Quiz 1 Flashcards
normal vitals: newborn <28 days
HR: 120 - 160
BP: 60-90 / 20-60
RR: 30 - 60
Temp: 96.4 - 99.1
normal vitals: toddlers 1-4 yo
HR: 90 - 140
BP: <120 / <80
RR: 24 - 40
Temp: 96.4 - 99.1
normal vitals: school age 5-11 yo
HR: 75 - 100
BP: <120 / <80
RR: 18 - 30
Temp: 96.4 - 99.1
normal vitals: adolescents ≥13 yo
HR: 60 - 90
BP: <120 / <88
RR: 12 - 16
Temp: 96.4 - 99.1
normal vitals: adults
HR: 60 - 100
BP: <130 / <85
RR: 12 - 20
Temp: 96.4 - 99.1
Focused/Problem-Oriented Assessment
- pt alrdy had comprehensive exam
- being seen for follow up visit or when pt has new problem/Sx(s)
Episodic/Follow-Up Assessment
pt comes in w/ specific issue then had follow up check up that evaluates Tx results
Components of health assessment
- comprehensive health Hx/interview
- CC(s) of Sx(s) noted in pt’s own words
- HPI: chronological account of problems OLD CART-ed
- PMHx: allergies, childhood/adult illnesses, health maintenance, meds
- Family Hx: causes of death and illnesses/disorders
- ROS: categorize Sxs to body systs
- Health patterns: personal/social Hx influencing health/illness
- Physical exam/vitals
- ADPIE
Categorizing problems: most to least severe
- Cluster via body region:
- Ie. CC of headache ⇒ localized to skull and brain ⇒ S&Ss occurs in 1 single syst ⇒ likely 1 disease explains it
- Multisystem conditions: cluster w/ corresponding S&S
- Ie. pt has cough, hemoptysis, weight loss ⇒ record lung cancer high on problem list
- Sifting thru data and asking questions that allows you to temporarily ignore minor issues
- Ie. asking what produces and relieves pt’s chest pain and getting answer that exercise and rest does ⇒ lets you focus on issue being of cardiovasc and musculoskel cysts and set aside it being GI syst issue
- Ie. chest pain is substernal and burning happens only after meals ⇒ focus on it likely being GI tract issue
- Cluster data to single or multiple problems
- Ie. cluster via age: younger ppl likely to have 1 disease VS. older ppl likely to have multiple
- Ie. cluster via time of Sxs: know natural Hx of diseases and conditions to figure out relevance
beginning level therapeutic communication
- Active listening: paying close attention to what pt is communicating, being aware of their emotional state
- Guided questioning: facilitate pt’s fullest communication by encouraging pt to disclosures while minimizing risk for distorting pt’s ideas or missing significant details
- Nonverbal communication: pay attention to eye contact, facial expression, posture, head position
- can mirror pt’s paralanguage (quality of speech) like tone, volume, etc.
- Empathetic responses/validation/reassurance
- Summarizing: capsule summary of pt’s story to identify/confirm what you know/don’t know → asking pt if there are other info they’d like to add and correct any misunderstandings
- Transitions: tell pt you’re changing directions during interview → orient pt w/ brief transitional phrases → clearly tell pt what to expect or do next
- Empowering pt: convey interest in person, follow pt’s lead
Causes for abnormal HR
- ↑ : coronary blockage, stress/anxiety, exercise, caffeine, dehydration
- ↓ : sleeping, septic infection, rapid loss of blood, hypothermia
Causes for abnormal BP
- ↑ : high sodium and low potassium levels, being angry/distressed, exercising, smoking
- ↓ : significant blood loss, diuretics, dehydration, hypothermia, sepsis
Causes for abnormal RR
- ↑ : asthma attack, high altitudes, smoking
- ↓ : substance overdose, brain injury to certain regions, hyperthyroidism, sleep apnea
Causes for abnormal Temp
- ↑ : fever, heat exhaustion
- ↓ : anorexia, anemia, hypothyroidism
Cultural competence
need for set of skills necessary to care for ppl of diff cultures in a way that’s respectful, ethical, effective
Cultural humility
- process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners
- Process that includes examining cultural beliefs and cultural systs of both pts and nurses to locate points of cultural dissonance or synergy that contribute to pts’ health outcomes
spiritual distress
when pt experiences disruption in life principle that pervades person’s being and integrates and transcends one’s biologic and psychological nature
National CLAS standards
- Principle standard: provide quality care and services responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, other communication needs
- Governance, Leadership, Workforce: educate and train governance, leadership, workforce in culturally and linguistically appropriate policies and practices
- Communication and Language Assistance: offer language assistance to pts who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services
- Engagement, Continuous Improvement, Accountability: establish culturally and linguistically appropriate goals, policies, management accountability
SDOH: SSEIFOPE
- social
- spiritual
- environmental
- financial
- occupational
- physical
- emotional
TIC before, during, after exam
- before: check for nonverbal cues, no sudden movements, keep eye contact, keep hands in sight
- during: transitions, drapping and modesty, permission to do everything, warning abt incoming touch sensations, keep within eyesight, use simple clinical language, tell them length of exam, take breaks
- after: discuss results, ask if they have any questions, thank them
nutritional assessment: Hx and physical exam
- HPI/ROS: note change in weight, appetite, energy, smell/taste, difficulty chewing or swallowing
- Family Hx (FH): note obesity, allergies, eating disorders, EtOH abuse, short stature, metabolic conditions
- PMH: note chronic conditions that affect metabolism, food allergies, eating disorders, trauma, depression, anxiety
- Psycho-Social Hx (PSH): note money for food, time, ability to prep own food, access to healthy food, dentures, feeding tubes, etc.
- Meds: pay attention to those affecting metabolism, effect weight or have special diet considerations
- Dietary intake: note fat, Na+, protein levels, produce, special diets
- Exercise: note type of exercise in detail
Objective Manifestations of Nutritional Deficiencies in Following Systems: skin, hair, nails, EENT, cardiovasc, GI, musculoskel, neuro
- Skin: dry skin, low turgor (dehydration), edema (↓ protein), ecchymosis (↓ Vit K)
- Hair: dull, alopecia (↓ protein, fatty acids)
- Nails: clubbing (↓ Fe), white spots (↓ zinc), white streaks (heavy metal exposure)
- Eyes-nose-mouth-throat: mucous membranes moist/pink (dehydration), tongue w/ papillae (↓ riboflavin), neck masses (↓ iodine)
- Cardiovasc: arrhythmia (↓ + ↑ K), heart block (↓ Mg), any peripheral edema, pulses palpable, bp lvls
- GI: distended abdomen (ascites)
- Musculoskeletal: muscle weakness, wasting (↓ protein), peripheral neuropathy (↓ thiamin), skeletal malformation (↓ Vit D)
- Neurologic: altered mental status (dehydration), paresthesia (↓ B12)
BMI: underweight, normal weight, overweight, obesity
- underweight: <18.5
- normal weight: 18.5 - 24.9
- overweight: 25 - 29.99
- obesity: ≥ 30
waist circumference
- high circumference ⇒ increased risk for cardiovasc disease
- Females norm: ≤ 35
- Males norm: ≤ 40
Anorexia Nervosa
- Restricted calories w/ significantly low BMI
- Sxs: dizziness, irregular heartbeat, low bp, poor concentration/focus, SOB, bloating/abdominal pain, muscle weakness
Bulimia Nervosa
- Repeated binge eating + use of inappropriate compensatory behavior to prevent weight gain (ie. self-induced vomitting)
- Sxs: swollen cheeks/jawline, GI problems, scars/scrapes on knuckles, irregular menstrual periods, muscle weakness, bloodshot eyes, dehydration
Binge Eating Disorder
- Most common
- Repeated binge eating episodes during & person feels loss of control and marked distress over their eating
- Not followed by purging, excessive exercise, or fasting
- Sxs: diabetes, high bp, high cholesterol, heart disease/stroke, certain cancers, gallbladder disease, depression, anxiety
Refeeding Syndrome
- Severe electrolyte and fluid shifts associated w/ metabolic abnormalities in malnourished pts undergoing refeeding (orally, enterally, parenterally)
- S&Ss: electrolyte imbalances (↓ K; + ↓ Mg), Vit deficiencies (↓ thiamine), altered glucose metabolism, fluid imbalance (salt retention), impaired organ function, cardiac arrhythmias
who’s at risk for Malnutrition
- Poverty
- Old age
- Socially isolated
- Physical disability
- Emotionally/Mentally impaired
- Lack of teeth
- Ill-fitting dentures
- Alcoholism
- Drug abuse
who’s at risk for Obesity
- Being poor in middle-income country adopting western lifestyle
- BMI > 25
- Lack of physical activity
- Not enough sleep
- Chronic stress
- Steroids
who’s at risk for refeeding syndrome
- Malnourished
- Chronic nutritionally deprived
- Prolonged fasters
- Massive weight loss in obese pts (including gastric surgeries)
- Chronic ethanol (EtOH)
- Anorexia nervosa
- Prolonged IV fluids
Serum albumin
↓ lvls = protein deficiency (reflects albumin lvls last 3-4 wks)
Prealbumin
reflects albumin lvls from last 2-3 d
HgB/HCT
many reflect ↓ Fe, folate, Vit B12 (or hemorrhage), overhydration/dehydration
Transferrin: related to iron
- ↓ lvls = may reflect low protein stores/production, infection, cancer
- ↑ lvls = severe iron deficiency
Glucose
related to diabetes mellitus (DM)
Hgb A1C: another way to measure glucose
- Looks at average over last 3 months
- < 5.5 = normal VS. > 5.6 high
Lipids: HDL, LDL, Triglycerides
- Affected by intake of fatty foods, carbs, EtOH
- Genetic disposition
- ↑ lvls LDL, Triglycerides = increased risk of CVD, (peripheral vasc disease) PVD, CVA
Vit D and Ca+
↓ lvls = increased risk of osteoporosis and some CA
