test 1 Flashcards
COLDSPA acronym
character
onset
location
duration
severity
pattern
associated factors
nursing open ended qeustions
can’t be answered with yes or no. requires more detail
what is health
a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity
8 dimensions of health
physical, emotional, social, spiritual, environmental, intellectual, financial, occupational
health assessment
the process used to evaluate the health status of a person
nursing assessment
focus on patient response to diagnosis or disease
healthy people 2030
framework to improve overall health of induviduals
beginning the exam: set the stage
reflect on approach
adjust lighting
check equipment
use precautions
cardinal techniques of examination
close observation
auscultation
palpation
percussion
how to conduct an exam
move head to toe, starting with right side
ADPIE
assessment
diagnosis
planning
implementation
evaluation
objective data
what you see- signs
physical exam
lab reports
radiologic findings
subjective data
what patient tells you- symptoms
history
chief complaint
OLDCART
old cart: onset
when did symptom begin
old cart: location
where is the sign/symptom located
oldcart: duration
how long has this been going on
old cart: characteristic
what does it feel like? severity ?
old cart: associated manifestations
what else is happening when the patient experiences this? any other symptoms?
old cart: receiving factors
anything the patient tried to receive the symptoms? did it help
oldcart; treatments
any interventions the patient has already tried
what does OLDCART fall under in ADPIE
assessment
ADPIE - diagnosis
based on real or potential health problems
based on assessment data and problem list
ADPIE- planning
best course of action for patient
short term and long term goals
be realistic
ADPIE: implementation
can be completed by patient, family, or health care team
individualized for each patient
relates to nursing diagnosis and planned goals
ADPIE: evaluation
continues process toward goals
helps determine if plan needs revised
steps in clinical reasoning
identify
cluster
interpret
make
develop
manual heart rate
radius
30 secs multiply by 2
if irregular count for minute
resp rate
30 secs times 2
with stephoscope
labored or unlabored?
Even?
deep or shallow?
pulse ox
oxygen saturation.
wait until you get even waveform
convert F to C
Subtract 32 and multiply by 5/9
celsius to farenheit
multiply by 9/5 and add 32
assessment for pain
include vital signs
ask comfort level- get rating
can use quotes of patient
normal bp
<120 / <80
prehypertension
120-139 / 80-89
hypertension stage 1
140-159 / 90-99
diabetes or renal bp
150-159 / 90-99
hypertension stage 2
> 160 / >100
ausculatory gap
don’t hear bp noise - gap
occlusion point
when you stop hearing radial point- add 20-30
normal temp
98.6 F / 37 C
normal resp rate
12-20 no diff breathing
normal oxygen sat
95-100%
nociceptive or somatic pain
related to tissue damage
neuropathic pain
related to injury of PNS or CNS
Idiopathic pain
pain w out identifiable cause
psychogenic pain
many factors influence pain
pre interview HA
review medical and nursing records, set goals, adjust environment
HA introduction
greet patient, put them at ease
HA working phase
listen to patients story, identify and respond, clarify, test diagnostic hypothesis, negotiate a plan
HA termination
summarize, discuss plan
therapeutic communication techniques
active listening, guided questioning, nonverbal communication, empathic responses, validation, reassurance, summarizing, transitions, empowering the patient
things not to do w angry patients
dont take things personally
dont isolate yourself w a angry person
for the LGBTQ community
dont assume gender
establish birth general and gender identity
for patients with language barrier
work with a qualified interpreter
for patients with personal problems
dont give advice outside of nursing
health history components
chief complaint, history of illness, allergies, medications, childhood illness, adult illness, health maintenance, health patterns
for alcohol consumption
ask them what type of drink, how many they have, when was the last one
when explaining things to patients
dont use medical words to patients, speak basic knowledge
if a patient seems depressed
go into suicidal screening
cultural competence
recognizes the need for a set of skills necessary to care for people of different cultures
3 dimensions of cultural humility
self awareness
respectful communication
collaborative partnerships
stolls guidelines for spiritual assessment
concept of god or diety
sources of hope and strength
religious practices
relation between spiritual beliefs and health
four physical assessment techniques in order when initiating a health assessment
Inspection
palpation
percussion
auscultation
what to do about silent patients
be attentive and encouraging
what to do about confusing patients
possible mental status exam
check responses again
seek permission to speak with family members
patients with altered capacity
dont have the ability to make healthcare decisions
what to do about talkative patients
focus on what seems important to the patient
set limits where needed
what to do about crying patients
be supportive
helping deaf patient
find out there preferred method of communication
assessing patients hard at hearing
see if they use a hearing aid and if its working
dont speak fast
eliminate background noise
blind patient
establish contact
orient patient to surrounding
poor vision patient
encourage glasses or contacts
genogram
diagram for family history
female- circle
male- square
divorce- connected with 2 lines crossed
deeased- line through shape
sensitive topics
sexual history, mental health history, family violence
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination.
Shins and ankles
Groin, hips, and knees
Breasts
Chest and thorax
Cardiovascular
breast, chest & thorax, cardiovascular, groin + hips & knees, then shins and ankles
Which equipment should the nurse use to validate the degrees of joint mobility?
goniometer
far eye sight check
snellen chart
A nurse is performing percussion on a client’s back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. What describes this finding
resonance
One of the body’s normal physiologic responses to pain is
diaphoresis
using the diaphragm, the nurse would expect to hear
high pitched sounds
A nurse must assess a client’s red reflex. Which piece of equipment will the nurse need for this?
Ophthalmoscope
FIFE
feelings
ideas
function
expectations
