Module 1 Flashcards
Assessment Mneunomic for history of present illness: OLD CARTS
O - onset (when did it start?)
L - location
D - duration (is it constant? does it come and go? does it happen when you eat/when you move?)
C - character
A - alleviating/aggravating
R - radiation
T - timing (what were you doing when this started?)
S - severity
What are some of the objective effects and signs of pain?
Stress response (increased respirations), muscle tension, facial grimacing, guarding, bracing, rubbing painful areas
What are the 5 broad categories of pain?
acute pain
musculoskeletal pain
complex regional pain syndrome (CRPS)
chronic pain
neuropathic pain
What are the 4 types of musculoskeletal pain?
1) visceral pain - abdominal organs
2) somatic pain
3) cutaneous pain (skin
layers, “burning” “sharp”)
4) referred pain (cardiac pain; phantom pain)
Chronic pain
“no known cause or treatment” - affects approx. 40% of US population
How does aging influence pain?
Pain is prevalent in older adults, pain sensation is NOT diminished, pain is NOT considered a normal consequence of aging
What is the pain rating scale (0-10) with the faces called?
Wong-Baker FACES Pain Rating Scale
What pain scale is used for infants (2 months to 7 months) and includes the following categories: face, legs, activity, cry, consolability?
Score from 0-10
FLACC scale
What do JHACO standards require in regards to pain?
Pain must be assessed and reassed regularly
How do you assess a patient’s level of consciosness?
-Alertness
-Orientation: (person, place, time & situation)
How do you assess Orientation?
Person: what is your name?
Place: where are you right now?
Time: do you know the date? what month? what year? (specific - > general)
Situation: what brought you in here today?
What are the 4 steps of psychomotor assessment (the ‘doing of health assessment’)?
Inspection (looking)
Palpation - (touching)
Percussion (honestly - not done often) - drumming to know what’s going on based on the sound
Auscultation (listening)
The ulnar aspect is more sensitive to _____
vibration
The dorsal aspect is more sensitive to _____
heat
Temperature is regulated by this part of the brain
hypothalamus
What do neonates do instead of shivering?
They have special brown adipose tissue that can be broken down if more heat is needed
How does aging affect temperature regulation?
It’s easier for the elderly to overheat because they have fewer sweat glands (this is also true for infants)
All of the following are examples of _____:
Radiation
Convection
Conduction
Evaporation
Mechanisms of heat loss
What is the normal range for temperature?
36.7 - 37
what are the steps of the nursing process?
assessment, diagnosis, planning, implementation, evaluation
define nursing diagnosis
clinical judgment made by a nurse to identify and describe a client’s actual or potential health problems
nursing diagnosis vs medical diagnosis
Nursing diagnoses are different from medical diagnoses provided by physicians, which focus on identifying diseases or medical conditions. Nursing diagnoses, on the other hand, focus on the client’s response to their health status or life situation. They provide a framework for nurses to understand and communicate the client’s unique needs and guide the development of an individualized care plan.
“Impaired Gas Exchange,” “Acute Pain,” “Ineffective Coping,” “Risk for Falls,” and “Impaired Mobility” are all examples of _____
nursing diagnoses
what are the three components of a nursing diagnosis?
problem, etiology (or related factors), signs & symptoms
what are the three types of nursing assessments?
emergency, comprehensive, focused
what are the components of an emergency assessment?
A: Airway
-Assess and ensure a patent airway.
-Look for obstructions or potential issues compromising breathing.
-Perform interventions like positioning, suctioning, or advanced airway management.
B: Breathing
-Assess rate, depth, and quality of respirations.
-Auscultate lung sounds.
-Identify signs of respiratory distress or inadequate oxygenation.
-Administer supplemental oxygen or assist ventilations as needed.
C: Circulation
-Evaluate heart rate, blood pressure, and peripheral perfusion.
-Assess for signs of shock and peripheral pulses.
-Monitor cardiac rhythm.
-Perform interventions such as fluid resuscitation or medication administration.
D: Disability
-Assess neurological status (consciousness, pupil reactions, motor responses).
Identify signs of brain injuries, strokes, or neurological deficits.
E: Exposure/Environmental control
-Remove clothing for a thorough physical examination.
-Address environmental factors (e.g., extreme temperature)
comprehensive nursing assessment
-a thorough and systematic process of gathering information about a patient’s health status, medical history, current concerns, and overall well-being
-Involves observation, interviews, physical examination, and reviewing relevant medical records
what is the purpose of a comprehensive nursing assessment?
The purpose of a comprehensive nursing assessment is to establish a holistic understanding of the patient’s health, identify actual or potential health problems, and develop an individualized plan of care
what are the components of a comprehensive nursing assessment?
Health History: Past illnesses, surgeries, allergies, medications, family history, lifestyle.
Physical Examination: Systematic assessment of body systems, vital signs, palpation, percussion, auscultation.
Psychosocial Assessment: Mental health, emotions, cognitive abilities, social support, coping mechanisms.
Functional Assessment: ADLs, independence, mobility, assistive devices.
Pain Assessment: Location, intensity, duration, aggravating/relieving factors, impact on activities.
Risk Assessment: Identify potential risks (falls, pressure ulcers, medication interactions).
Cultural Assessment: Beliefs, values, practices influencing health perception and care preferences.
Documentation and Data Analysis: Accurate documentation, data organization, identification of patterns.
Importance: Establishes patient’s health status, identifies problems, guides personalized care planning.
what is a focused assessment?
a focused assessment is a targeted and specific assessment conducted to gather information about a particular problem, concern, or a specific body system
what is SBAR communication?
Situation
Background
Assessment
Recommendation
It provides a concise framework for clear and organized VERBAL communication during handoffs, transfers, and when reporting changes in a patient’s status
which is bigger on a stethoscope - the bell or diaphragm?
the diaphragm
what do you use the diaphragm of a stethoscope for? what kind of pressure do you apply?
-Commonly used for high-frequency sounds, such as lung and bowel sounds, as well as normal heart sounds
-Apply firm pressure
what do you use the bell of a stethoscope for? what kind of pressure do you apply?
-used for low-frequency sounds, such as murmurs and some vascular sounds
-apply light pressure
otoscope
An otoscope is a medical device used to examine the ears and ear canal for diagnostic purposes.
Define sentinel event
an unexpected occurrence or death that results in serious harm or poses a risk of serious harm to a patient in a healthcare setting
Three quarters of all sentinel events are caused by a failure in ______
communication
What is an acute/urgent respiratory rate?
less than 8
more than 28
What is an acute/urgent HR?
less than 50
greater than 120`
what is considered acute/urgent for oxygen saturation?
acute change in O2 status less than 90 despite oxygen administration
what is considered acute/urgent for a fever?
greater than 102.2 F (39 C)
Point-of-care documentation
Refers to the practice of recording patient information in real-time at the location where care is provided, typically using electronic health record systems or mobile devices.
Clinical pathway
A standard plan of care for patients with a specific medical condition or undergoing a specific procedure
what is the normal range for temperature?
36.5-37C ( 97.7-98.6F)
what are 5 factors influencing BP?
1) Cardiac output: The amount of blood pumped by the heart per minute, which is determined by the heart rate and stroke volume.
2) Peripheral resistance: The resistance encountered by blood flow in the arteries, influenced by factors like blood vessel constriction, vessel elasticity, and blood viscosity.
3) Blood volume: The total amount of blood in the body, which can be affected by factors such as hydration status, fluid balance, and hormone regulation.
4) Blood viscosity: The thickness or stickiness of the blood, influenced by factors like red blood cell count and plasma protein levels.
5) Autonomic nervous system activity: The balance between the sympathetic and parasympathetic divisions of the autonomic nervous system, which can impact blood vessel constriction or dilation and heart rate.
when would you call rapid response for temperature?
<95
>103.3
This type of pain originates from the skin, muscles, bones, joints, or connective tissues, typically described as a sharp, localized, and well-defined sensation
Somatic pain
this type of pain originates from abdominal organs and is often described as gnawing or crampy
visceral pain
what are some possible causes of temperature elevation?
-infection
-overexertion
-hypothalamus problem
-medications or illegal drugs
-overdressing
low temp causes
severe infection
hypothalamus problem
underactive thyroid
slow metabolism of the elderly
Hypothermia temp
<35C
<95F
Hyperthermia temp
> 37.8C
Number of heartbeats per minute
Heart rate
Heart rate, heart rhythm/regularity and amplititude are the components that make up the _______
pulse
How do you report the AMPILITUDE of the pulse?
0 non-palpable
+1 diminished (hard to feel)
+2 normal (what you would expect for most people)
+3 bounding (could be caused by overhydration or exertion)
what are possible causes for tachycardia?
-recent exercise
-fever
-anxiety, fear, pain
-blood loss, anemia, or dehydration
-respiratory distress
-medications or illegal drugs
-caffeine ingestion or smoking
what are the possible causes of bradycardia?
-conditioned athlete
-hypothermia
-immobility or sleep
-medications or illegal drugs
what is the technique for finding a pulse?
-find a peripheral pulse site, usually radial pulse
-gently apply index and middle fingers
-count the pulsations you feel in 30 seconds and multiply by 2 (unless it’s irregular, then count for a full minute)
apnea
no breath
dyspnea
difficulty breathing
bradypnea
slow breaths
tachypnea
fast breaths
respiratory rate, rhythm, and depth/effort are components to assess _______
respirations
what are some words you can use to describe the depth and effort of respirations?
shallow, normal, deep
labored, unlabored
what are possible causes of tachypnea?
-fever
-exercise
-blood loss or anemia
-stimulant drugs
-respiratory illness (e.g. COPD)
-Metabolic problem (e.g. diabetic ketoacidosis)
what are possible causes of bradypnea?
-sedation
-sleep
-medication/drugs
-brain stem injury
-dying
the force that the blood places on the arterial walls
blood pressure
blood pressure is measured in _____
mm Hg (millimeters of mercury)
if a patient is losing blood you would expect the blood pressure to _____
drop
what are the ranges for prehypertension for SBP and DBP?
SBP 120-129
OR
DBP 80-89
white coat syndrome
BP is elevated due to anxiety over the appointment/situation
hypertensive crisis:
SBP > ?
DBP > ?
SBP >180
OR
DBP > 110
at what rate do you want to deflate the sphygmamanometer to get an accurate blood pressure?
2 mm Hg / second (one dash on the meter)
Korotokoff sounds
-pulsation sounds
-the most important are 1 (start) and 5 (silence)
-it takes a trained ear to hear sounds 2-4
what variables affect blood pressure?
-gender (men tend to have higher)
-family history (genetics)
-lifestyle (sendentary lifestyle deconditions the heart)
-diurnal variations (time of day)
-exercise
-body position (feet must be flat on the floor and not crossed)
-stress (white coat syndrome)
-pain
-medications
-diseases
Orthostatic hypotension
AKA postural hypotension
low BP when standing from seated/lying
dizziness, blacking out, lightheaded
what causes orthostatic hypotension?
Decreased circulating volume
Medical conditions
Dehydration
Medications
Mental status is assessed throughout the physical examination. What will you be evaluating?
-grooming- poor hygiene
-emotional status- bright affect, depressed
-body language-slumped, lack of eye contact
Besides A&O x4, what are some ways to describe LOC?
Alert
Confused -“disoriented”- difficulty following commands, poor memory
Drowsy - pt is lethargic
Stupor - pt responds only briefly to repeated stimuli
Comatose - pt is unresponsive
If patient has Glasglow Coma Scale of 3, is this concerning?
Yes - this would be high priority
If patient has a Glasglow Coma Scale of 15, is this concerning?
No patient is responsive and alert - this is normal
How to assess short-term memory?
-Three word recall after 5-10 mins (e.g. bed, phone, chair)
-OR go in after breakfast - “what did you have for breakfast?”
How to assess long-term memory?
-Ask something you can pull from their history
Mini-Cog and the mini mental status examnination (MMSE)
-cognition
-these are not used to diagnose anyone, but as an initial assessment
For cognitive ability, if you sense a problem you can assess a patient’s higher-level thinking and motors skills with the ____ _____ _____ ____.
Mini-Mental Status Examination (MMSE)
This screening test includes the following:
-object recognition
-serial 7’s or simple math
-spelling - forward or backwards
-following written directions
-copying a sentence or a picture of a clock or a house
-tell the meaning of a phrase
Mini-Mental Status Examination (MMSE)
What is the total score of the MMSE ?
30 is a perfect score
Three word recognition and recall and clock drawing are components of the ___ _____ assessment
mini cog
What is CIWA?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Scale
Below are the categories covered by the 10 items of the ______
Agitation
Anxiety
Auditory disturbances
Clouding of sensorium
Headache
Nausea/vomiting
Paroxysmal sweats
Tactile disturbances
Tremor
Visual disturbances
CIWA
What proportion of women are victims of violence?
1/3 of women are victims of violence worldwide
-often goes unreported
what’s a good way to assess daily routine?
“what does a typical day look like for you?”
Delirium
Generally has an underlying medical cause - resolves after treatment of cause
a simple physical examination performed to assess the hydration status or fluid balance in the body
turgor test
what equipment is used to inspect the skin?
paper tape measures, penlights, magnifying glass, sterile cotton tipped applicator
nevi/nevuses
moles
subcutaneous tissue is made up of ______ tissue
adipose
sensation & perception, thermoregulation, fluid balance, synthesis of vit D, excretion, immunity are all functions of the _______
skin
These plates of keratin are on your hands
nails
this cancer of the melanocytes has a strong genetic component and often rapid progression
melanoma
what are the side effects of steroids?
-weight gain
-anger
-suppress immune system
-
an inflammatory disease of the sebaceous follicles of the skin, marked by comedones, papules, and pustules
acne
a chronic immune disorder that causes the skin to develop silvery, scaly plaques
psoriasis
a chronic inflammatory skin condition characterized by red, itchy, and sometimes scaly patches on the skin
eczema
the most common and most preventable cancer in the US
skin cancer
UV radiation from indoor tanning beds increase risk of melanoma by _____
75%
systemic color change of the skin due to excessive levels of bilirubin in the blood, may cause lasting neurological damage if left untreated
jaundice
skin presentation often seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood
pallor/pale
a blue, grey, or dark purple discoloration of the skin or mucous membranes that reflects poor oxygenation
cyanosis
carotenemia
a benign yellowing of the skin due to increased dietary intake of carotene in the diet, from foods such as carrots, sweet potatoes, pumpkin, corn, yams, spinach, beans
red, pink skin color, may indicate inflammation, fever, or increased blood flow
erythema
chronic autoimmune condition that causes loss of pigmentation that causes patches of skin to lose pigment or color
vitiligo
inherited disorder caused by the total or partial absence of an enzyme that produces melanin
albanism
this neurological condition that causes rapid, repetitive, involuntary eye movements often occurs with albanism
nystagmus
a site of the eye seen by pulling down the eyes that can be used to assess for pallor (esp helpful w dark skinned individuals)
conjunctiva
what conditions can affect skin texture?
-autoimmune disorders
-hormonal conditions/changes
-rosacea
-acne
-eczema
an overgrowth of connective tissue and commonly seen on dark skinned individuals
keloid formation
A
B
C
D
E
of melanoma
MEMORIZE
Asymmetry
Border - borders are uneven
Color - variety of shades, or may be red or blue
Diameter - usually larger than 6 mm (but may be smaller at first)
Evolving
what questions would you use to assess a rash?
-when did you first develop the rash?
-is the rash constant or intermittent?
-is this the first time? where did the rash start?
-did the rash spread?
-was the rash itchy, tender, or painful?
-is there anything that makes it better or worse?
-what products are you using on your skin? any new products?
these small (<0.5 cm) red, itchy lesions are known as hives or _____
wheals
small (<0.5 cm) , flat freckle in a bigger patch (>1 cm)
macule
another words for “pus-sy” drainage
purulent
excoriation
scratching (hollow)
erosion
depressed, moist shiny
erosions of different layers of skin
ulcer
linear break in the skin
fissure
A specific area of skin that is innervated by a single spinal nerve, often used in clinical settings to assess sensory disturbances or diagnose nerve-related conditions
A dermatome
A medical term used to describe a skin eruption or rash that follows the distribution pattern of a dermatome, resembling the pattern seen in herpes zoster (shingles)
Zosteriform
what bony prominences are at risk of having pressure injuries?
-back of head
-shoulders
-knees
-heels
-elbow
-lower back/buttocks
-hip
pressure injury characterized by non-blanchable red area
stage 1
pressure injury characterized by damage to the dermis “full-thickness”
stage 3
what’s the difference between stage 3 and 4 pressure injuries?
stage 4 will have damage to bone, tendon, or muscle
Unilateral swelling, redness, tenderness, pain, and warmth in an extremity are possible indicators of these complications
deep vein thrombosis or phlebitis
Additional risk factors for pressure injuries
Poor skin hygiene
Diabetes mellitus
Diminished sensory perception (pain awareness)
Fractures
History of corticosteroid therapy
Immunosuppression
Increased body temperature
Microvascular dysfunction
Multiple organ dysfunction syndrome (MODS)
Previous pressure injuries
Significant obesity or thinness
Terminal illness/end-of-life/dying process
What is the SPICES tool?
The Fulmer SPICES tool (Fulmer & Wallace, 2012) has proved effective in identifying common problems experienced in older adults that can lead to negative outcomes.:
S—Sleep disorders
P—Problems with eating or feeding
I—Incontinence
C—Confusion
E—Evidence of falls
S—Skin breakdown
What are some common causes of delirium?
Delirium may not have one specific cause, and in older adults may be due to drug interactions, circulatory or metabolic problems, nutritional deficiencies, or a worsening illness that triggers inflammatory processes and disrupts neurotransmitters.
Delirium screenings
Confusion Assessment Method (CAM)
https://consultgeri.org/try-this/general-assessment/issue-13
Identifies delirium quickly. Long and short versions are available.
Delirium Observation Screening (DOS)
http://sagelink.ca/dos_delirium
Consists of 13 items focused on routine observation of verbal and nonverbal behaviors.
Mini-Cog
https://mini-cog.com
Two-part test to determine if dementia or cognitive impairment is present (even in early stages). Takes 3 to 5 minutes to administer.
Mini-Mental Status Exam (MMSE)
http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE
The original MMSE contains 30 questions and screens for cognitive impairment, estimates the severity of cognitive impairment, and documents changes over time with respect to decline or response to treatment.
MMSE Second Edition
http://www4.parinc.com/Products/Product.aspx?ProductID=MMSE-2
The second edition may be useful in populations with milder forms of cognitive impairment.
Neecham Confusion Scale
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1852304
Consists of nine items and is used to detect early stages of delirium; does not differentiate between dementia and delirium.
Vital sign range for newborns
35.9–36.9 (96.7–98.5)
70–190
30–40
73/55
Vital sign range for infants
37.1–38.1 (98.7–100.5)
80–160
20–40
85/37
VS for Toddler
37.1–38.1
98.7–100.5
80–130
25–32
89/46
VS for Child
36.8–37.8 (98.2–100)
70–115
20–26
95/57
VS for Preteen
35.8–37.5
96.4–99.5
65–110
18–26
102/61
VS for Teen
35.8–37.5
96.4–99.5
55–105
12–22
112/64
VS for older adult
Aged Adult (65+ years)
35.8–36.8 (96.4–98.3)
40–100
16–24
120/80
body temperature is usually about ____ lower in the early morning
0.6°C (1.0° to 2.0°F) (sometimes even a little more in children)
Women tend to experience more fluctuations in body temperature than do men, probably as the result of changes in hormones. The increase in ________ secretion at ovulation increases body temperature as much as 0.3° to 0.6°C (0.5° to 1.0°F).
Women tend to experience more fluctuations in body temperature than do men, probably as the result of changes in hormones. The increase in progesterone secretion at ovulation increases body temperature as much as 0.3° to 0.6°C (0.5° to 1.0°F).
Fever occurs in response to an upward displacement of the thermoregulatory set point in the ______, caused by pyrogens (substances that cause fever).
hypothalamus
However, when fever is equal to or greater than 41°C (106°F), it is referred to as ______ and is a medical emergency. The body must be cooled rapidly to prevent brain damage
hyperpyrexia
heat-loss mechanisms in the body
sweating, vasodilation, increased respirations
________ differs from fever in that the hypothalamic set point is not changed, but in situations of extreme heat exposure or excessive heat production (e.g., during strenuous exercise), the mechanisms that control body temperature are ineffective.
Hyperthermia
A fever of 38.3°C (101°F) or higher that lasts for 3 weeks or longer without an identified cause is diagnosed as an _____
FUO (fever of unknown origin)
______ fever is the result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or increased intracranial pressure.
Neurogenic
Physical Effects of Fever
Loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase.
Therapeutic hypothermia, the purposeful lowering of the core body temperature, has been used to improve outcomes after ________
cardiac arrest
Death may occur when body temperature falls below _____, but survival has been reported in isolated cases (such as in drowning in very cold water or burial in snow) when body temperatures have fallen in the range of severe hypothermia (28°C [82.4°F])
35°C (95°F)
Risk factors for hypothermia
Chronic conditions—such as alcoholism, malnutrition, and hypothyroidism—increase the risk of hypothermia. Patients in the perioperative period and newborn infants are also at increased risk.
Physical Effects of Hypothermia
Patients with hypothermia may experience poor coordination, slurred speech, poor judgment, amnesia, hallucinations, and stupor. Respirations decrease and the pulse becomes weak and irregular with lowering blood pressure.
The axilla remains the most common place for temperature measurement in the ______
neonate
Because the insertion of the thermometer into the rectum can ____ the heart rate by stimulating the vagus nerve, assessing a rectal temperature for patients with heart disease or after cardiac surgery may not be allowed in some institutions.
slow
assessing a rectal temperature is contraindicated in patients who are _____ (have low white blood cell counts, such as in leukemia) and in patients who have certain neurologic disorders (e.g., spinal cord injuries).
neutropenic
At these two sites, a temp of 100 F is considered a normal reading
temporal
rectal
The pulse is regulated by the autonomic nervous system through the _____ node (the pacemaker) of the heart.
sinoatrial (SA)
When the stroke volume decreases, such as when the blood volume is decreased because of hemorrhage, the heart rate ______ to try to maintain the same cardiac output.
increases
Women on average have slightly _____ pulse rates than men.
higher
Pulse rate ______ as a person ages due to decreased metabolic rate.
decreases
Fever tends to _____ the heart rate
increase
Causes for bradycardia
when metabolic needs are decreased (e.g., during sleep, in hypothermia, in trained athletes at rest)
Certain medications, such as beta blockers; from vagal stimulation (e.g., from bearing down to have a bowel movement), during suctioning of respiratory secretions, severe pain, and in increased intracranial pressure and MI.
A type of chronic pain that arises from damage or dysfunction in the nervous system
Often described as a more constant and persistent sensation that can be challenging to treat
It is different from nociceptive pain, which is the normal response to tissue damage or injury
neuropathic pain
There are several mechanisms involved in ______ pain, including peripheral sensitization, neuronal windup, and central sensitization.
neuropathic
This mechanism of neuropathic pain occurs as a result of an inflammatory process. In response to tissue damage or inflammation, the nerves in the affected area become sensitized, leading to an increased sensitivity to pain. Nonpainful stimuli, such as light touch or pressure, can trigger pain sensations (allodynia) or make the pain more intense (hyperalgesia). In other words, the nerves become overly responsive, and previously nonpainful stimuli now generate pain signals
Peripheral sensitization
This mechanism of neuropathic pain involves a phenomenon where repetitive or prolonged stimulation of pain-sensing nerves leads to an increased sensitivity and responsiveness in those nerves. It can result in the development of hyperalgesia and allodynia not only in the immediate area of the stimulation but also in nearby regions that are not typically associated with pain. Essentially, the nerves “wind up” and become hypersensitive, amplifying the pain signals
Neuronal windup
This mechanism of neuropathic pain refers to the phenomenon where the pain signals generated by peripheral nerves continue to be processed and “remembered” by the central nervous system (spinal cord and brain) even after the peripheral stimulation ceases. In other words, the central nervous system becomes more sensitive to pain signals and can overreact to nonpainful stimuli. This can lead to ongoing pain and the perception of pain even in the absence of ongoing tissue damage or inflammation
Central sensitization
What are some risks of inadequately treated pain?
-Impairs pulmonary function
-Decrease immune response
-Prolongs hospital stay
-May result in neuropathic pain syndromes
A chronic and often debilitating condition that typically occurs after an injury or trauma to a limb. It is characterized by persistent and severe pain that is out of proportion to the initial injury. Commonly affects the arms, legs, hands, or feet.
Complex regional pain syndrome (CRPS)
A commonly used scale for measuring subjective experiences, particularly pain intensity, where patients rate their pain on a continuum using a horizontal line
Visual Analog Scale
A commonly used scale for measuring subjective experiences, particularly pain intensity, where patients rate their pain on a continuum using a horizontal or vertical line
Visual Analog Scale
A pain assessment tool that utilizes a series of descriptive words or phrases to represent different levels of pain intensity
Verbal descriptor scale (VDS)
A scale used to assess pain intensity, where individuals select a number from 0 to 10 to represent their pain level
Numeric Pain Intensity Scale
Combined thermometer scale (combines Visual Analog Scale and Numeric Pain Intensity Scale)
Multidimension pain scale used for experimentally induced circumstances, following procedures, with several medical–surgical conditions
McGill Pain Questionnaire
Multidimensional pain scale initially used for cancer pain, also valid for chronic nonmalignant pain
Brief Pain Inventory
Pain scale used for chronic pain
Brief Pain Impact Questionnaire (BPIQ)
Combined thermometer scale
-Verbal Descriptor Scale (VDS) and Numeric Pain Intensity Scale (NPI)
when is a diagnosis of stage 1 hypertension made?
BP over 140/90 on 2+ separate occasions
(Either SBP >140+ OR DBP >110)
when is stage 2 hypertension made?
SBP 160+
OR
DBP 100+
How do you know a BP cuff fits correctly?
The inflatable part of the cuff (the bladder) should cover about 80% of the upper arm
The cuff should cover 2/3 of the distance from the elbow to the shoulder
Under what circumstances should an arm NOT be used for taking a blood pressure?
A BP cuff should never be placed over any clothing, on an arm that has an IV or dialysis shunt, or on the side of a recent mastectomy or surgical procedure
How does taking a BP on the leg affect the accuracy of the measurement?
The SBP will be 10-40 mmHg higher in this site
The DBP will be about the same
How is orthostatic BP diagnosed?
-BP taken lying down, then 1 min after standing up , then standing up again in another 2 mins
ABNORMAL findings:
-HR increases by 20+ bpm
-SBP decreases by 20+
-DBP decreases by 10+
Patient becomes dizzy or faints
Glasgow Coma Scale
Assesses the level of consciousness and neurological function in individuals with a brain injury or other conditions affecting the brain
Mild brain injury: score of 13-15
Moderate brain injury: 9-12
Severe brain injury: 3-8
A brief initial cognitive screening tool with 3 steps used to assess a person’s cognitive function and detect possible cognitive impairment
1) Tell pt 3 unrelated words
2) Pt draws a clock
4) Pt recalls the 3 words
Mini-Cog
If you sense a problem with a mini-cog, you can assess a patient’s higher-level thinking with a this exam which includes the following:
Object recognition
Serial 7’s or simple math
Spelling- forwards or backwards
Following written directions
Copying a sentence or a picture of a clock or house
Tell the meaning of a phrase
Normal: 24-30 points
Mil: 18-23 points
Severe: 0-17 points
Mini-Mental Status Examination (MMSE)
How do you organize mental status assessment with ABCT plus MMSE?
Appearance: overall, posture, movement, hygiene, grooming, dress
Behavior: level of consciousness, eye contact, facial expressions, speech
Cognitive function: orientation, attention span, memory, judgment
Thought processes and perceptions: MMSE/Mini-Cog
Where can you assess color changes on dark-skinned people?
Conjunctiva, palm of the hand, mucous membranes
Peripheral cyanosis: A blue, grey, slate, or dark purple
discoloration of the skin or mucous membranes caused by deoxygenated or reduced
hemoglobin in the blood; may
occur with decreased cardiac
output.
Vitiligo: Autoimmune
disorder that causes
smooth, white patches of
skin all over the body
Peripheral cyanosis
Autoimmune disorder that causes smooth, white patches all over the body
Vitiligo
What is the difference between sclera and conjunctiva?
the sclera is the tough outer layer of the eye that provides structure and protection, while the conjunctiva is a thin mucous membrane that covers the front surface of the eye and lines the inside of the eyelids, acting as a protective barrier and lubricating the eye.
Bluish discoloration to the
skin related to decreased circulating oxygen;
best assessed in the oral mucosa, conjunctiva
of the eyes, lips, and tongue
central cyanosis
Red, pink skin color; may indicate
inflammation, fever, or increased blood flow. In
carbon monoxide poisoning, the individual will
have a bright red cherry face and upper trunk
Erythema
Inherited disorder caused by the total or
partial absence of an enzyme that produces melanin
albanism
an inflammatory skin condition causing redness, swelling, and
spider-like blood vessels to develop on the middle of the face
Rosacea
An overgrowth of connective tissue and commonly
seen on dark skinned individuals
keloid
Common causes of rashes
Diet, stress, medications, allergies, hormone imbalance, autoimmune disease, kidney disease, toxic reactions, digestive problems
Primary vs secondary lesions
Occur in reaction to the external or internal
environment. They
Primary vs secondary lesions
Primary lesions occur in reaction to the external or internal environment. They may be present at birth or develop later in life. Secondary lesions are changes to primary
What is a normal finding for the size of a nevus?
<0.6 cm (6 mm)
The following are all _____ lesions
< 0.5 cm
Macule: small, flat (freckle) – PATCH is BIGGER (1 cm+)
Papule: solid, elevated, rough texture (mole) – PLAQUE is BIGGER (0.5+)
Vesicle: raised, filled with serous blood or clear fluid (herpes simplex) – CYST
is BIGGER and encapsulated (1 cm+)
Pustule: vesicle filled with pus (acne)
Nodule: solid, elevated (fatty lipoma) – TUMOR is BIGGER (0.5+)
Wheal: hives (red, itchy)
primary
A pattern of skin involvement that follows the dermatomal distribution of a nerve, often seen in conditions like herpes zoster (shingles).
Zosteriform
A specific area of skin that is primarily supplied by a single spinal nerve or nerve root.
Dermatome
Hair changes can be related to:
Diet
Stress
Genetics
Infection
Infestation
Endocrine disorders
Nail changes can be related to:
Nutrition
Stress
Systemic disease
Vitamin deficiency
Infection
Nail biting or picking
Nail care
A nail abnormality characterized by changes in the shape, texture, and angle of the nails, typically involving the fingers but can also affect the toes
Clubbing
