk for a stroke
CAD, cardiac failure, PAD, hypertension, smoker, diabetes, irregular cardiac rhythms, diet and nutrition, obesity, physical inactivity, history of TIA
129
Pronator drift
Often first sign of motor weakness
Suggests mild hemiparesis and lesion on opposite side
130
Muscle stregth grading scale regarding neuro testing?
0-5 (No contraction to normal contraction)
131
GCS amd what it assesses
Glasgow coma scale
Assesses 3 aspects
Eyes opening (PERRL)
Verbal response conversation appropriate, confused, inappropriate, incomprehensible, none.
Motor Response Obeys verbal command, localizes pain, withdraws, abnormal flexion, abnormal extension, none.
Score is 3-15
13-15= Mild impairment
9-12= Moderate impairment
3-8 = severe impairment or coma
132
When assessing a GCS scale, when would u intubate?
GCS less than 8
133
What is the Katz scale of independence in ADLs
Grading someone's independence
a 1 or 0 for the six categories of daily living (eating, dressing, bathing, continence, transferring, toileting)
134
Glaucoma
Group of eye disease causing vision problems through damaged optic nerve
135
Cerumen
Wax substance secreted by glands in external ear canal
136
Perforation
Hole that develops through wall of body organ
137
Supine
Lying on the back with face upward
138
Entropion
An inversion or turning inward of an edge; i.e margin of lower eyelid
139
Photophobia
Unusual intolerance of light
Occurs in measles, rubella, meingitis, and inflammatino of the eyes
140
Epiphora
Abnormal overflow of tears down the cheeks by excess excretion of tears or obstruction of lacrimal ducts
141
Conjunctivitis
Pink eye - inflammation of the conjunctiva from infection or allergies
142
Strabismus
Condition in which one eye is turned in another direction than the other
143
Blepharitis
Inflammatory swelling of one of the sebacous glands of theeylid
144
Vestibulor neuronitis or labyrinthitis
Inflammation of the inner ear may cause vertigo
145
Otitis edema
infection of the external auditory canal
146
VIsual firled
Area within where objects may be seen when the eye is fixed on something
147
Distortion
distortion of shapes
148
nyctalopia
night blindness
149
Exophthalamas proptosis
Protrusion of one or two eyes
150
nystagmus
involuntary eye movement appearing jerky
151
Tinnitus
Subjective ringing, buzzing, tinkling or hissing sound in the ear
152
