Quiz 1 Flashcards
Bloom’s Taxonomy
Remember
Understand
Apply
Analyze
Evaluate
Create
Evidence based practice
Clinical questions
Sources of evidence
Synthesize evidence
Apply evidence
Assess outcomes
- combines research, evidence, clinical knowledge, pt preferences, clinican experitise, physical exam
Nursing process
assessment
diagnosis
planning
implementation
evaluation
Subjective data
opion
what patient says
gained through interview
Objective data
what nurse observes during an exam, fact
Data bases
complete
focused
follow up
emergency
Health assessment
systematic and continous collection of data, sorting, analzying, and organizating that data; and the documentation and communication of the data collected
Therapeutic communication
purposeful conversation between nurse, pt, families
- used to reach health related goals, build trust, and maintain relationships
Characteristics of communication in healthcare
client centered, purposeful, planned, and goal directed
Essential components of therapeutic communications
time, active listening, caring, non judgemental attitude, honesty, trust, empathy
Communication
exchange of information so each person clearly understands the other, important so healthcare team knows what is going on
Faciliation
general leads like nodding
Clarification
simplify statements and ask for agreement
EX “… is this correct”
Reflection
sit quietly, allows pt time to think and answer
Explanation
share facutal and objective information
Empathy
reflects on feelings and puts them into words, sounds like you are feeling sad about…
Controntation
honest feedback
Interpretation
based on your inference/links events
Summary
final review of conversation
nontherapeutic techniques
why?
defensive
challenging the pt
changing the subject
giving advice
sterotypical comments
value judgement
feelings on hold
false reassureance
Vital signs
an objective measure of the body’s basic functions
temperature, RR, pulse, blood pressure
follows facility guidlines
Temperature
mechanism of regulation
- stable core temp of 37. 2 C
- feedback mechanism regulated in hypothalamus of brain
Oral temperatures
accurate and conveinent
sublingual
37C is normal
35.8-37.3 C range
Rectal measures
0.4 C to 0.5C higher than oral, closer to core temperature
Temperature measures
oral temperature
rectal temperature
tympanic membrane
temporal artery
Hyperthermia
above 38C
Hypothermia
below 36C
Febrile
with fever
afebrile
no fever
Factors that influence temperature
dirunal (24 hr) cycle
menstruation cycle
exersize
age (wider range in children, lower temp in older adults)
Pulse
pressure wave that expans and recoils the artery when the heart contracts and beats
check
HR
Heart rhythm
heart force
Locations to check pulse
mostly brachial and radial
Normal HR
50-95 bpm
bradykardia
less than 50 bpm
tachycardia
greater than 95 bpm
Force of pulse
heart’s stroke volume
3+ full bounding
2+ normal
1+ weak and thready
0 absent
Factors that influence pulse
fluid status
fever
medications
exercise
anxiety
Respriations
normally relaxed, regular, automatic, and silent
Normal 12-20
Bradypnea
less than 12 rr/min
tachypnea
greater than 20 rr/min
Factors influencing respiration by the following
o2 status
age
anxiety
blood pressure
how strong blood moves through BV
systolic
when the heart contracts
120
diastolic
when the heart rests
80
pulse pressure
difference between systolic and diastolic
Factors controling bp
cardiac output
peripheral vascular resistance
volumne of circulating blood
viscosity
elasticity of vessel walls
cardiac output
increase in CO leads to increase BP
decrease in CO leads to decrease BP
peripheral vascular resistance
vasoconstrictuion increases BP
vasodilation decreases BP
Volumne of cirulating blood
fluid retention leads to increased BP
hemorrhages leads to decreased BP
Viscosity
increase associated with increase BP
elasticity of vessel walls
increasing rigidity assoicated with increase in BP
Factors influencing bp
nonmodifiable: age, gender, race, diurnal rhythm
modifiable: weight, exercise, emotions, stress
Korotkoff Sounds
phases of sound 1-5, 1 is systolic (first apperance of sound)
5 is diastolic (final disappearnce of sounds)
Common errors in BP measurement
taking when active or emotional, wrong cuff size, reinflanting during procudure, wrong arm/leg position
Infants/Children temperature
avoid rectal route
-use oral route when old enough to keep mouth closed 4/5
- electronic thermometer because unbreakable
aging adults temperature
-changes in body temp, agin person less likely to have fever and at greater risk for hypothermia
- temperature less reliable index of older person’s true health state
Children pulse
-children older than 2 use radial site
-rate normally fluctuates more with children
Aging Adults pulse
-rhthym might be irregular
- radial artery may fee stiff. rigid, and tortous in older person
- increasingly rigid arterial wall needs faster upstroke of blood, so poluse is easier to palpate
Children respiration
watch infants abdomen for movement, because infants repsriation are normally more diaphragmatic than thoracic
-sleeping is most accurate in infants
- count for a full minute due to pattern variation
Aging adult respiration
-decrease vital capcity and decreased inspiratory reserve volumen
-shallower insirpatory phase and an increased respriatory rate
BP children
BP is not normally check in children less than 3 years of age
-cuff width must cover 2/3 of upper arm
-pediatric end piece
Agin adults bp
-aorta and major arteries tend to harden with age
-systolic pressure increases
- both systolic and diastolic pressures increase, difficult to tell the difference between aging and hypertension
Orthostatic vital signs
a drop in systolic pressure grater than 20 mmHg or diastolic pressure greater than 10mmhg after changing in a standing postion
-laying down, sitting, standing
Thigh pressure
normally higher than arm
diastolic often the same
BP measured here when arm is excessivly high
checking for coarctation of aorta
Pain
unpleasent sensory and emotional experience assoicated with or resembling that associated with, actual or potential tissuse damage
-personal experience
-person’s report of an experience as pain should be respected
Nociceptive pain
develops when functioning and intact nerve fibers in the periphery and CNS are stimulated
-Transduction
-Transmission
-Perception
-Modulation
Neurpathic pain
result of nerve damage or malfunctioning nervous system
-type of apin that does not follow typical phases
-abnormal processing of pain message that is difficult to assess and treat
- tends to progress with time
- often percieved long after site of injury heals
Dieabetes, shingles, HIV/AIDs, phantom limb pain
Somatic pain
pain receptors in tissues are activated
visceral pain
pain receptors in pelivs, abdomen, chest, intestine are activated
-vauge and not localized
reffered pain
felt at particular site but originates from another loction
Nociceptive quality of pain
somatic: throbbing, aching, cramping, sharp
Visceral: squeezing, pressure, aching
Neuropathic pain quality
burning, shooting, tingling
acute pain
protective pain
less than 3 months post surgical
-short term and self limiting
- self protective purpose
chronic pain
malignant and nonmalignant
-does not stop when injury heals
- outlasts its protective purpose
breakthrough pain
when gap in drug relief and pain between treatments occur
inital pain assessment tool
McCaffrey Inital pain assessment
SUBJECTIVE
location, intensity, quality, onset/duration/varitation, manner of expressing pain, relieving factors, aggravating factors, effect of pain
Pain rating scales
SUBJECTIVE
Numeric: 0-10
Verbal: describe pain
Visual: have pt mark on horizontal scale
Brief Pain Inventory
severity and its impact on functioning
Short form McGill Pain
assesses pain rating using 2 subscales
Sensory with 11 words
Affective with 4 words
Physical exams
OBJECTIVE
-joints, muscle, skin, abdomen
physical findings may not always support the pts subjective pain reports, particulatry for those with chronic pain
Nonverbal acute pain
gaurding
grimacing
moaning, agitation, restlessness, stillness
Diaphoesis
change in vital signs
Chronic pain behavoirs
shows more variability than acute pain
bracing
diminished activity
sighing
change in appetite
Infant pain
feel pain!
use FLACC until 3
Face, legs, activity, cry, consolability
Face Pain Scale
CRIES (post surgical)
Aging Adults pain
not a normal part of aging
PAINAD scale (dementia)
General Survey
study of the whole person
- general health state and any obvious physical characteristics
-objective parameters
-overal impressions
-Physical apperance, body structure, mobility, and behavoir
Physical apperance
age
sex
LOC
skin color
facial features
overall apperance
body structure
stature
nutrition
symmetry
posture
position
body build, contou
obvious physical deformity
Mobility
gait
ROM
behavior
facial expression
mood and affect
speech
speech pattern
dress
personal hygeine
Anthropometric measurement
assess the size and body composition
nutritional health status
presence of disease
BMi
does not measure body fat directly, but BMI correlated with more direct measures of body fat
weight/height2
underweight: less than 18
18-24: normal
25-39- overweight
greather than 40= obese
waist circumference
female: belwo 35 inches
male: below 40 inches
increased risk for metabolic syndrome, diabetes, hyperlipidemia, cardiovascular disease
Infant growth
growth spurts
percentiles in BMI
Head and chest circumferance
at birth every visit up to age 2, annual until 6 years
newborn: head 32-38cm
6 months-2years: equals chest
after 2 years: chest larger than head
Sign vs symptom
sign: something that can be observed externally
symptoms: is felt internally
Assessment
collection of data about the individuals health state
objective and subjective data
trying to make a diagnosis
Interview
database made up of general survey, health history, physical assessment, patient’s record and lab studies
Factors effecting data colelction
Internal: liking others, respect, empathy, ability to listen, self awareness
External: ensure privacy, refuse interuptions, physical environment, distance between you and pt, note taking
Health history
purpose is to collect subjective data, providng a complete picture of the person’s past and present health
8 parts of health history
biographic data, reason for seeking care, present health, past health, medication reconciliation, family history, review of system, functional assessment
biographic data
name/age/birthdate/place
address/phone number
gender and marital status
record source of info
want pt to give info if avaible
reason for seeking care
chief complaint!
quote if possible, 1-2 symptoms and their duration
pt enters with…
Present health
chronological record of the CC from the 1st symptom until now
-location, character, quanity, timing, setting, aggravating factors, associated factors, patients perception
OLD CARTS
onset
location
duration
character
aggravating and assoicated factors
releiving facotrs
timing
severity
Past health
childhood illness
accidents or injuries
seroius or chronic illness
hospitilizations
operations
obseteric history
immunization
last exam data
allergies!!
Medication reconciliation
list of current medications, reduce errors and promote pt saftey
Family history
conditions that could be inherited
-cornory heart disease, stroke, T2 DM, obesity, blood disorders, cancers, arthrits, sickle cell disease, allergies, alcohol or drug addiction, mental illness
Review of System
subjective data
ask about all symptoms that aren’t CC
evaluate related systems
double check in case significant data were omitted in present health section
evalutate health promotion practice: add health promotion statement
Functional assessment
measures self care ability
ADLs: bathing, dressing, toileting, eating walking
Instrumental ADLs: those needed for independant living
Spiritual resources?
SOAP
subjective, objective, assessment, plan
SBAR
situation
background
assessment
recommendation
