RLE: prelim Flashcards
INTERVIEW PROCESS AND HEALTH HISTORY CHECKLIST PHASES (4)
pre-introductory
introductory
working
evaluation/closing phase
COLDSPA
character
onset
location
duration
severity
pattern
associated factors
PQRST
- pallative/provoking/precipitating factors
- wuality
- radiation/region
- severity
- temporal factors/timing
working phase
- demographic data
- chief complaint
- HPI
- past health history
- family health history
COLDSPA: (How does it feel, look, smell, sound, etc.?)
Character
COLDSPA: (When did it begin; is it better, worse, or the same since it began?)
Onset
COLDSPA: (Where is it? Does it radiate?)
Location
COLDSPA: (How long does it last? Does it recur?)
Duration
COLDSPA: (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever experienced]?)
Severity
COLDSPA: (What makes it better? What makes it worse?)
Pattern
COLDSPA: (What other symptoms do you have with it? Will you be able to continue doing your work or other activities [leisure or exercise]?
Associated factors
PQRST: (What makes it better? What makes it worse? (.e.g. argument, exercise, resting)
Palliative / Provoking / Precipitating Factors
PQRST: (Describe what exactly is it like? e.g. pressure, dull, aching, tight, squeeze)
Quality
PQRST: (Where is the pain? Does it spread anywhere?)
Radiation/Region
PQRST: (How severe is it? On a scale of 1 to 10, how would you rate? (mild, moderate, severe)
Severity
PQRST: (When did this begin? Does the intensity of the pain change with time? Have you had this before?)
Temporal Factors / Timing
During assessment of the head, the nurse inspects and palpates simultaneously and auscultates. The nurse examines the skull, face, eyes, nose, sinuses, mouth, and pharynx.
assessing skull and face
normal findings: Inspect the skull for size, shape, and symmetry.
Rounded (normocephalic and
symmetric, with frontal, parietal, and occipital prominences);
smooth skull contour
abnormal findings: Inspect the skull for size, shape, and symmet
Lack of symmetry, increased skull
size with more prominent nose and
forehead;
longer mandible (may
indicate excessive growth hormone
or increased bone thickness)
normal findings: Palpate the skull for nodules or masses and depressions.
Smooth, uniform consistency;
absence of nodules/ masses or
depression
abnormal findings: Palpate the skull for nodules or masses and depressions.
Sebaceous cysts;
local deformities from trauma;
masses;
nodules
To indicate an inherited or chronic disorder with typical facies such as Grave’s disease, hyperthyroidism with myxedema, cushing syndrome or acromegaly.
Inspect the facial features.
normal findings: Inspect the facial features.
Symmetric or slightly asymmetric
facial features;
palpebral fissures equal in size,
symmetric nasolabial folds
abnormal findings: Inspect the facial features.
Increased facial hair;
low hair line;
thinning of eyebrows;
asymmetric features;
exophthalmos;
myxedema facies;
moon face
abnormal findings: Inspect the eyes for edema and hollowness.
Periorbital edema;
sunken eyes
abnormal findings: Note symmetry of facial movements.
Asymmetric facial movements (e.g.,
eye cannot close completely);
dropping of lower eyelid and mouth;
involuntary facial movements (i.e., tics and tremors)
Inspect skin color (best assessed under natural light and on areas not exposed to the sun).
RATIONALE
Some medications can cause
photosensitivity reactions after
being exposed to the sun.
Some clients may
exhibit allergic skin reaction to
specific drugs.
Some medications can cause
photosensitivity reactions after being exposed to the sun. It
often appears [time] after
taking the medication and
leaves after [???]
24 hours;
discontinuing the medication
Normal skin color:
Varies from light to deep brown;
from ruddy pink to light pink;
from yellow overtones to olive
abnormal skin color:
Pallor, cyanosis, jaundice, erythema
Inspect uniformity of skin color
RATIONALE
As light hits the skin’s surface, it is either reflected diffusely back,
scattered, or absorbed by particles within the skin.
??? is the result of
reflected and absorbed light
from unpigmented skin, mixed
with colors of various constitutive pigments, such as ???
Skin color ;
melanin’s, hemoglobin’s, and carotenes
normal uniformity of skin color:
Generally, uniform except in areas
exposed to the sun;
areas of lighter pigmentation (Palms, lips, nail beds) in dark-skinned People
abnormal uniformity of skin color:
Areas of either hyperpigmentation
or hypopigmentation
occurs when something disrupts the usual balance of fluids in your cells.
Edema
result of edema
an abnormal amount of fluid
accumulates in your tissues
(interstitial space). Gravity pulls
the fluid down into your legs
and feet.
[???] edema is common in older adults and pregnant women, but it can occur at any age
Peripheral
skin lesion: Touching a patient
conveys ??? and ??? (where appropriate) that the patient’s rash is ???.
empathy and reassurance;
the patient’s rash is not contagious
an important but underestimated
examination modality. … For
localized lesions, palpation
identifies tenderness,
consistency, induration, depth
and fixation.
Palpation
normal: Inspect, palpate, and describe skin lesions
Freckles,
some birthmarks that have not changed since childhood,
and some long-standing vascular birthmarks (strawberry or port-wine hemangiomas),
some flat and raised nevi;
no abrasions or other lesions
nevi
moles
abnormal: Inspect, palpate, and describe skin lesions
Various interruptions in skin
integrity;
irregular, multicolored, or raised nevi,
some pigmented birthmarks such as melanocytic nevi,
and some vascular birthmarks such as cavernous hemangiomas.
Even these deviations from normal may not be dangerous or require treatment.
Assessment by an advanced-level
practitioner is required.
normal/abnormal? strawberry or port-wine hemangiomas
normal
normal/abnormal? melanocytic nevi & cavernous hemangiomas
abnormal
normal skin moisture:
Moisture in skinfolds and the axillae
(varies with environmental
temperature and humidity, body temperature, and activity)
abnormal skin moisture:
Excessive moisture (e.g., in
hyperthermia);
excessive dryness
(e.g., in dehydration)
Palpate skin temperature.
Compare the two feet and the two hands, using the ?
backs of your fingers
Palpate skin temperature.
Compare the two feet and the two hands
RATIONALE
Changes in sensation or temperature may indicate vascular or neurologic problems such as peripheral neuropathy related to diabetes mellitus or arterial occlusive disease.
Decreased sensation may put the client at risk for ???
developing pressure ulcers
normal skin temperature:
Uniform;
within normal range
skin turgor
fullness or elasticity of skin
Note skin turgor (fullness or
elasticity) by ???
lifting and pinching the skin on an extremity or on the sternum
When you pinch the skin
on your arm, for example, it
should spring back into place
with [duration]
a second or two
Having [???] means it takes longer for your skin to return to its usual position. It’s often used as a way to check for [???]
poor skin turgor ;
dehydration
abnormal skin turgor
Skin stays pinched or tented or
moves back slowly (e.g., in
dehydration).
WTD: Skin stays pinched or tented or moves back slowly (e.g., in
dehydration).
Count in seconds how long the skin remains tented
Examination of the hair includes assessment of [4]
evenness, thickness, texture, and oiliness
Inspect the evenness of growth
over the scalp.
NORMAL
evenly distributed hair
Inspect the evenness of growth
over the scalp.
RATIONALE
Scalp should be free
from dandruff, lesion
or parasites.
Inspect the evenness of growth
over the scalp.
ABNORMAL
Patches of hair loss (i.e., alopecia
Inspect hair thickness or thinness.
NORMAL
thick hair
Inspect hair thickness or thinness.
ABNORMAL
very thin hair
very thin hair (e.g., in???)
hypothyroidism
Inspect hair texture and oiliness.
NORMAL
Silky, resilient hair
Inspect hair texture and oiliness.
RATIONALE
Hair should be smooth not oily or dry
Inspect hair texture and oiliness.
ABNORMAL
Brittle hair (e.g., hypothyroidism);
excessively oily or dry hair
Note presence of infections or
infestations by ???
parting the hair in several areas, checking behind the ears and along the hairline at the neck.
Note presence of infections or
infestations
NORMAL
No infection or infestation
Note presence of infections or
infestations
RATIONALE
Many of these conditions show the
presence of Staphylococcus
aureus [SA] and response to antibiotic therapy
Note presence of infections or
infestations
ABNORMAL
Normal Flaking, sores, lice,
nits (lice eggs), and ringworm
Inspect amount of body hair.
RATIONALE
To determine the
quantity, quality and
distribution of hair.
Inspect amount of body hair.
ABNORMAL
Hirsutism (excessive hairiness) in women;
naturally absent or sparse leg
hair
what does naturally absent or sparse leg hair indicate?
poor circulation
Perform blanch test of capillary refill.
Press the nails between your thumb and index finger: look for blanching and return of pink color to nail bed. Perform on at least one nail on each hand and foot.
Inspect fingernail plate shape to
determine its curvature and angle.
NORMAL
Convex curvature;
angle of nail plate about 160°
Inspect fingernail plate shape to
determine its curvature and angle.
RATIONALE
Determined by the form of the underlying bone. A few layers of dead, compacted cells make the nail strong and rigid, yet somewhat flexible.
Inspect fingernail plate shape to
determine its curvature and angle.
ABNORMAL
Spoon nail;
clubbing (180° or greater)
Inspect fingernail and toenail texture.
NORMAL
Smooth texture
Inspect fingernail and toenail texture.
RATIONALE
To determine the quality of blood circulation
Inspect fingernail and toenail texture.
ABNORMAL
Excessive thickness or thinness or presence of grooves or furrows;
Beau’s lines discolored or detached
nail
Inspect fingernail and toenail bed color
NORMAL
Highly vascular and pink in light-skinned clients;
dark-skinned clients may have
brown or black pigmentation in
longitudinal streaks
Inspect fingernail and toenail bed color
RATIONALE
Color changes in nails may indicate a local or systemic problem.
Inspect fingernail and toenail bed color
ABNORMAL
Bluish or purplish tint (may
reflect cyanosis);
pallor (may reflect poor arterial circulation)
Inspect tissues surrounding nails.
NORMAL
Intact epidermis
Inspect tissues surrounding nails.
RATIONALE
The paronychium is the soft tissue border around the nail, and paronychia is an infection in this area.
Inspect tissues surrounding nails.
ABNORMAL
Hangnails;
paronychia (inflammation)
Perform blanch test of capillary refill.
NORMAL
Prompt return of pink or usual color (Generally, less than 2 seconds)
Perform blanch test of capillary refill.
RATIONALE
is performed on the nail beds as an
indicator of tissue perfusion and dehydration
Perform blanch test of capillary refill.
ABNORMAL
Delayed return of pink or usual color (May indicate circulatory
impairment)
the amount of blood flow to tissue
tissue perfusion
