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Health Assessment > Module 1 > Flashcards

Module 1 Flashcards

1
Q

Assessment Mneunomic for history of present illness: OLD CARTS

A

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

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2
Q

What are some of the objective effects and signs of pain?

A

Stress response (increased respirations), muscle tension, facial grimacing, guarding, bracing, rubbing painful areas

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3
Q

What are the 5 broad categories of pain?

A

acute pain
musculoskeletal pain
complex regional pain syndrome (CRPS)
chronic pain
neuropathic pain

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4
Q

What are the 4 types of musculoskeletal pain?

A

1) visceral pain - abdominal organs
2) somatic pain
3) cutaneous pain (skin
layers, “burning” “sharp”)
4) referred pain (cardiac pain; phantom pain)

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5
Q

Chronic pain

A

“no known cause or treatment” - affects approx. 40% of US population

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6
Q

How does aging influence pain?

A

Pain is prevalent in older adults, pain sensation is NOT diminished, pain is NOT considered a normal consequence of aging

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7
Q

What is the pain rating scale (0-10) with the faces called?

A

Wong-Baker FACES Pain Rating Scale

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8
Q

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

A

FLACC scale

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9
Q

What do JHACO standards require in regards to pain?

A

Pain must be assessed and reassed regularly

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10
Q

How do you assess a patient’s level of consciosness?

A

-Alertness
-Orientation: (person, place, time & situation)

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11
Q

How do you assess Orientation?

A

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?

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12
Q

What are the 4 steps of psychomotor assessment (the ‘doing of health assessment’)?

A

Inspection (looking)
Palpation - (touching)
Percussion (honestly - not done often) - drumming to know what’s going on based on the sound
Auscultation (listening)

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13
Q

The ulnar aspect is more sensitive to _____

A

vibration

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14
Q

The dorsal aspect is more sensitive to _____

A

heat

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15
Q

Temperature is regulated by this part of the brain

A

hypothalamus

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16
Q

What do neonates do instead of shivering?

A

They have special brown adipose tissue that can be broken down if more heat is needed

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17
Q

How does aging affect temperature regulation?

A

It’s easier for the elderly to overheat because they have fewer sweat glands (this is also true for infants)

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18
Q

All of the following are examples of _____:
Radiation
Convection
Conduction
Evaporation

A

Mechanisms of heat loss

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19
Q

What is the normal range for temperature?

A

36.7 - 37

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20
Q

what are the steps of the nursing process?

A

assessment, diagnosis, planning, implementation, evaluation

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21
Q

define nursing diagnosis

A

clinical judgment made by a nurse to identify and describe a client’s actual or potential health problems

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22
Q

nursing diagnosis vs medical diagnosis

A

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.

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23
Q

“Impaired Gas Exchange,” “Acute Pain,” “Ineffective Coping,” “Risk for Falls,” and “Impaired Mobility” are all examples of _____

A

nursing diagnoses

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24
Q

what are the three components of a nursing diagnosis?

A

problem, etiology (or related factors), signs & symptoms

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25
Q

what are the three types of nursing assessments?

A

emergency, comprehensive, focused

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26
Q

what are the components of an emergency assessment?

A

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)

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27
Q

comprehensive nursing assessment

A

-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

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28
Q

what is the purpose of a comprehensive nursing assessment?

A

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

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29
Q

what are the components of a comprehensive nursing assessment?

A

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.

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30
Q

what is a focused assessment?

A

a focused assessment is a targeted and specific assessment conducted to gather information about a particular problem, concern, or a specific body system

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31
Q

what is SBAR communication?

A

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

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32
Q

which is bigger on a stethoscope - the bell or diaphragm?

A

the diaphragm

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33
Q

what do you use the diaphragm of a stethoscope for? what kind of pressure do you apply?

A

-Commonly used for high-frequency sounds, such as lung and bowel sounds, as well as normal heart sounds
-Apply firm pressure

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34
Q

what do you use the bell of a stethoscope for? what kind of pressure do you apply?

A

-used for low-frequency sounds, such as murmurs and some vascular sounds
-apply light pressure

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35
Q

otoscope

A

An otoscope is a medical device used to examine the ears and ear canal for diagnostic purposes.

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36
Q

Define sentinel event

A

an unexpected occurrence or death that results in serious harm or poses a risk of serious harm to a patient in a healthcare setting

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37
Q

Three quarters of all sentinel events are caused by a failure in ______

A

communication

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38
Q

What is an acute/urgent respiratory rate?

A

less than 8
more than 28

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39
Q

What is an acute/urgent HR?

A

less than 50
greater than 120`

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40
Q

what is considered acute/urgent for oxygen saturation?

A

acute change in O2 status less than 90 despite oxygen administration

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41
Q

what is considered acute/urgent for a fever?

A

greater than 102.2 F (39 C)

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42
Q

Point-of-care documentation

A

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.

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43
Q

Clinical pathway

A

A standard plan of care for patients with a specific medical condition or undergoing a specific procedure

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44
Q

what is the normal range for temperature?

A

36.5-37C ( 97.7-98.6F)

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45
Q

what are 5 factors influencing BP?

A

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.

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46
Q

when would you call rapid response for temperature?

A

<95
>103.3

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47
Q

This type of pain originates from the skin, muscles, bones, joints, or connective tissues, typically described as a sharp, localized, and well-defined sensation

A

Somatic pain

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48
Q

this type of pain originates from abdominal organs and is often described as gnawing or crampy

A

visceral pain

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49
Q

what are some possible causes of temperature elevation?

A

-infection
-overexertion
-hypothalamus problem
-medications or illegal drugs
-overdressing

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50
Q

low temp causes

A

severe infection
hypothalamus problem
underactive thyroid
slow metabolism of the elderly

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51
Q

Hypothermia temp

A

<35C
<95F

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52
Q

Hyperthermia temp

A

> 37.8C

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53
Q

Number of heartbeats per minute

A

Heart rate

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54
Q

Heart rate, heart rhythm/regularity and amplititude are the components that make up the _______

A

pulse

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55
Q

How do you report the AMPILITUDE of the pulse?

A

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)

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56
Q

what are possible causes for tachycardia?

A

-recent exercise
-fever
-anxiety, fear, pain
-blood loss, anemia, or dehydration
-respiratory distress
-medications or illegal drugs
-caffeine ingestion or smoking

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57
Q

what are the possible causes of bradycardia?

A

-conditioned athlete
-hypothermia
-immobility or sleep
-medications or illegal drugs

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58
Q

what is the technique for finding a pulse?

A

-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)

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59
Q

apnea

A

no breath

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60
Q

dyspnea

A

difficulty breathing

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61
Q

bradypnea

A

slow breaths

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62
Q

tachypnea

A

fast breaths

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63
Q

respiratory rate, rhythm, and depth/effort are components to assess _______

A

respirations

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64
Q

what are some words you can use to describe the depth and effort of respirations?

A

shallow, normal, deep
labored, unlabored

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65
Q

what are possible causes of tachypnea?

A

-fever
-exercise
-blood loss or anemia
-stimulant drugs
-respiratory illness (e.g. COPD)
-Metabolic problem (e.g. diabetic ketoacidosis)

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66
Q

what are possible causes of bradypnea?

A

-sedation
-sleep
-medication/drugs
-brain stem injury
-dying

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67
Q

the force that the blood places on the arterial walls

A

blood pressure

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68
Q

blood pressure is measured in _____

A

mm Hg (millimeters of mercury)

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69
Q

if a patient is losing blood you would expect the blood pressure to _____

A

drop

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70
Q

what are the ranges for prehypertension for SBP and DBP?

A

SBP 120-129
OR
DBP 80-89

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71
Q

white coat syndrome

A

BP is elevated due to anxiety over the appointment/situation

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72
Q

hypertensive crisis:
SBP > ?
DBP > ?

A

SBP >180
OR
DBP > 110

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73
Q

at what rate do you want to deflate the sphygmamanometer to get an accurate blood pressure?

A

2 mm Hg / second (one dash on the meter)

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74
Q

Korotokoff sounds

A

-pulsation sounds
-the most important are 1 (start) and 5 (silence)
-it takes a trained ear to hear sounds 2-4

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75
Q

what variables affect blood pressure?

A

-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

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76
Q

Orthostatic hypotension

A

AKA postural hypotension
low BP when standing from seated/lying
dizziness, blacking out, lightheaded

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77
Q

what causes orthostatic hypotension?

A

Decreased circulating volume
Medical conditions
Dehydration
Medications

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78
Q

Mental status is assessed throughout the physical examination. What will you be evaluating?

A

-grooming- poor hygiene
-emotional status- bright affect, depressed
-body language-slumped, lack of eye contact

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79
Q

Besides A&O x4, what are some ways to describe LOC?

A

Alert

Confused -“disoriented”- difficulty following commands, poor memory

Drowsy - pt is lethargic

Stupor - pt responds only briefly to repeated stimuli

Comatose - pt is unresponsive

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80
Q

If patient has Glasglow Coma Scale of 3, is this concerning?

A

Yes - this would be high priority

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81
Q

If patient has a Glasglow Coma Scale of 15, is this concerning?

A

No patient is responsive and alert - this is normal

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82
Q

How to assess short-term memory?

A

-Three word recall after 5-10 mins (e.g. bed, phone, chair)
-OR go in after breakfast - “what did you have for breakfast?”

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83
Q

How to assess long-term memory?

A

-Ask something you can pull from their history

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84
Q

Mini-Cog and the mini mental status examnination (MMSE)

A

-cognition
-these are not used to diagnose anyone, but as an initial assessment

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85
Q

For cognitive ability, if you sense a problem you can assess a patient’s higher-level thinking and motors skills with the ____ _____ _____ ____.

A

Mini-Mental Status Examination (MMSE)

86
Q

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

A

Mini-Mental Status Examination (MMSE)

87
Q

What is the total score of the MMSE ?

A

30 is a perfect score

88
Q

Three word recognition and recall and clock drawing are components of the ___ _____ assessment

A

mini cog

89
Q

What is CIWA?

A

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Scale

90
Q

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

A

CIWA

91
Q

What proportion of women are victims of violence?

A

1/3 of women are victims of violence worldwide
-often goes unreported

92
Q

what’s a good way to assess daily routine?

A

“what does a typical day look like for you?”

93
Q

Delirium

A

Generally has an underlying medical cause - resolves after treatment of cause

94
Q

a simple physical examination performed to assess the hydration status or fluid balance in the body

A

turgor test

95
Q

what equipment is used to inspect the skin?

A

paper tape measures, penlights, magnifying glass, sterile cotton tipped applicator

96
Q

nevi/nevuses

A

moles

97
Q

subcutaneous tissue is made up of ______ tissue

A

adipose

98
Q

sensation & perception, thermoregulation, fluid balance, synthesis of vit D, excretion, immunity are all functions of the _______

A

skin

99
Q

These plates of keratin are on your hands

A

nails

100
Q

this cancer of the melanocytes has a strong genetic component and often rapid progression

A

melanoma

101
Q

what are the side effects of steroids?

A

-weight gain
-anger
-suppress immune system
-

102
Q

an inflammatory disease of the sebaceous follicles of the skin, marked by comedones, papules, and pustules

A

acne

103
Q

a chronic immune disorder that causes the skin to develop silvery, scaly plaques

A

psoriasis

104
Q

a chronic inflammatory skin condition characterized by red, itchy, and sometimes scaly patches on the skin

A

eczema

105
Q

the most common and most preventable cancer in the US

A

skin cancer

106
Q

UV radiation from indoor tanning beds increase risk of melanoma by _____

A

75%

107
Q

systemic color change of the skin due to excessive levels of bilirubin in the blood, may cause lasting neurological damage if left untreated

A

jaundice

108
Q

skin presentation often seen in anemia, a decrease in circulating red blood cells or blood flow, or absence of oxygenated blood

A

pallor/pale

109
Q

a blue, grey, or dark purple discoloration of the skin or mucous membranes that reflects poor oxygenation

A

cyanosis

110
Q

carotenemia

A

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

111
Q

red, pink skin color, may indicate inflammation, fever, or increased blood flow

A

erythema

112
Q

chronic autoimmune condition that causes loss of pigmentation that causes patches of skin to lose pigment or color

A

vitiligo

113
Q

inherited disorder caused by the total or partial absence of an enzyme that produces melanin

A

albanism

114
Q

this neurological condition that causes rapid, repetitive, involuntary eye movements often occurs with albanism

A

nystagmus

115
Q

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)

A

conjunctiva

116
Q

what conditions can affect skin texture?

A

-autoimmune disorders
-hormonal conditions/changes
-rosacea
-acne
-eczema

117
Q

an overgrowth of connective tissue and commonly seen on dark skinned individuals

A

keloid formation

118
Q

A
B
C
D
E

of melanoma

MEMORIZE

A

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

119
Q

what questions would you use to assess a rash?

A

-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?

120
Q

these small (<0.5 cm) red, itchy lesions are known as hives or _____

A

wheals

121
Q

small (<0.5 cm) , flat freckle in a bigger patch (>1 cm)

A

macule

122
Q

another words for “pus-sy” drainage

A

purulent

123
Q

excoriation

A

scratching (hollow)

124
Q

erosion

A

depressed, moist shiny

125
Q

erosions of different layers of skin

A

ulcer

126
Q

linear break in the skin

A

fissure

127
Q

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

A dermatome

128
Q

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)

A

Zosteriform

129
Q

what bony prominences are at risk of having pressure injuries?

A

-back of head
-shoulders
-knees
-heels

-elbow
-lower back/buttocks
-hip

130
Q

pressure injury characterized by non-blanchable red area

A

stage 1

131
Q

pressure injury characterized by damage to the dermis “full-thickness”

A

stage 3

132
Q

what’s the difference between stage 3 and 4 pressure injuries?

A

stage 4 will have damage to bone, tendon, or muscle

133
Q

Unilateral swelling, redness, tenderness, pain, and warmth in an extremity are possible indicators of these complications

A

deep vein thrombosis or phlebitis

134
Q

Additional risk factors for pressure injuries

A

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

135
Q

What is the SPICES tool?

A

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

136
Q

What are some common causes of delirium?

A

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.

137
Q

Delirium screenings

A

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.

138
Q

Vital sign range for newborns

A

35.9–36.9 (96.7–98.5)

70–190

30–40

73/55

139
Q

Vital sign range for infants

A

37.1–38.1 (98.7–100.5)

80–160

20–40

85/37

140
Q

VS for Toddler

A

37.1–38.1

98.7–100.5

80–130

25–32

89/46

141
Q

VS for Child

A

36.8–37.8 (98.2–100)

70–115

20–26

95/57

142
Q

VS for Preteen

A

35.8–37.5

96.4–99.5

65–110

18–26

102/61

143
Q

VS for Teen

A

35.8–37.5

96.4–99.5

55–105

12–22

112/64

144
Q

VS for older adult

A

Aged Adult (65+ years)

35.8–36.8 (96.4–98.3)

40–100

16–24

120/80

145
Q

body temperature is usually about ____ lower in the early morning

A

0.6°C (1.0° to 2.0°F) (sometimes even a little more in children)

146
Q

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).

A

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).

147
Q

Fever occurs in response to an upward displacement of the thermoregulatory set point in the ______, caused by pyrogens (substances that cause fever).

A

hypothalamus

148
Q

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

A

hyperpyrexia

149
Q

heat-loss mechanisms in the body

A

sweating, vasodilation, increased respirations

150
Q

________ 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.

A

Hyperthermia

151
Q

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 _____

A

FUO (fever of unknown origin)

152
Q

______ fever is the result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or increased intracranial pressure.

A

Neurogenic

153
Q

Physical Effects of Fever

A

Loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase.

154
Q

Therapeutic hypothermia, the purposeful lowering of the core body temperature, has been used to improve outcomes after ________

A

cardiac arrest

155
Q

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])

A

35°C (95°F)

156
Q

Risk factors for hypothermia

A

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.

157
Q

Physical Effects of Hypothermia

A

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.

158
Q

The axilla remains the most common place for temperature measurement in the ______

A

neonate

159
Q

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.

A

slow

160
Q

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).

A

neutropenic

161
Q

At these two sites, a temp of 100 F is considered a normal reading

A

temporal
rectal

162
Q

The pulse is regulated by the autonomic nervous system through the _____ node (the pacemaker) of the heart.

A

sinoatrial (SA)

163
Q

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.

A

increases

164
Q

Women on average have slightly _____ pulse rates than men.

A

higher

165
Q

Pulse rate ______ as a person ages due to decreased metabolic rate.

A

decreases

166
Q

Fever tends to _____ the heart rate

A

increase

167
Q

Causes for bradycardia

A

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.

168
Q

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

A

neuropathic pain

169
Q

There are several mechanisms involved in ______ pain, including peripheral sensitization, neuronal windup, and central sensitization.

A

neuropathic

170
Q

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

A

Peripheral sensitization

171
Q

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

A

Neuronal windup

172
Q

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

A

Central sensitization

173
Q

What are some risks of inadequately treated pain?

A

-Impairs pulmonary function
-Decrease immune response
-Prolongs hospital stay
-May result in neuropathic pain syndromes

174
Q

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.

A

Complex regional pain syndrome (CRPS)

175
Q

A commonly used scale for measuring subjective experiences, particularly pain intensity, where patients rate their pain on a continuum using a horizontal line

A

Visual Analog Scale

176
Q

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

A

Visual Analog Scale

176
Q

A pain assessment tool that utilizes a series of descriptive words or phrases to represent different levels of pain intensity

A

Verbal descriptor scale (VDS)

177
Q

A scale used to assess pain intensity, where individuals select a number from 0 to 10 to represent their pain level

A

Numeric Pain Intensity Scale

178
Q
A

Combined thermometer scale (combines Visual Analog Scale and Numeric Pain Intensity Scale)

179
Q

Multidimension pain scale used for experimentally induced circumstances, following procedures, with several medical–surgical conditions

A

McGill Pain Questionnaire

180
Q

Multidimensional pain scale initially used for cancer pain, also valid for chronic nonmalignant pain

A

Brief Pain Inventory

181
Q

Pain scale used for chronic pain

A

Brief Pain Impact Questionnaire (BPIQ)

182
Q
A

Combined thermometer scale

-Verbal Descriptor Scale (VDS) and Numeric Pain Intensity Scale (NPI)

183
Q

when is a diagnosis of stage 1 hypertension made?

A

BP over 140/90 on 2+ separate occasions

(Either SBP >140+ OR DBP >110)

184
Q

when is stage 2 hypertension made?

A

SBP 160+
OR
DBP 100+

185
Q

How do you know a BP cuff fits correctly?

A

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

186
Q

Under what circumstances should an arm NOT be used for taking a blood pressure?

A

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

187
Q

How does taking a BP on the leg affect the accuracy of the measurement?

A

The SBP will be 10-40 mmHg higher in this site
The DBP will be about the same

188
Q

How is orthostatic BP diagnosed?

A

-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

189
Q
A

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

190
Q

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

A

Mini-Cog

191
Q

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

A

Mini-Mental Status Examination (MMSE)

192
Q

How do you organize mental status assessment with ABCT plus MMSE?

A

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

193
Q

Where can you assess color changes on dark-skinned people?

A

Conjunctiva, palm of the hand, mucous membranes

194
Q

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

A

Peripheral cyanosis

195
Q

Autoimmune disorder that causes smooth, white patches all over the body

A

Vitiligo

196
Q

What is the difference between sclera and conjunctiva?

A

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.

197
Q

Bluish discoloration to the
skin related to decreased circulating oxygen;
best assessed in the oral mucosa, conjunctiva
of the eyes, lips, and tongue

A

central cyanosis

198
Q

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

A

Erythema

199
Q

Inherited disorder caused by the total or
partial absence of an enzyme that produces melanin

A

albanism

200
Q

an inflammatory skin condition causing redness, swelling, and
spider-like blood vessels to develop on the middle of the face

A

Rosacea

201
Q

An overgrowth of connective tissue and commonly
seen on dark skinned individuals

A

keloid

202
Q

Common causes of rashes

A

Diet, stress, medications, allergies, hormone imbalance, autoimmune disease, kidney disease, toxic reactions, digestive problems

203
Q

Primary vs secondary lesions

A

Occur in reaction to the external or internal
environment. They

203
Q

Primary vs secondary lesions

A

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

204
Q

What is a normal finding for the size of a nevus?

A

<0.6 cm (6 mm)

205
Q

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)

A

primary

206
Q

A pattern of skin involvement that follows the dermatomal distribution of a nerve, often seen in conditions like herpes zoster (shingles).

A

Zosteriform

207
Q

A specific area of skin that is primarily supplied by a single spinal nerve or nerve root.

A

Dermatome

208
Q

Hair changes can be related to:

A

 Diet
 Stress
 Genetics
 Infection
 Infestation
 Endocrine disorders

209
Q

Nail changes can be related to:

A

 Nutrition
 Stress
 Systemic disease
 Vitamin deficiency
 Infection
 Nail biting or picking
 Nail care

210
Q

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

A

Clubbing

Health Assessment (8 decks)

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