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Health Assessment > Quiz 1 > Flashcards

Quiz 1 Flashcards

1
Q

Bloom’s Taxonomy

A

Remember
Understand
Apply
Analyze
Evaluate
Create

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2
Q

Evidence based practice

A

Clinical questions
Sources of evidence
Synthesize evidence
Apply evidence
Assess outcomes
- combines research, evidence, clinical knowledge, pt preferences, clinican experitise, physical exam

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3
Q

Nursing process

A

assessment
diagnosis
planning
implementation
evaluation

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4
Q

Subjective data

A

opion
what patient says
gained through interview

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5
Q

Objective data

A

what nurse observes during an exam, fact

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6
Q

Data bases

A

complete
focused
follow up
emergency

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7
Q

Health assessment

A

systematic and continous collection of data, sorting, analzying, and organizating that data; and the documentation and communication of the data collected

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8
Q

Therapeutic communication

A

purposeful conversation between nurse, pt, families
- used to reach health related goals, build trust, and maintain relationships

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9
Q

Characteristics of communication in healthcare

A

client centered, purposeful, planned, and goal directed

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10
Q

Essential components of therapeutic communications

A

time, active listening, caring, non judgemental attitude, honesty, trust, empathy

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11
Q

Communication

A

exchange of information so each person clearly understands the other, important so healthcare team knows what is going on

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12
Q

Faciliation

A

general leads like nodding

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13
Q

Clarification

A

simplify statements and ask for agreement
EX “… is this correct”

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14
Q

Reflection

A

sit quietly, allows pt time to think and answer

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15
Q

Explanation

A

share facutal and objective information

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16
Q

Empathy

A

reflects on feelings and puts them into words, sounds like you are feeling sad about…

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17
Q

Controntation

A

honest feedback

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18
Q

Interpretation

A

based on your inference/links events

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19
Q

Summary

A

final review of conversation

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20
Q

nontherapeutic techniques

A

why?
defensive
challenging the pt
changing the subject
giving advice
sterotypical comments
value judgement
feelings on hold
false reassureance

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21
Q

Vital signs

A

an objective measure of the body’s basic functions
temperature, RR, pulse, blood pressure

follows facility guidlines

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22
Q

Temperature

A

mechanism of regulation
- stable core temp of 37. 2 C
- feedback mechanism regulated in hypothalamus of brain

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23
Q

Oral temperatures

A

accurate and conveinent
sublingual
37C is normal
35.8-37.3 C range

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24
Q

Rectal measures

A

0.4 C to 0.5C higher than oral, closer to core temperature

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25
Q

Temperature measures

A

oral temperature
rectal temperature
tympanic membrane
temporal artery

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26
Q

Hyperthermia

A

above 38C

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27
Q

Hypothermia

A

below 36C

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28
Q

Febrile

A

with fever

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29
Q

afebrile

A

no fever

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30
Q

Factors that influence temperature

A

dirunal (24 hr) cycle
menstruation cycle
exersize
age (wider range in children, lower temp in older adults)

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31
Q

Pulse

A

pressure wave that expans and recoils the artery when the heart contracts and beats
check
HR
Heart rhythm
heart force

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32
Q

Locations to check pulse

A

mostly brachial and radial

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33
Q

Normal HR

A

50-95 bpm

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34
Q

bradykardia

A

less than 50 bpm

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35
Q

tachycardia

A

greater than 95 bpm

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36
Q

Force of pulse

A

heart’s stroke volume
3+ full bounding
2+ normal
1+ weak and thready
0 absent

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37
Q

Factors that influence pulse

A

fluid status
fever
medications
exercise
anxiety

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38
Q

Respriations

A

normally relaxed, regular, automatic, and silent
Normal 12-20

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39
Q

Bradypnea

A

less than 12 rr/min

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40
Q

tachypnea

A

greater than 20 rr/min

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41
Q

Factors influencing respiration by the following

A

o2 status
age
anxiety

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42
Q

blood pressure

A

how strong blood moves through BV

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43
Q

systolic

A

when the heart contracts
120

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44
Q

diastolic

A

when the heart rests
80

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45
Q

pulse pressure

A

difference between systolic and diastolic

46
Q

Factors controling bp

A

cardiac output
peripheral vascular resistance
volumne of circulating blood
viscosity
elasticity of vessel walls

47
Q

cardiac output

A

increase in CO leads to increase BP
decrease in CO leads to decrease BP

48
Q

peripheral vascular resistance

A

vasoconstrictuion increases BP
vasodilation decreases BP

49
Q

Volumne of cirulating blood

A

fluid retention leads to increased BP
hemorrhages leads to decreased BP

50
Q

Viscosity

A

increase associated with increase BP

51
Q

elasticity of vessel walls

A

increasing rigidity assoicated with increase in BP

52
Q

Factors influencing bp

A

nonmodifiable: age, gender, race, diurnal rhythm
modifiable: weight, exercise, emotions, stress

53
Q

Korotkoff Sounds

A

phases of sound 1-5, 1 is systolic (first apperance of sound)
5 is diastolic (final disappearnce of sounds)

54
Q

Common errors in BP measurement

A

taking when active or emotional, wrong cuff size, reinflanting during procudure, wrong arm/leg position

55
Q

Infants/Children temperature

A

avoid rectal route
-use oral route when old enough to keep mouth closed 4/5
- electronic thermometer because unbreakable

56
Q

aging adults temperature

A

-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

57
Q

Children pulse

A

-children older than 2 use radial site
-rate normally fluctuates more with children

58
Q

Aging Adults pulse

A

-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

59
Q

Children respiration

A

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

60
Q

Aging adult respiration

A

-decrease vital capcity and decreased inspiratory reserve volumen
-shallower insirpatory phase and an increased respriatory rate

61
Q

BP children

A

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

62
Q

Agin adults bp

A

-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

63
Q

Orthostatic vital signs

A

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

64
Q

Thigh pressure

A

normally higher than arm
diastolic often the same
BP measured here when arm is excessivly high
checking for coarctation of aorta

65
Q

Pain

A

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

66
Q

Nociceptive pain

A

develops when functioning and intact nerve fibers in the periphery and CNS are stimulated
-Transduction
-Transmission
-Perception
-Modulation

67
Q

Neurpathic pain

A

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

68
Q

Somatic pain

A

pain receptors in tissues are activated

69
Q

visceral pain

A

pain receptors in pelivs, abdomen, chest, intestine are activated
-vauge and not localized

70
Q

reffered pain

A

felt at particular site but originates from another loction

71
Q

Nociceptive quality of pain

A

somatic: throbbing, aching, cramping, sharp
Visceral: squeezing, pressure, aching

72
Q

Neuropathic pain quality

A

burning, shooting, tingling

73
Q

acute pain

A

protective pain
less than 3 months post surgical
-short term and self limiting
- self protective purpose

74
Q

chronic pain

A

malignant and nonmalignant
-does not stop when injury heals
- outlasts its protective purpose

75
Q

breakthrough pain

A

when gap in drug relief and pain between treatments occur

76
Q

inital pain assessment tool
McCaffrey Inital pain assessment

A

SUBJECTIVE
location, intensity, quality, onset/duration/varitation, manner of expressing pain, relieving factors, aggravating factors, effect of pain

77
Q

Pain rating scales

A

SUBJECTIVE
Numeric: 0-10
Verbal: describe pain
Visual: have pt mark on horizontal scale

78
Q

Brief Pain Inventory

A

severity and its impact on functioning

79
Q

Short form McGill Pain

A

assesses pain rating using 2 subscales

Sensory with 11 words
Affective with 4 words

80
Q

Physical exams

A

OBJECTIVE
-joints, muscle, skin, abdomen
physical findings may not always support the pts subjective pain reports, particulatry for those with chronic pain

81
Q

Nonverbal acute pain

A

gaurding
grimacing
moaning, agitation, restlessness, stillness
Diaphoesis
change in vital signs

82
Q

Chronic pain behavoirs

A

shows more variability than acute pain
bracing
diminished activity
sighing
change in appetite

83
Q

Infant pain

A

feel pain!
use FLACC until 3
Face, legs, activity, cry, consolability
Face Pain Scale
CRIES (post surgical)

84
Q

Aging Adults pain

A

not a normal part of aging
PAINAD scale (dementia)

85
Q

General Survey

A

study of the whole person
- general health state and any obvious physical characteristics
-objective parameters
-overal impressions
-Physical apperance, body structure, mobility, and behavoir

86
Q

Physical apperance

A

age
sex
LOC
skin color
facial features
overall apperance

87
Q

body structure

A

stature
nutrition
symmetry
posture
position
body build, contou
obvious physical deformity

88
Q

Mobility

A

gait
ROM

89
Q

behavior

A

facial expression
mood and affect
speech
speech pattern
dress
personal hygeine

90
Q

Anthropometric measurement

A

assess the size and body composition
nutritional health status
presence of disease

91
Q

BMi

A

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

92
Q

waist circumference

A

female: belwo 35 inches
male: below 40 inches
increased risk for metabolic syndrome, diabetes, hyperlipidemia, cardiovascular disease

93
Q

Infant growth

A

growth spurts
percentiles in BMI

94
Q

Head and chest circumferance

A

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

95
Q

Sign vs symptom

A

sign: something that can be observed externally
symptoms: is felt internally

96
Q

Assessment

A

collection of data about the individuals health state
objective and subjective data
trying to make a diagnosis

97
Q

Interview

A

database made up of general survey, health history, physical assessment, patient’s record and lab studies

98
Q

Factors effecting data colelction

A

Internal: liking others, respect, empathy, ability to listen, self awareness
External: ensure privacy, refuse interuptions, physical environment, distance between you and pt, note taking

99
Q

Health history

A

purpose is to collect subjective data, providng a complete picture of the person’s past and present health

100
Q

8 parts of health history

A

biographic data, reason for seeking care, present health, past health, medication reconciliation, family history, review of system, functional assessment

101
Q

biographic data

A

name/age/birthdate/place
address/phone number
gender and marital status
record source of info
want pt to give info if avaible

102
Q

reason for seeking care

A

chief complaint!
quote if possible, 1-2 symptoms and their duration
pt enters with…

103
Q

Present health

A

chronological record of the CC from the 1st symptom until now
-location, character, quanity, timing, setting, aggravating factors, associated factors, patients perception

104
Q

OLD CARTS

A

onset
location
duration
character
aggravating and assoicated factors
releiving facotrs
timing
severity

105
Q

Past health

A

childhood illness
accidents or injuries
seroius or chronic illness
hospitilizations
operations
obseteric history
immunization
last exam data
allergies!!

106
Q

Medication reconciliation

A

list of current medications, reduce errors and promote pt saftey

107
Q

Family history

A

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

108
Q

Review of System

A

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

109
Q

Functional assessment

A

measures self care ability
ADLs: bathing, dressing, toileting, eating walking
Instrumental ADLs: those needed for independant living
Spiritual resources?

110
Q

SOAP

A

subjective, objective, assessment, plan

111
Q

SBAR

A

situation
background
assessment
recommendation

Health Assessment (3 decks)

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