MIDTERM Flashcards
what the person says about himself or herself during history taking
SUBJECTIVE DATA
what you as the healthcare professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
OBJECTIVE DATA
HOW TO VALIDATE DATA
validating or checking the accuracy and reliability of data
EG. in addictions treatment, a clinician will corroborate data with a family member or friend in order to verify the accuracy of Ellen’s history
NURSING PROCESS
- assessment
- diagnosis
- outcome identification
- planning
- implementation
- evaluation
4 TYPES OF DATA
- COMPLETE DATABASE
- EPISODIC OR PROBLEM-CENTRED DATABASE
- FOLLOW-UP DATABASE
- EMERGENCY DATABASE
THIS KIND OF DATA INCLUDES:
- includes a complete health history and full physical examination
- describes the current and past health state and forms a baseline against which all future changes can be measured
- yields the first diagnoses
COMPLETE DATA
THIS KIND OF DATA INCLUDES:
- collected for limited or short-term problem
- concerns mainly one problem, one cue complex or one body system
EPISODIC OR PROBLEM-CENTRED DATA
THIS KIND OF DATA INCLUDES:
- status of any identified problems should be evaluated at regular and appropriate intervals:
- what change has occurred?
- is the problem getting better or worse?
- what coping strategies are used?
FOLLOW-UP DATA
THIS KIND OF DATA INCLUDES:
- calls for rapid collection of the data - often compiled concurrently with life-saving measures
- diagnosis must be swift and sure
- requires more rapid collection of data than the episodic database
EMERGENCY DATA
DISADVANTAGES OF note taking during an interview
DISADVANTAGES
- breaks eye contact too often
- shifts your attention away from the person - diminishes his/her sense of importance
- can interrupt patient’s narrative flow
- impedes your observation of patient’s nonverbal behaviour
- threatening to the patient
ADVANTAGES OF note taking during an interview
ADVANTAGES
- helps memory
- increases accuracy
- provides interview cues
TRUE OR FALSE
interview usually takes longer with older adults
TRUE - because they have a longer story to tell
TRUE OR FALSE
adolescents know a lot about health assessment and dont need explanations
FALSE
why is building a rapport with adolescents is essential?
because otherwise they might not participate
TRUE OR FALSE?
it is important to adjust the pace of the interview to the aging person
TRUE -
give them time to remember - do not rush them
WHY IS IT IMPORTANT TO AVOID AN abrupt or awkward closing to an interview?
can destroy rapport and leave a negative impression
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
* egocentric - sees the world mostly from his/her own point of view * everything revolves around them * communication is direct, concrete, literal and set in the present * use simple, short sentences with a concrete explanation
preschooler (2-6)
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
- can tolerate and understand other perspectives
- more objective and realistic
- wants to know functional aspects - how things work & why things are done
- can verbalize important data to add to history
- pose questions about school, friends or activities
school-age child (7-12)
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
* fluctuate between mature and childlike responses * value their peers & crave acceptance * think adults don't understand them
adolescent (13-19)
THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?
- focused on finding out the meaning of life and the purpose of his/her own existence
- adjusting to inevitability of death
- be aware that symptoms of illness are even more frightening when they mean physical limitation or threaten independence
- always address the person by the last name
older adult
Reason for seeking care – how to chart
- record the patient’s exact words enclosed in quotations
- “Want to start jogging and need checkup.”
Questions to ask when someone states they are allergic to a medication
- Note both the allergen (medication, food, or contact agent, cushy as fabric or environmental agent) AND the reaction (rash, itching, runny nose, watery eyes, difficulty breathing)
Purpose of a functional assessment
- functional assessment questions provide data on the lifestyle and type of living environment to which the person is accustomed
subjective sensation that the person feels from the disorder
symptom
objective abnormality that you as the examiner could detect on physical examination or lab reports
sign
Techniques of physical assessment
- INSPECTION
- PALPATION
- PERCUSSION
- AUSCULTATION
5 Percussion notes
RESONANT HYPERRESONNANT TYMPANY DULL FLAT
TYPE OF SOUND HEARD WHEN PERCUSSING:
- normal lung tissue
RESONANT
TYPE OF SOUND HEARD WHEN PERCUSSING:
- normal over child’s lung
- abnormal in the adult, over lungs with increased amount of air (emphysema)
HYPERESONNANT
TYPE OF SOUND HEARD WHEN PERCUSSING: over air-filled viscus, such as stomach or intestines
TYMPANY
TYPE OF SOUND HEARD WHEN PERCUSSING: relatively dense organ, as liver and spleen
DULL
TYPE OF SOUND HEARD WHEN PERCUSSING: when no air is present, over thigh muscles, bone or tumour
FLAT
TRUE OR FALSE?
STETHOSCOPE MAGNIFIES SOUND
FALSE -
* does not magnify sound but does block out extraneous room sounds
PART OF STETHOSCOPE TO USE TO AUSCULTATE: for high-pitched sounds, such as breath, bowel, and normal heart sounds.
DIAPHRAGM
PART OF STETHOSCOPE TO USE TO AUSCULTATE: for soft, low-pitched sounds, such as extra heart sounds or murmurs.
BELL
DEVELOPMENTAL CARE FOR WHICH AGE GROUP:
- timing - 1 to 2 hours after feeding when baby is not too drowsy or hungry
- environment - warm
- considerations - infant will not object to being nude or being touched, but make sure hands & equipment are warm
- voice - use soft, crooning voice
- eye contract - lock eyes from time to time
- facial expression - baby prefers a smiling face to frowning face
- movements - smooth and deliberate, not jerky
- distractions - use pacifier during invasive steps or distract with brightly coloured toys
INFANT - developmental stage: establishing trust
WHAT IS THE INFANTS DEVELOPMENTAL STAGE KNOWN AS?
ESTABLISHING TRUST
DEVELOPMENTAL CARE FOR WHICH AGE GROUP:
- need to explore is in conflict with dependency on parent
- often results in frustration
- may be difficult to examine
- may be fearful of invasive procedures and dislike being restrained
TODDLER
WHAT IS THE TODDLERS DEVELOPMENTAL STAGE KNOWN AS?
developing autonomy
WHAT IS THE General Survey
- overall impression of the patient
WHEN DOES THE GENERAL SURVEY BEGIN?
- begins when you first encounter him or her
4 AREAS COVERED IN GENERAL SURVEY
- physical appearance
* 2. body structure
* 3. mobility
* 4. behavior
- physical appearance
2 THINGS TO NOTE WHEN PERFORMING GENERAL SURVEY OF INFANTS AND CHILDREN
- PARENTAL BONDING
2. PHYSICAL GROWTH
3 THINGS TO NOTE WHEN PERFORMING GENERAL SURVEY OF OLDER ADULTS
- PHYSICAL APPEARANCE
- POSTURE
- GAIT
TRUE OR FALSE?
in terms of blood pressure, there is normally a gradual decline that occurs throughout childhood and into the adult years
FALSE. gradual rise is normal
CAUSE OF TRIPOD POSITIONING
BREATHING DIFFICULTIES OR LUNG DISEASE
PROPER WAY TO TAKE RADIAL PULSE:
- palpate the radial pulse at the flexor aspect of the wrist laterally along the radial bone
- push until you feel the strongest pulsation
- if rhythm is regular, count the number of beats in 30 seconds and multiply by 2
4 THINGS TO NOTE IN RADIAL PULSE
- RATE
- RHYTHM
- FORCE
- ELASTICITY
THINGS TO REMEMBER WHEN TAKING Blood Pressure
- ARM AT HEART LEVEL
- FEET ON FLOOR
- PALPATE RADIAL ARTERY AND NOTE WHEN IT DISAPPEARS WHILE CUFF IS INFLATING
- ADD 20-30 MM HG
- DEFLATE CUFF SLOWLY AND GRADUALLY
WHAT ARE THESE SYMPTOMS CHARACTERISTIC OF:
- irregularity commonly found in children and young adults
- heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing down to normal with expiration
Sinus arrhythmia
the maximum pressure felt on the artery during left ventricular contraction (or systole).
systolic blood pressure
is the elastic recoil (or resting) pressure the blood exerts constantly between contractions.
diastolic blood pressure
is the difference between the systolic and diastolic pressures and reflects the stroke volume.
Pulse pressure
Reason for checking for auscultatory gap before doing BP
- this will avoid missing the auscultatory gap - a period when Korotkoff’s sounds disappear during auscultation
Assessment findings indicating acute pain
- guarding
- grimacing
- vocalizations such as moaning
- agitation
- restlessness
- stillness
- diaphoresis
- change in vital signs
pain-indicating behaviours
- rocking
- negative vocalization
- frowning
- grimacing
- noisy breathing
- irritability
- agitation
- rubbing a panful area
- bracing
__________ PAIN:
- pain originates from the larger interior organs (kidney, stomach, intestine, gallbladder, pancreas)
- constant or intermidant
visceral
__________ PAIN:
superficial pain derived from skin surface or subcutaneous tissues (joints, tendons, muscles or bone)
somatic
__________ PAIN:
- pain initiated or caused by a primary lesion or dysfunction of the nervous system
- caused by injury to either peripheral or central nervous system
neuropathic
________ PAIN: persistant pain present for 6 months or longer
chronic