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Nurs321 > Quiz 1 > Flashcards

Quiz 1 Flashcards

1
Q

Types of Health Assessment

A

Comprehensive, Problem based or focused, Episodic or follow up assessment, screening

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2
Q

Signs

A

Objective, what you observe

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3
Q

Symptoms

A

Subjective, what the patient reports

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4
Q

Levels of Health Promotion*

A

Primary: Prevents disease
Secondary: Early identification
Tertiary: Minimizing severity and disability

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5
Q

Give examples of the different levels of health promotion*

A

Primary: vaccination
Secondary: diagnosing asymptomatic hypertension
Tertiary: Dialysis for renal failure

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6
Q

Goals of the interview

A
  • discover information leading to diagnoses and management
  • provide information about diagnoses
  • negotiate and share in health care management
  • counsel about disease prevention
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7
Q

Factors that enhance communication

A 
Courtesy
Comfort
Confidentiality
Connection
Confirmation
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8
Q

If the patient doesn’t understand what you are saying remember to:

A

Facilitate: encourage the patient to say more
Reflect: repeat what you’ve heard
Clarify: ask “what do you mean”
Empathize: (not sympathize) Show understanding and acceptance
Confront: Address disturbing patient behavior
Interpret: Repeat what you’ve heard to confirm the patients meaning

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9
Q

Setting for the interview

A
  • comfort
  • removal of all physical barriers
  • good lighting
  • privacy
  • relatively quiet
  • unobtrusive access to a clock
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10
Q

Structure of the History

A
  • The identifiers: name, date, time, age, gender, race, occupation, and referral source
  • Chief complaint
  • History of present illness (HPI)
  • Past medical history (PMH)
  • Family history (FH)
  • Personal and social history (SH)
  • Review of systems (ROS)
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11
Q

How do you clarify a patients response?

A

By asking where, when, what, how and why questions.

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12
Q

How should you end the history portion of the interview?

A

By verifying and summarizing what you have heard.

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13
Q

What should be included in the medical-surgical portion of the health history interview?

A
  • childhood illness and immunizations
  • previous injuries
  • chronic medical conditions
  • previous hospitalizations
  • previous surgeries
  • obstetric history
  • allergies
  • current medications
  • last exam date
  • dietary preferences or restrictions
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14
Q

When do you take down the HPI

A

-History of present illness is only taken down when the patient has a chief complaint, since this information is obtained form the patient it will be considered objective.

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15
Q

What information is gathered with HPI?

A

OLD CART

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16
Q

Which portion of the history do ADL and Nutrition belong?

A

Personal/Social (psychosocial)

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17
Q

Review of the systems (ROS)

A
  • The review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease…usually the final portion of the health history. [general constitutional systems, skin hair and nails, head and neck, lymph nodes, chest and lungs, breasts, heart and blood vessels, peripheral vascular, hematologic, gastrointestinal, diet. endocrine, genitourinary, musculoskeletal, neurological, psychiatric,]
  • concluding questions
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18
Q

GENERAL CONSITUTIONAL SYMPTOMS*

A

fever, chills, malaise, fatigability, night sweats, sleep patterns, weight (average, preferred, present, change)

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19
Q

Concluding health history questions

A
  • Is there anything else that you think would be important for me to know?
  • What problem concerns you the most?
  • What do you think is the matter with you?
  • What worries you the most about how you are feeling?
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20
Q

KEY POINTS TO REMEMBER WITH HEALTH HISTORY:

A
  • Document everything
  • Most everything you need to know you can learn from taking the history
  • Ask open ended questions
  • Avoid appearing judgmental
  • Practice :)
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21
Q

What is OLD CART

A

Onset, Location, Duration, Characteristic Symptoms, Associated manifestations, Relieving factors, Treatment

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22
Q

What are some nonverbal cues of pain to look for during an assessment?

A
  • guarding an area of the body
  • decrease in social interaction
  • aggression
  • increase in body movements
  • irritability: increased confusion
  • pacing/rocking
  • VS changes
  • Pallor
  • Diaphoresis
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23
Q

Assessment (with pain example)

A

Ask the patient their pain level on a scale of 0-10 (do NOT use vital signs as clues of pain; the patients self report is to be believed, accepted, and documented as the patients true level of pain)
______________________________________
Assessment is the subjective and objective data
-key points should be clustered and analyzed
-a prioritized problem list should be formulated
*The assessment phase continues throughout the entire patient encounter, which provides the potential for updates in the plan of care based on new assessments and data

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24
Q

Plan (with pain example)

A

-Priority: need to medicate ASAP
-Develop outcome: self-report pain level will be at a 4 in less than 2 hours of PO MS/orders
-Identify interventions: massage, environment control (dim lights, maintain quiet room), breathing techniques
-Document plan of care
______________________________________
Always identify your expected outcomes
Individualize the outcome (has morphine worked with this individual before?)
Be realistic
ALWAYS include a time frame

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25
Q

Diagnoses

A

-Interpret the data we collected on the patient from observation of behaviors, and from the history and self-report of pain
-Make inferences or draw conclusions
-Nursing Diagnoses ex: acute pain
-Document the nursing diagnoses
_______________________________________
The diagnoses will be formulated based on the problem, it has a nursing focus, it sets the stage for the remainder of the care plan.

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26
Q

Implementation

A
  • Review the PLANNED interventions you made
  • Schedule and coordinate anything that may be part of the plan
  • Collaborate with other team members
  • SUPERVISE the implementation that was delegated
  • Involve the patient in what is going on
  • DOCUMENT the care that is provided
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27
Q

Evaluation

A
  • Refer to the outcomes you listed in the plan
  • Summarize the results that you find
  • Take action to modify your care plan if necessary
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28
Q

Steps in the nursing process*

A

ADPIE

  • Assessment
  • Diagnoses
  • Plan
  • Intervention
  • Evaluation
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29
Q

Techniques for physical evaluation

A
  • Inspection (visual examination) [first step]
  • Palpation (use of touch for examination)
  • Percussion (tapping of fingers for examination)
  • Auscultation (auditory examination)
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30
Q

Vital Signs

A
  • Heart rate
  • Blood pressure
  • Respirations
  • Temperature
  • Pain
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31
Q

AAOx3

AAOx4

A

-ask time, place, person
-ask time, place, person, purpose
[part of oriented in mental alertness category]

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32
Q

Blood pressure

-indicated ranges for adults

A 
Normal:   S120   D80 
can be as low as 90/60
Prehypertension:   S120-139   D80-89
Hypertension
     Stage 1   S140-159   D90-99
     Stage 2   S160   D100
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33
Q

Heart rate: normal adult range

A

60-100

observe: rate, rhythm, strength, equality

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34
Q

Respirations: normal adult range

A

12-20

observe: rate, rhythm, depth, effort

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35
Q

Temperature range

-detailed information

A

98.6F (37C), normal, but not THE normal
most reliable, core taken w/tympanic, next reliable is the oral
Tympanic: 1.4F (.8C) higher than oral
Oral: 98.6F (37C) [96.4-99.1normal]
Axillary: lags behind rapid temp changes in core
Rectal:0.5-1F higher than oral

36
Q

What is the heart rate?

A

An indirect reflection of the contraction of the myocardium.
RRR=regular rate and rhythm
Normal=sinus
Irregular=time between beats is variable

37
Q

Pulse pressure

A

the difference between systolic and diastolic

38
Q

Pain scales

A
  • Numeric pain scale, descriptive pain scale, visual analogue scale (uses a centimeter ruler to mark pain for future comparison), the painometer (measures intensity, quality, and localization), wong/baker faces rating scale (used in peds usually for 3 years and older), the oucher (pictures of faces and different versions for white, blacks, and Hispanics)
  • FLACC: Behavioral pain assessment for non-verbal children (categories face, legs, activity, cry, consolability), checklist for nonverbal pain
39
Q

What is white coat hypertension?*

A

•Describes hypertension in people whose blood pressure measurements are higher in the office than at home or in more relaxed settings, usually >140/90. This phenomenon occurs in 10% to 25% of patients, especially women and anxious individuals, and may last for several visits. Try to relax the patient and remeasure the blood pressure later in the encounter.

40
Q

Apical pulse*

A

just under 4th rib down, 5th intercostal space

count for one full minute (1min)

41
Q

Components of a brief head to toe

A
  • Inspection (think safety)
  • Vital signs
  • Brief ROS
  • Brief physical assessment
  • Documentation
  • Always patient specific
42
Q

Inspection (the patient and the room)

A

The patient:

  • Level of consciousness (LOC)
  • Affect
  • Posture
  • Mobility
  • Skin color
  • Surgical site

The room:

  • IV lines and pumps
  • O2
  • call light
  • safety
43
Q

Initial vital signs in a brief head to toe?

Vital +

A

-Pain
-Temperature
-Blood pressure
-Respirations
-Heart rate (pulse)[radial AND apical]
+
-Pulse oximetry
-Weight

44
Q

ROS during brief head to toe

A
  • How are you feeling today?
  • Any changes from last night/this morning?
  • How have you been sleeping?
  • Any changes in your appetite?
  • When was your last bowel movement?
  • What is your current pain level?
45
Q

Rhonchi

A

-can be eliminated by coughing, crackles and wheezes cannot

46
Q

Full Head to Toe Assessment

A
  1. VS
  2. While taking VS observe aspects (i.e. race, gender, culture, age, physical features)
  3. Assess speech and AAOx4
  4. Inspect pupils
  5. Assess hearing
  6. Assess skin
  7. Breath sounds
    • vesicular (soft, low pitched)
    • bronchovesicular
    • bronchial (loud, higher pitched)
    • rhonchi
  8. Cardiovascular (chest pain, SOB)
    • aorta
    • pulmonic
    • erbs
    • tricuspid
    • mital
  9. Abdomen
  10. Muskuloskeletal
47
Q

Brief Physical Assessment

A
  • Focused: patient specific
  • Mental Status
  • Ausculate (heart, breath, and bowel sounds)
  • Palpate radial and pedal pulses
  • Neuro/MS: PERRLA (pupils), Extremity Movement
48
Q

Documentation (brief head to toe)

A
  • Identifying data (i.e. name, dob, gender)
  • What the patient says
  • What you observe
49
Q

Mental Status

A

The total expression of a person’s emotional responses, mood, cognitive functioning, and personality.

50
Q

Dysarthria=

A

defective articulation

51
Q

Aphasia=

A

disorder of language

52
Q

Flight of ideas=

A

continuous flow of accelerated speech in which a person changes from topic to topic with loose to no association.

53
Q

Incoherence=

A

illogical, lack of meaning

54
Q

Echolalia=

A

repetition of words and phrases of others

55
Q

CAGE

A

Cut down, Annoyed, Guilty, Eye opener
-Two or more affirmative answers to CAGE suggest misuse of alcohol
-ALWAYS SCREEN FOR DRUG AND ALCOHOL ABUSE!
______________________________________
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing you about your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves, get rid of a hangover, or start the day?

56
Q

Who is at risk for depression

A

Especially watch for symptoms in patients who are young, female, single, divorced, separated, seriously or chronically ill, or bereaved. Those with a prior family history are also at risk.

57
Q

Dysphoria=

A

irritability

58
Q

Anhedonia

A

loss of pleasure in daily activities

59
Q

Symptoms of Depression

A

Dysphoria, Anhedonia, change in appetite, change in sleep , psychomotor retardation/ agitation, guilt/worthlessness, fatigue/lack of energy, decreased concentration/ indecisiveness, suicidal thoughts/plan

  • Symptoms must be present nearly everyday, most of the day
  • Must cause impairment in social or occupational aspects of life
  • Symptoms not attributed to recent bereavement, medication, medical condition
60
Q

Afebrile

A

body temperature is not elevated, no fever

61
Q

Apnea

A

absence of breathing, no respirations

62
Q

Blood pressure

A

force of blood against arterial walls, normal 120/80

63
Q

Bradycardia

A

slow heart rate/pulse, pulse rate slow below 60 beats/min in an adult

64
Q

Bradypnea

A

slow rate of breathing, <10

65
Q

Diastolic pressure

A

least amount of pressure exerted on arteriole walls which occurs when the heart rate is at rest between ventricular contractions, ventricles are at rest and filling

66
Q

Dyspnea

A

difficulty or labored breathing

67
Q

Dysrhythmia

A

an abnormal cardiac rhythm

68
Q

Eupnea

A

normal respirtations

69
Q

Febrile

A

condition in which the body temperature is elevated, fever

70
Q

Fever

A

elevation above the upper limit of normal body temperature, synonym for pyrexia

71
Q

Hypertension

A

blood pressure elevated above the upper limit of normal
stage 1 140-159/90-99
stage 2 160 or higher/ 100 or higher

72
Q

Hyperthermia

A

High body temperature

73
Q

Hypotension

A

blood pressure below the lower limit of normal (>90), signs include pallor, skin mottling, clamminess, confusion, increased pulse rate, decreased urinary output, should be reported to MD immediately

74
Q

Hypothermia

A

low body temperature, 93.2-95.0F

75
Q

Korotkoff sounds

A

series of sounds that corresponds to changes in blood flow through artery as pressure is released; Phase 1, first faint, clear tapping or thumping sounds Systolic BP; Phase 2- muffled whoosing or swishing sound; Phase 3- blood flows freely, crisp intense sound, thumping quality but softer than phase 2; Phase 4-muffled and with a soft blowing sound; Phase 5- pressure difference when last sound is heard, period of silence - Diastolic BP

76
Q

Orthopnea

A

type of dyspnea in which breathing is easier when patient is standing or sitting

77
Q

Orthostatic hypotension

A

temporary fall in blood pressure or elevation of pulse associated with assuming an upright position; synonym for postural hypotension, considered significant if SBP decreases by 20-30 mmHg or a pulse increased by 40bpm. Take BP and pulse in supine, sitting, or standing positions. Take 1-3 minutes after position changes. Assess for dizziness, weakness, or syncope (fainting)

78
Q

Pulse

A

wave produced in the wall of the artery with each beat of the heart

79
Q

Pulse deficit

A

difference between apical and radial pulse rates; can use 1 nurse technique or 2 nurse technique; assess for difference in rates between sites

80
Q

Pulse pressure

A

difference between systolic and diastolic pressure

81
Q

Respiration

A

gas exchange between the atmospheric air in the alveoli and blood in the capillaries

82
Q

Systolic pressure

A

highest point of pressure on the arterial walls when the ventricles contract; contraction of the ventricles and ejection of the blood

83
Q

Tachycardia

A

rapid heart rate; when pulse rate is 100-180 beats/min; decrease cardiac filling time, which in turn decreases stroke volume and cardiac output

84
Q

Tachypnea

A

rapid rate of breathing, shallow, >24

85
Q

Temperature

A

refers to the hotness or coldness of a substance

86
Q

Vital signs

A

body temperature, pulse and respiratory rates and blood pressure. Pain is the 5th vital sign, pulse ox; synonym for cardinal signs

87
Q

FUO

A

Fever of unknown origin

Nurs321 (4 decks)

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