test 1 Flashcards
what is subjective data?
What the person says about themselves
what is objective data
What you observe by inspection, percussion, palpation, and auscultation during physical examinations
what is clinical reasoning methods?
- diagnostic reasoning
-Nursing process
-Critical thinking
what is diagnostic reasoning?
1) attending to available cues
2) formulating a diagnostic hypothesis
3) gathering data relative to tentative hypothesis
4) evaluating each hypothesis with new data to arrive at the final diagnosis
what is the nursing model consists of?
- assessment –>diagnostic reasoning–> planning–> implementation–> evaluation
Critical Thinking and Priorities?
First-level priority problems: These are immediate and life-threatening issues, such as those affecting a patient’s airway, breathing, or circulation (ABC Vital Signs).
Second-level priority problems: These are urgent but not immediately life-threatening, including concerns like acute pain.
Third-level priority problems: These are important but less urgent issues, often related to education, knowledge, or resource allocation for long-term care.
Collaborative problems: These require the involvement of multiple healthcare professions, often for managing complex or chronic conditions.
the concepts of health
Biomedical model
–-> Health = absence of disease
Behavioural model
–->Treatment of disease + prevention
Socioenvironmental model
–-> Sociological and environmental aspects
what is the purpose of interview?
- gather data
- establish rapport
- teaching(health promotion)
implied contract
time and place
intro and explanation
purpose of the interview
length of interview
what will occur
others present
confidentiality
what can assist in the conversation with pt?
- facilitation
- silence
- reflection
- empathy
- clarification
-interpretation
-explanation
-summary
Ten Traps of Interviewing
providing false reassurance
giving unwanted advice
using authority
using avoidance language
engaging in distancing
professional jargon
using leading or biased questions
talking to much
interrupting
using “why” questions
Non Verbal Cues
physical appearance
posture
gestures
facial expressions
eye contact
voice
silence
bodily exposure and touch
to complete health history
- Biographical data
- Source of history
- Reason for seeking care
– Record as quote - Current health or history of current illness
– OPQRSTUAAA
inspection
concentrated watching
general survey
compare sides (symmetry)
palpation
involves using touch to examine the body’s structures, identify tenderness, masses, temperature variations, and pulses
what do we use finger tips for during palpation?
skin texture, presence
of lumps
how about dorsum (back of hand palpation)
used for temp
Base of Fingers or Ulnar Surface
Vibration
Percussion
- involves tapping or striking the body to assess internal structures and identify abnormalities.
- it help’s evaluate the density, size, and location of organs and tissues within the body, particularly in the chest and abdomen.
what are the types of Percussion?
Direct percussion
– Striking hand contacts body directly
Indirect percussion
– Stationary hand
– Striking hand
Characteristics of percussion?
– Resonant: lungs
– Hyper-resonant: hyperinflated lungs
– Tympany: stomach
– Dull : solid organs, bones
– Flat: bones
Auscultation
involving the use of a stethoscope to listen to sounds
– Diaphragm: High pitched
– Bell: Low pitched
Vital Signs - Normal Ranges (TPRBPSP02)
Temperature
-oral: 35.8-37.3
-tympanic: 36.5-37.5
Pulse: 60-100 bpm
Respiratory rate: 12-20 respirations per minute
-blood pressure: 120/80
- oxygen saturation: >95% on room air
pain assessment
Korotkoff’s sounds
Stage 1 is where sound starts = systolic blood pressure
Stage 5 is where sound ceases = diastolic blood pressure
respiration less than 10 called
Bradypnea
respiration more than 10 called
Tachypnea
pulse less than 60
Bradycardia
pulse more than 100
Tachycardia
the force of the pulse
0=absent
1=weak
2=normal
3=bounding
Apical Pulse - 5th intercostal space at midclavicular line
pulse deficit - mismatch between apical pulse and peripheral pulse
stages of measuring blood pressure
Stages
fully compressed = silence(120+)
partially compressed =korotkoffs sounds (80-120)
free flowing = silence (0-80)
stage 1 is where sound starts
stage 5 is where sound ceases
Auscultatory Gap - silence in the middle of korotkoffs sounds, not normal
Inspection of Musculoskeletal
size and contour of each joint
skin and tissue of each joint
note swelling and discolouration
visual differences between muscle symmetrically
Palpation of Musculoskeletal
skin temperature
muscles
bony articulations
joint capsule
Temporomandibular joint
Inspection
Palpation
- Open and close mouth
Range of motion
- Open mouth maximally, test muscle strength
- Protrude and retract lower jaw
- Side to side/laterally
Palpate muscles of mastication
Cervical Spine
Inspection
- Alignment of head and neck
Palpate
- Spinous processes and muscles
Motion and expected range
- Touch chin to chest
- Lift chin
- Move each ear to shoulder
- Turn chin to each shoulder
(REPEAT WITH OPPOSING FORCE)
shoulders
Inspection
- Compare shoulders posteriorly and anteriorly
- Pain
Palpate
- Shoulders and axillae
- Palpate bilaterally, comparing side to side
- Start at clavicle and work out to shoulder
Motion and expected range
- Flexion and hyperextension
- Abduction and adduction
- Internal rotation
- External rotation
(REPEAT WITH OPPOSING FORCE)
elbow
Inspect while flexed and extended
Palpate - flex arm 70 degrees and support arm
Motion and expected range
- flexion and extension
- Pronation and supination
(REPEAT WITH OPPOSING FORCE - support the joint with one hand and provide opposing force with the other)
wrist & hand
Inspect
- Joints and dorsal and palmar sides
- Positioning of wrist and fingers, abnormalities, skin, muscles
Palpate
- Over each joint in the hand
- Support hand
- Start at wrist and move toward distal fingers
Muscle testing
- Flex against resistance: Arm supine on table
- Grip strength
Special Considerations
- Phalen test: Hold hands back to back for 60 seconds. Expected - no symptoms
- Tinel’s Sign: Direct percussion at median nerve Expected - no symptoms
hip
Raise leg
* Bend knee to chest
* Flex knee and hip and swing foot out
and in
* Swing leg laterally & medially
* Adduction and abduction
* Stand and swing leg back
knee
- Inspect
- Joint and muscle
- Palpate
- Supine position and relaxed quadriceps muscle
- Start proximal (above patella) and move distal
- Motion and expected range
- Bend knee
- Extend knee
- Watch knee during gait
- Muscle strength
- Flex knee against resistance
ankle and foot
Inspect - sitting, standing, and walking
Palpate joints
- Start proximal and move distal
- Support the ankle while palpating
Motion and expected range
- Point toes down
- Turn soles out
- Flex and straighten toes
Muscle strength - flex and extension against resistance
spine
- Inspect
- Standing – posture
- Palpate spinous processes
- Motion and expected range
- Stabilize pelvis
- Bend sideways, forwards, backwards
- Twist shoulders to each side
Techniques of Communication
- Introducing the Interview
- The Working Phase
- Open and Closed Questions
- How your responses can impact the interview
- Ten Traps of Interviewing!
- Non-verbal Skills
- Closing the Interview
when inspecting the skin
we look for changes in color, lesions, texture, moisture levels, temperature, turgor, and signs of edema or swelling
- also assess wounds, scars, skin integrity, hygiene, and inquire about allergies and skin conditions.
subjective data for Neurological System assessment
- Headache
- Head Injury
- Dizziness or Vertigo
- Seizures
- Tremors
- Weakness
- Incoordination
- Numbness/Tingling
- Difficulty Swallowing
- Difficulty Speaking
- Significant Past History
- Environment or Occupational
hazards - Older Adult
- Falls, Cognitive Function, Tremor,
Vision Changes
what is introducing phase
is the initial stage of a conversation or interaction where participants greet each other, introduce themselves, state the purpose or context, build rapport, and set expectations.
what is Working Phase
– Open ended questions first
* Listen FOR concerns
* Listen TO descriptions
* Listen for what is missing
– Closed ended questions
* Specific information
* Elicits facts
* Limits rapport
Examples of how do you close an interview with pt?
Is there anything else you would like to mention?
Are there any questions you would like to ask?
Are there any other areas I should have asked
about?
Did we accomplish what you had hoped?
what does oxygen Saturations measure?
Measures percentage of oxygen bound to the hemoglobin
Stage 1 Pressure Ulcer
epidermis only
-Intact skin with non-blanchable redness in a localized area.
- Typically found over bony prominences.
- May exhibit changes in firmness, softness, or temperature compared to adjacent skin.
Stage 2 Pressure Ulcer:
- Partial thickness skin loss involving the epidermis and dermis.
- Presents as a shallow open ulcer with a red-pink wound bed.
- May appear as a clear fluid-filled blister.
- No slough present.
Stage 3 Pressure Ulcer
-Full thickness tissue loss, with subcutaneous fat visible.
- No exposure of bone, tendon, or muscle.
- May include undermining and tunnelling.
Stage 4 Pressure Ulcer
-Full thickness tissue loss with exposed bone, tendon, or muscle.
-Often includes undermining and tunnelling.
Deep Tissue Pressure Injury
- Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration.
- May involve epidermal separation revealing a dark wound bed or blood-filled blister.
Unstageable Pressure Ulcer
Full thickness loss where the base of the ulcer is covered by slough and/or eschar in the wound bed.
Mucosal Membrane Pressure Ulcer
Ulcers found on mucosal membranes.
-Typically caused by devices at the location of the injury.
-These ulcers cannot be staged due to mucosal anatomy.
Incontinence/Moisture Lesion
-Caused by incontinence or moisture, not pressure and shear.
-Skin remains damp, and the damage may occur in various skin areas, not limited to bony prominences.
how do we assess mental status?
Level of Consciousness
* Arousal
*Gross response to stimuli
* Glasgow Coma Scale
* Awareness
* Aware of orientation
* Name, location, time
* A & O x 3
Cranial Nerve I
Olfactory
Function: Responsible for the sense of smell. (coffee test smell)
Cranial Nerve II
optic
Function: Responsible for vision.
Mnemonic: “Optic for eyesight; think of binoculars.”
Cranial Nerve III, IV and VI (3,4,6)
- Oculomotor (CN III) controls most eye muscles for eye movement and pupil constriction.
- Trochlear (CN IV) controls the superior oblique muscle for downward and lateral eye movement.
- Abducens (CN VI) controls the lateral rectus muscle for moving the eye outward.
Mnemonics:
“Oculomotor moves your eyes and makes your pupils constrict.”
“Trochlear, the ‘down and out’ nerve, helps you look down and out.”
“Abducens abducts your eye, making it look outward.”
Cranial Nerve V (5)
trigeminal nerve
Function: Sensation in the face, as well as chewing muscles.
Mnemonic: “Trigeminal touches your face and lets you chew gum in three branches.”
Cranial Nerve VII
facial
Function: Controls facial expressions, taste, and salivation.
Mnemonic: “Facial gives your face expression and taste.”
Cranial Nerve VIII
Vestibulocochlear
Function: Responsible for hearing and balance.
Mnemonic: “Vestibulocochlear helps you hear the sounds of your crazy vestibule party.”
Cranial Nerve IX (9)
Glossopharyngeal
Function: Involved in swallowing, taste, and sensation in the back of the throat.
Mnemonic: “Glossopharyngeal glosses over the back of your throat.”
Cranial Nerve X
Vagus
Function: Controls many visceral functions, including heart rate, digestion, and speech.
Mnemonic: “Vagus wanders through your body, affecting heart, gut, and larynx.”
Cranial Nerve XI
Spinal Accessory nerve
Assessing size, strength, ROM and resistance of the
Sternocleidomastoid and Trapezius
( Controls neck and shoulder muscles.)
Cranial Nerve XII
Hypoglossal
Function: Controls the tongue muscles for speech and swallow
OPQRSTUV??
Onset: when did this begin and how
Provocative: what makes the pain start
Quantity / Quality: what does it feel like and is it constant
Radiation / Region: where does it actually hurt and does it spread to other parts of the body
Severity: on a scale of 1-10, 10 being the worst pain in your life
Timley: when did it occur and how often does it happen
Understanding: what is the patients perception of the pain
Value: what does the patient expect their pain level to be
