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Health Assessment LECT | Quiz/Exam 1 > Quiz 1 > Flashcards

Quiz 1 Flashcards

1
Q

normal vitals: newborn <28 days

A

HR: 120 - 160
BP: 60-90 / 20-60
RR: 30 - 60
Temp: 96.4 - 99.1

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2
Q

normal vitals: toddlers 1-4 yo

A

HR: 90 - 140
BP: <120 / <80
RR: 24 - 40
Temp: 96.4 - 99.1

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3
Q

normal vitals: school age 5-11 yo

A

HR: 75 - 100
BP: <120 / <80
RR: 18 - 30
Temp: 96.4 - 99.1

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4
Q

normal vitals: adolescents ≥13 yo

A

HR: 60 - 90
BP: <120 / <88
RR: 12 - 16
Temp: 96.4 - 99.1

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5
Q

normal vitals: adults

A

HR: 60 - 100
BP: <130 / <85
RR: 12 - 20
Temp: 96.4 - 99.1

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6
Q

Focused/Problem-Oriented Assessment

A
  • pt alrdy had comprehensive exam
  • being seen for follow up visit or when pt has new problem/Sx(s)
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7
Q

Episodic/Follow-Up Assessment

A

pt comes in w/ specific issue then had follow up check up that evaluates Tx results

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8
Q

Components of health assessment

A
  • 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
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9
Q

Categorizing problems: most to least severe

A
  • 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
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10
Q

beginning level therapeutic communication

A
  • 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
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11
Q

Causes for abnormal HR

A
  • ↑ : coronary blockage, stress/anxiety, exercise, caffeine, dehydration
  • ↓ : sleeping, septic infection, rapid loss of blood, hypothermia
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12
Q

Causes for abnormal BP

A
  • ↑ : high sodium and low potassium levels, being angry/distressed, exercising, smoking
  • ↓ : significant blood loss, diuretics, dehydration, hypothermia, sepsis
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13
Q

Causes for abnormal RR

A
  • ↑ : asthma attack, high altitudes, smoking
  • ↓ : substance overdose, brain injury to certain regions, hyperthyroidism, sleep apnea
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14
Q

Causes for abnormal Temp

A
  • ↑ : fever, heat exhaustion
  • ↓ : anorexia, anemia, hypothyroidism
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15
Q

Cultural competence

A

need for set of skills necessary to care for ppl of diff cultures in a way that’s respectful, ethical, effective

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16
Q

Cultural humility

A
  • 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
17
Q

spiritual distress

A

when pt experiences disruption in life principle that pervades person’s being and integrates and transcends one’s biologic and psychological nature

18
Q

National CLAS standards

A
  • 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
19
Q

SDOH: SSEIFOPE

A
  • social
  • spiritual
  • environmental
  • financial
  • occupational
  • physical
  • emotional
20
Q

TIC before, during, after exam

A
  • 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
21
Q

nutritional assessment: Hx and physical exam

A
  • 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
22
Q

Objective Manifestations of Nutritional Deficiencies in Following Systems: skin, hair, nails, EENT, cardiovasc, GI, musculoskel, neuro

A
  • 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)
23
Q

BMI: underweight, normal weight, overweight, obesity

A
  • underweight: <18.5
  • normal weight: 18.5 - 24.9
  • overweight: 25 - 29.99
  • obesity: ≥ 30
24
Q

waist circumference

A
  • high circumference ⇒ increased risk for cardiovasc disease
  • Females norm: ≤ 35
  • Males norm: ≤ 40
25
Q

Anorexia Nervosa

A
  • Restricted calories w/ significantly low BMI
  • Sxs: dizziness, irregular heartbeat, low bp, poor concentration/focus, SOB, bloating/abdominal pain, muscle weakness
26
Q

Bulimia Nervosa

A
  • 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
27
Q

Binge Eating Disorder

A
  • 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
28
Q

Refeeding Syndrome

A
  • 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
29
Q

who’s at risk for Malnutrition

A
  • Poverty
  • Old age
  • Socially isolated
  • Physical disability
  • Emotionally/Mentally impaired
  • Lack of teeth
  • Ill-fitting dentures
  • Alcoholism
  • Drug abuse
30
Q

who’s at risk for Obesity

A
  • Being poor in middle-income country adopting western lifestyle
  • BMI > 25
  • Lack of physical activity
  • Not enough sleep
  • Chronic stress
  • Steroids
31
Q

who’s at risk for refeeding syndrome

A
  • Malnourished
  • Chronic nutritionally deprived
  • Prolonged fasters
  • Massive weight loss in obese pts (including gastric surgeries)
  • Chronic ethanol (EtOH)
  • Anorexia nervosa
  • Prolonged IV fluids
32
Q

Serum albumin

A

↓ lvls = protein deficiency (reflects albumin lvls last 3-4 wks)

33
Q

Prealbumin

A

reflects albumin lvls from last 2-3 d

34
Q

HgB/HCT

A

many reflect ↓ Fe, folate, Vit B12 (or hemorrhage), overhydration/dehydration

35
Q

Transferrin: related to iron

A
  • ↓ lvls = may reflect low protein stores/production, infection, cancer
  • ↑ lvls = severe iron deficiency
36
Q

Glucose

A

related to diabetes mellitus (DM)

37
Q

Hgb A1C: another way to measure glucose

A
  • Looks at average over last 3 months
  • < 5.5 = normal VS. > 5.6 high
38
Q

Lipids: HDL, LDL, Triglycerides

A
  • Affected by intake of fatty foods, carbs, EtOH
  • Genetic disposition
  • ↑ lvls LDL, Triglycerides = increased risk of CVD, (peripheral vasc disease) PVD, CVA
39
Q

Vit D and Ca+

A

↓ lvls = increased risk of osteoporosis and some CA

Health Assessment LECT | Quiz/Exam 1 (4 decks)

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