TEST 1 Flashcards
WHY DO WE USE CRITICAL THINKING
- ANALYZE COMPLEX DATA
- MAKE DECISIONS
- ANALYZE PROBLEMS
- INDIVIDUALIZE INTERVENTIONS
HOW DO WE USE CRITICAL THINKING
TO LEARN TO ASSESS, REASSESS AND MODIFY IF NECESSARY. WE ARE PROBLEM SOLVING AND SELF IMPROVING SIMULTANEOUSLY.
COMPARE NORMAL VS ABNORMAL, CLUSTERING, PATTERN RECOGNITION, SETTING PRIORITIES
CLUSTERING
HOW CONDITIONS INTERRELATE WITH/EFFECT ONE ANOTHER
DIAGNOSTIC REASONING
ANALYZING DATA AND MAKING CONCLUSIONS TO ID DIAGNOSES
SETTING PRIORITES
FIRST LEVEL (CRITICAL)
SECOND LEVEL (COULD BECOME CRITICAL)
THIRD LEVEL (IMPORTANT BUT CAN WAIT IF NECESSARY)
SIX STEPS OF THE NURSING PROCESS
- ASSESMENT
- DIAGNOSIS
- OUTCOME IDENTIFICATION
- PLANNING
- IMPLEMENTATION
- EVALUATION
ASSESSMENT
Collect data using evidence-based assessment techniques
DIAGNOSIS
compare findings with normal vs. abnormal variation. Interpret data, make hypotheses
OUTCOME IDENTIFICATION
ID expected outcomes that are: individualized, culturally sensitive, realistic and measureable
PLANNING
Establish priorities, develop outcomes, ID interventions, document plan of care
IMPLEMENTATION
Use evidence-based interventions to implement.
EVALUATION
What’s your progress? Do we need to re-assess?
FIRST LEVEL PROBLEMS
IMMEDIATE/LIFE THREATENING
Airway
Breathing
Circulation
Vital signs concerns
SECOND LEVEL PROBLEMS
Mental status changes, untreated medical problems that can worsen
THIRD LEVEL PROBLEMS
NOT IMMEDIATE THREAT TO HEALTH
Lack of education about medications or disease process
collaborative problems
Tx involves multiple disciplines
evidence based practice (ebp)
systemic approach to practice that emphasizes the use of best evidence is combination with the clinician’s experience, as well as the patient preferences and values, to make decision about care and treatment
how long can it take for research to become practice
17 years
four types of data collection
complete data base
episodic/focused or problem centered data base
follow up data base
emergency data base
complete data base
includes a complete health Hx & complete PE; baseline set of data; screens for pathology, initial list of dx
episodic/focused or problem centered data base
for limited or short-term problem; focus is on one problem & one system
follow up data base
done at appropriate intervals for identified problems
emergency data base
need a rapid collection of data & quick diagnosis
biomedical model
(Western tradition) absence of disease; focus is on diagnosis & treatment of disease
wellness
moving toward optimal level of functioning, different levels of wellness
holistic health
includes the whole person (mind, body, spirit), person & environment
health promotion
focuses on the positive acts that enhance health status
prevention
includes guidelines that focus on the connection between health & personal behavior
holistic model aspects
culture, value, family, social roles, self care behaviors, job related and emotional stress, developmental tasks, patterns of coping, performance of ADLs, environmental factors, available resources
social determinants of health
education- access and quality
health care- access and wuality
economic stability
neighborhood and build environment
social and community context
culture
combination of the nonphysical traits such as values, beliefs, attitudes & customs, shared by a group of people and passed from one generation to the next (Kozier & Erb,2004).
cultural assessment
Systematic appraisal of an individual’s beliefs, values, & practices for the purpose of providing culturally competent health care (Jarvis, 2004)
transcultural considerations that are a universal phenomenon
Dynamic and ever changing
Learned from birth
Shared by all members of the cultural group
Adapted to environmental and technical factors
Adapted to natural resources
National Standards for Culturally & Linguistically Appropriate Services in Health Care
Health care organizations should ensure that patients receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language
3 components of culturally and linguistically appropriate services in hc
- effective care
- respectful care
- cultural and linguistic competence
what is subculture
Different characteristics, beliefs, values, attitudes shared by groups within a culture
what are sub culture characteristics based on
ethnicity
religion
occupations
health related characteristics
gender and sexual preference
cultural imposition
tendency to impose your beliefs, values, and patterns of behavior on individuals from another culture
culture shock
state of disorientation to a different cultural group
ethnocentrism
tendency to view your own way of life as the most desirable and best
acculturation
the process of adopting the cultural traits or social patterns of another group
religion
an organized system of beliefs concerning the cause, nature & purpose of the universe, especially in the belief in or the worship of God (Allah, God,Yahweh, Jehovah)
spirituality
result of each person’s unique life experience & the personal effort to find purpose & meaning in life
religious beliefs and spirituality in health care
Influences how one perceives the cause of illness,its severity, & preference for a healer(s)
as a caregiver, what do you need to do regarding culture, values, and religious beliefs in health care
First understand your own cultural values, beliefs, attitudes, & practices-
Secondly, identify the client’s meaning of health
*Cultural Assessment
course of illness may be perceived in 3 major ways
- biomedical or scientific
- naturalistic or holistic view
- magicoreligious
folk healers
Hispanics: Curandero, espiritualista, yerbo
Blacks: Hougan, spiritualist, or “old lady”
Native Americans: Shaman or medicine (wo)man
Asians: Herbalist, acupuncturists or bone setters
Amish: Braucher
first step to cultural competency
Understand your own heritage on the basis of cultural beliefs, attitudes, and practices that are relevant to health and illness
second step of cultural competency
Identify the meaning of health to the person you are working with.
third step of cultural competency
Understand the health care delivery system, how it works, what it does, and meanings, costs, and consequences of procedures that are important to you and patient
RESPECT accronym
Realize your and your patient’s heritage
Examine patient within the context of his cultural health and illness practices
Select simple questions and ask them slowly
Pace your questions throughout the exam
Encourage patient to discuss meanings of health & illness from their prespective
Check patient’s understanding & acceptance of health practices
Touch patient according to their cultural heritage- very important
the goal of the interview
Record a complete health history(subjective data)
Identify health strengths & problems.
Establish a bridge to the physical exam
in a successful interview, you will
Gather information (complete & accurate). Both subjective and objective data
Establish rapport & trust
Teach about the health state
Build rapport for continuing therapeutic relationship
Begin teaching of health promotion & disease prevention
the contract of the interview
to establish parameters
Time & place-
Introduction-
Explain roles-
Purpose of the interview-
Length of the interview-
Expectations-
Confidentiality-
Cost: $, time, emotion
communication facilitators
Privacy
Comfort
Reduce noise
Remove distractions
Correct distance
Eye level
Eye contact
communication blocks
Lack of privacy
Uncomfortable
Loud noises
Distractions
Distance: Too close or too far
Height: too tall or too short
Shifting eyes
introductory phase of the interview
Initiating the informal contract
- -Address the patient using his/her surname
- - Introduce yourself & explain your role
- - State the reason for the interview
working phase
Obtaining the health related data
* Open-ended questions: enables the person to express more information
* * Closed-ended/direct questions: ask for specific information
nonverbal communication
Physical appearance
Posture
Gestures
Facial expression
Eye contact
Touch
Personal space & territoriality
examiner’s responses
Facilitation- “un-huh, continue, yes”- a general lead
* Silence/nonverbal/listen- “Silence is golden!”
* Reflection- echo client’s words*
* Empathy- recognize feelings, acceptance* Clarification- “define – , I heard you say, is that correct?”
* Confrontation- after observing an action or statement, you draw the person’s attention on it
* Interpretation- correlate data input
* Explanation- providing information, explain procedure
* Summary- signal that termination is coming, brief summary ofinterview
termination phase of the interview
review of the data, termination of the interview is imminent
ten traps of interviewing
Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using “Why” questions
child and parent
interview developmental considerations
Provide toys
avoid putting parent on the defensive
refer to the child by name
refer to parent by name
infant/parent
interview developmental considerations
use firm, gentle handling
keep parent in view
preschooler (2-6)
interview developmental considerations
Use short, simple sentences-
Avoid expressions with different meanings- Give a simple explanation of equipment
school age (7-12)
interview developmental considerations
ask the child first about S/S, then the parent Ask about school, friends
Explain (in simple terms) equipment & procedures
adolescent
interview developmental considerations
Show respect & acceptance
Be honest, provide truthful information
Stay in character
Use ice breakers
Keep questions short & simple, ask about personal issues
Inform them what information must be given to others
older adults
interview developmental considerations
Allow extra time for the interview
Adjust the pace
Consider any physical/mental limitations
Use touch when culturally accepted
special needs
interview considerations
Hearing impaired
Acutely ill
Intoxicated
Crying
Sexually aggressive
Angry
Anxious
Too personal
cultural impact on the interview
Gender-May be offensive for female to exam male unchaperoned or vice versa
Sexual Orientation-Do not make assumptions
Language Barriers-Utilize use of interpreter
subjective data
biographical data
Reason for seeking care
HPI
Past history (PMH- previous medical history) Family history
ROS
Functional assessment
biographical data
name, address, phone number, age, birth date, birth place, gender, marital status, race, ethnic origin, occupation
source of history
note the person providing the history and whether she/he is a reliable source
reason for seeking care
brief statement, usually a symptom, put into quotation marks
Location, Character or quality, Quantity or severity, Timing, Setting, Aggravating or relieving factors, associated factors, Client’s perception
PQRSTU accronym
Provocative/precipitating & palliative (alleviating)
Quality or Quantity
Region or Radiation
Severity- use pain scale (1-10)
Timing
Understanding client’s perception
past history
childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history (Gra__,Term___,Preterm___, Ab___, Living____), immunizations, lastexam date, allergies (medication, food or contact agent and the type of reaction)
family history
age & health or cause of death of relatives (blood), construct a family tree (genogram)
ros
review of systems
General overall health status
Skin & hair
Head- Eyes & ears (last vision or hearing test, glasses or contacts)
Nose & sinuses, mouth & throat
Neck
Breast & axilla (breast self-exams, last mammogram)
Respiratory system
Cardiovascular system (last ECG or other cardiac tests)
Peripheral vascular
ros
review of systems
continued
Gastrointestinal system
Urinary system
Male genital system (testicular self-exams,penile discharge)
Female genital system (age of menarche, last menstrual period, cycle & duration, vaginal discharge or itching, last gyn exam & Pap test)
Sexual history (Currently in sexual relationship, dyspareunia, erectile dysfunction, STDs, use of contraceptives, use of condoms)
ros
review of systems
continued
Musculoskeletal system
Neurologic system
Hematologic system
Endocrine system
functional assessment
includes ADLs
Self-esteem, self-concept
Activity/exercise
Sleep/rest patterns
Nutrition/elimination
Interpersonal relationship/resources
Spiritual resources
Coping & stress management
Personal habits (tobacco, alcohol & street drugs)- PPD X yrs = pack yrs- Alcohol- CAGE test, TWEAK questionnaire
Environmental/hazards
Intimate partner violence
Occupational health
HEEADSSS
assessment of the adolescent- psychosocial scale
H- Home Environment
E- Education & Employment
E- Eating
A- peer-related Activities
D- Drugs
S- Sexuality
S- Suicide/Depression
S- Safety
Comprehensive Older Person’s Evaluation
Preliminary cognition questionnaire
Demographic section
Social support section
Financial section
Psychological health section
Physical health
ADLs
assess mental status
Emotional & cognitive functioning
Mental disorder- Organic disorders or Psychiatric mental illness
behaviors
assessment of mental status
Consciousness
Language
Mood & affect
Orientation
Attention
Memory
Abstract reasoning
Thought process
Thought content
Perceptions
a, b, c, t
mental status exam components
appearance
behavior
cognition
thought processes
when would you do a full mental status exam
behavior concerns family
brain lesions
aphasia
symptoms of psychiatric mental illness
appearance
mental health assessment
Posture
Body movements
Dress
Grooming & hygiene
level of consciousness
mental health assessment- behavior
Alert- Awake or easily aroused, fully aware or environment, responds appropriately
Lethargic/Somnolent- Not fully alert, drifts off to sleep when stimulated, drowsy, will answer correctly to questions when aroused but quickly goes back to sleep
Obtunded- Difficult to arouse
Stupor/ Semi-Coma- Spontaneously unconscious,responds only to persistent and vigorous shake orpain. Reflexes are present
Coma- Completely unconscious. No response to pain or to any external or internal stimuli. May ormay not have reflexes present.
behavior
mental health assessment
loc
facial expression
speech
mood/affect
cognitive functions
mental health assessment
Orientation- Time- Place- Person
Attention span
Recent memory
Remote memory
New learning (Use The Four Unrelated WordsTest)
Clients with aphasia – use additional testingfor word comprehension, reading & writing
Judgment
thought processes and perceptions
mental health assessment
Thought processes
Thought content
Perceptions
Suicidal thoughts- screen!!!
denver II
developmental competence for mental health assessment
Age range: birth to 6 yrs.
Time required: 10-25 min.
Tests for functions: gross motor, language,fine motor-adaptive, & personal-social skills
Screening tool- Detects developmental delays, NOT diagnostic
Scoring: “normal”, “abnormal”,“questionable”
mini cog
mental health assessment
Takes 3-5 minutes to administer
Only has 2 components:
3-item recall test
Clock drawing test
Mini-Cog tests executive function,including ability to plan, manage time,organize activities, and manage working memory
mmse
mini mental status exam
mental health assessment
Tests memory, orientation, reading,writing, following commands
Takes 5-10 minutes to complete
Results can be affected by educational level
assessment techniques
use senses: sight smell hearing and touch
skills required in assessment
inspection Palpation* Percussion* Auscultation
inspection
(need good lighting &adequate exposure)
* LOOK
* Start with general survey
* Symmetry
* Instruments : otoscope, speculum ophthalmoscope, penlight
palpation
Purpose: assess for temp,moisture, texture, swelling or lumps, tenderness/pain, organ size,pulsations/vibrations/crepitation
Use different parts of the hands
Light versus deep palpation versus bimanual
percussion
Purpose: to assess underlying structures by eliciting a palpable vibration & characteristic sound
Indirect versus direct percussion
* Indirect: both hands are used (stationary hand & striking hand), used to percuss the adult thorax and abdomen
* Direct: striking hand directly contacts the skin, used to percuss the infant’s thorax & the adult’s sinuses
characteristics of percussion notes
Resonant (clear, hollow sound): over normal lung tissue
- Hyperresonant (booming sound): normal over the child’s lung, abnormal over the adult lung
- Tympany (drumlike): over the air filled organs (stomach & intestines)
- Dull (muffled thud): over relatively dense tissue (liver & spleen)
- Flat (dead stop of sound): no air, over bone, dense muscle, or tumor
auscultation
listening to bodily sounds (heart, blood vessels, lungs, and abdomen)
auscultations require
Ears
Stethoscope
Good fit & quality
Diaphragm & bell
* Diaphragm (flat endpiece): used for high-pitched sounds (breath sounds & normal heartsounds, abdominal bowel sounds)
* Bell (cuplike shape endpiece): used for low-pitched sounds(extra heart sounds or murmurs, & bruits
assessment setting
Examination room
Examination table
Safe environment
what creates a safe environment for assessment
Clean equipment
Clean vs. used area (for equipment)
Nosocomial infections (prevent)
Wash hands, use gloves when needed
Standards precautions
Transmission-based precautions
equipment for assessment
Platform scale with height attachment
Sphygmomanometer
Stethoscope
Thermometer
Pulse oximeter
Flashlight/penlight
Otoscope/opthalmoscope
Tuning fork
equipment for assessment
continued
Nasal speculum
Tongue Depressor
Pen
Flexible tape measure
Reflex hammer
Sharp object
Cotton balls
gloves
general approach to the clinical setting
Patient’s emotional state
Examiner’s emotional state
hands on approach to the clinical setting
Measurement and vital signs
Begin with person’s hands
Concentrate on one step at a time
Examination sequence
Brief health teaching
When findings are complicated
*Summarize findings for the patient
infants
clinical setting
Keep parent present
Have eye contact & use soft voice, smile
Use smooth & deliberate movements
Use pacifier
Use bright colored toys
Permit older infant to touch instruments
Sequence: do least distressing steps first(heart, lungs, abdomen), elicit the Moro reflex at the end
toddler
autonomy stage
clinical setting
fear of invasive procedures
- Sit or lay toddler on parent’s lap
- Initially greet the toddler & parent
- Allow time for the child to size you up (first focus more on parent)
- Let parent undress the toddler
- Don’t offer a choice when it is not possible
- Use limited choices whenever possible- Sequence: note motor skills/gait during interview), start with “games”, then nonthreatening areas, do distressing procedures last (ear, throat)
preschool child
developing initiative
clinical settings
Have parent present (can place on lap)
- Leave underpants on until genital exam
- Explain procedures to the child
- Allow child to touch/hold instruments
- Provide reassurance
- Compliment the child
- Sequence: first do thorax, abdomen,extremities, genitalia, then do head, nose,throat, & ears last
school age child
developing industry
clinical setting
Is modest
- Begin with small talk
- Demonstrate equipment
- Simple explanations of how the body work
- Allow child to listen to heart sounds
- Sequence: head to toe approach
adolescent
developing self identity
clinical setting
Have adolescent sit on exam table
- Examine without parent or siblings
- Give feedback on bodily changes are normal
- Refer to Sex Maturity Rating Scale
- Promote wellness behaviors
- Sequence: head to toe approach
aged adult
integrity versus despair
clinical setting
May need to be supine if frail
- Sequence: head to toe, organized to limitposition changes
- Allow for rest periods as needed
- Use touch when culturally appropriate
- Assess for confusion
general survey
physical appearance
body structure
mobility
behavior
physical appearance
general survey
Age
Gender
Level of consciousness
Skin color
Facial features
NAD
body structure and mobility
general survey
Body structure- Stature
Mobility- Gait steady or not, ROM
behavior
general survey
facial expression
mood & affect
Speech
Dress
personal hygiene
most common anthropometric measures
heigh and weight
measurement
general survey
Weight- Use a balance scale or electronic standingscale- Recommended range for height
Height – use measuring pole on scale
** Note any gain or loss of weight.
* Obesity: > 120% ideal body weight
temperature
vital signs
Hypothalamus (thermostat mechanism)
Influencing factors:* Diurinal cycle* Menstrual cycle* Exercise* Age
routes of temperature mechanisms
Oral* Electronic* Axillary* Rectal* Tympanic
pulse
vital signs
stroke volume
Technique of measurement
Rate
Normal rate for age- Bradycardia- Tachycardia
Rhythm- Sinus arrhythmia- Ventricular arrhythmia
Force
respirations
vital signs
Rate
Depth
Effort
Techniques of measurement
blood pressure
vital signs
force of blood pushing against the blood vessels
systolic pressure
maximum pressure felt on artery during systole
diastolic pressure
elastic, recoil or resting pressure; exerted on blood vessel walls during diastole
pulse pressure
difference between systolic & diastolic pressures (reflects stroke volume
mean arterial pressure
map
pressure forcing blood into the tissues (averaged over the cardiac cycle)
influences on bp
Age - Gender- Race - Diurinal rhythm- Weight - Emotions- Exercise - Stress
Physiologic factors controlling blood pressure
- Cardiac output
- Peripheral vascular resistance
- Volume of circulating blood
- Viscosity of the blood
- Elasticity of blood vessels
*all have a direct relationship
normal bp
<120/<80
prehypertension
120-129/<80
hypertension stage I
130-139/80-89
hypertension stage II
> 140/>90
hypertensive crisis
> 180/>120
blood pressure measurement
- sphygmomanometer
- Cuff width and size
- Common errors in BP measurement
- Orthostatic (or postural) hypotension
- BP measurement in the thigh
- thigh pressure higher than in the arm
is pain a vital sign
many consider it the 5th vital sign
3 types of pain
nocioceptive
neuropathic
psychogenic
general patho of pain
Subjective, complex experience
Nocioceptors = Nerve endings that detect pain
Nociception: refers to the way noxious stimuli are perceived as pain
4 phases of nocioception
- Transduction = injury
- Transmission = travel
- Perception = “Ouch!!”
- Modulation = “That’s better”
Neuropathic Pain (aka Neurogenic)
Abnormal processing of pain occurs
Difficult to assess & treat
Pain persists on a neurochemical level
Exact mechanism ?
Injury to peripheral neurons –>spontaneous firing of nerve fibers –>hyperexcitablility of dorsal horn neurons
sources of pain
Visceral pain= organ
Deep somatic pain= bone or soft tissue
Cutaneous pain= skin and subcut tissue
Referred pain = felt one place but originates in another
acute pain
Serves a purpose
◦ Withdrawal helps
◦ May seek help or treatment
◦ Rest, healing
◦ Learn from the experience
◦ Temporary- will go away, oftenwith or without treatment
chronic persistent pain
◦ Serves no purpose
◦ Withdrawal does not help
◦ Makes no difference
◦ Makes no difference
◦ Nothing to be learned fromexperience
◦ Permanent- pain remains and cancause other illnesses including depression & altered behavior
breakthrough pain
◦ Spike in pain level intensity in an otherwisecontrolled situation
◦ Potential Causes◦ medication losing effectiveness prior to next dose ◦ Incident occurs that increases pain
infants
pain developmental care
- Neurotransmitters and connections to the thalamus are present by 20 weeks gestation
- Inhititory NTs not up to sufficient levels until birth
- Can feel pain (as much as adults)
- High risk for undertreatment for pain
aging adult
pain developmental considerations
Not a normal process of aging
Commonly caused by chronic diseases
At risk for undertreatment: thought to be “expected”
Sensation of pain intact with dementia
cultural and gender differences
pain
Influenced by several factors
- societal expectations
- hormones
- genetic makeup
Cultural Influences Pain Perception
Opioid Epidemic
initial pain assessment tool
Where is your pain?
When did it start?
What does your pain feel like?
How much pain do you have?
What makes it worse or better?
Any limitations in your functioning or activities?
What is your usual behavior with pain?
What does this pain mean to you?
numeric pain scale
0-10
faces pain scale
for younger kids
objective data for assessing pain
Assess joints for size, contour, tenderness, any crepitation, and range of motion
Inspect skin for color, lumps or masses, lesions, or swelling
Inspect abdomen for contour and symmetry
Observe for nonverbal behaviors of pain for:
* Acute pain: guarding, grimacing, moaning,restlessness,
* Chronic pain: adaptation to pain leads to more subtle indicators (rubbing, bracing, sighing, decreased movement, change in appetite, sleeping)
signs and symptoms of pain
Cardiac- Tachycardia, ↑ BP, ↑ CO, ↑ O2 demand
Pulmonary- Hypoventilation, hypoxia, ↓ cough, atelectasis
GI- N/V, Ileus
GU- oliguria, retention
MS- spasm, joint stiff
CNS- fear, anxiety, fatigue
Immune- Impaired immunity, impaired wound healing
long term effects of chronic pain
depression, isolation, limited mobility & function, confusion, family distress, diminished QOL
Regardless of the reason for seeking care you will do a brief mental status exam on all patients. This exam will include A,B,C,&T. What does each letter stand for? What would be data you would pay attention to for each letter?
A- AppearancePosture, body movements, dress, grooming & hygiene
B- BehaviorLOC, facial expressions, speech, mood and affect
C- Cognitive FunctionOrientation, Attention Span, memory (recent and remote), new learning
T- Thought Procesess/PerceptionsThought processes, thought content, abnormal perceptions (hallucinations?)
We discussed situations where you would complete a more detailed mental status exam. What are those situations?
Family/Friends have expressed concern “this is different for them”
History of brain lesion or psychiatric illness
Experiencing aphasia
We also discussed tools to help assess development in children and cognition/confusion/dementia in adults. The ______ is used to assess develop in children. The __________ and _____________ can help assess confusion inolder adults. Out of these 2 adult options the _____________ is the better choice for screening for dementia
denver II
mmse
mini cog
mini cog
In addition to the rate of the pulse what is another piece of information we collect?
Force/Strength
what are the different ratings of pulse strength? what is normal?
0 Absent
1+ Weak and thready
2+ Normal
3+ Bounding
What are the different stages of blood pressure for adults?
Normal <120/80
Prehypertensive 120-129/80
Stage I 130-139/80-89
Stage II >140/>90
Crisis >180/>120
What are the 2 main factors affecting BP?
Volume and vessel size
While completing morning vitals the patient tells you they are experiencing pain. What all would you ask them about for a pain assessment?
Quantity, quality, where, when/timing, things that make it better/worse, affect on ADLS/what does this pain mean to the patient
Are all patients going to act the same when experiencing pain?
No, very subjective experience
If using OPS what would indicators the patient is experiencing pain?
hanges in vital signs (HR, RR), facial expressions, moaning, moving around in bed, inconsolable
Which patient populations would the OPS be used in?
babies/infants, confused or those unable to communicate
The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the patient’s pain, what is the most appropriate pain assessment toll for the nurse to use?
a. Face, Legs, Activity, Cry, Consolability Scale
b. Visual Analog Scale
c. FACES Pain Scale
d. Numeric Pain Intensity Scale
c
When assessing a client’s complaint of pain which characteristics would the nurse make sure to assess? Select all that apply
a. Quality of pain
b. Quantity of pain
c. Onset/Duration of pain
d. Aggravating & Alleviating Factor
a, b, c, d
The nurse has entered the patient’s room for the first time. What information would the nurse gather as part of a general survey? Select all that apply.
a. Age
b. Skin color
c. Position in bed
d. Bowel sounds
e. Capillary refill
f. Signs of distress
a, b, c, f
While reviewing vitals the nurse sees that a patient’s HR is 52. What is the nurse’s best choice in this scenario?
a. Note the pulse as normal and continue documenting.
b. Notify the physician of the low pulse.
c. Re-assess the pulse
d. Compare this finding to the patient’s previous vitals.
c or d
*D. was original correct answer b/c you would like to see if this is consistent with previous results, if not then I could go reassess. However, I believe reassess first was stressed in fundamentals so I will accept either answer
The nurse is providing care for a patient who is experiencing a panic attack. The panic attack is leading to vasoconstriction. How would vasoconstriction affect blood pressure?
a. No affect
b. Cause an increase in blood pressure
c. Cause a decrease in blood pressure
b
The nurse is providing care for a hospitalized client. Which problem would the nurse correctly identify as a third-level problem?
a. Gasping breaths with nasal flaring
b. Elevated glucose level
c. Impaired circulation
d. Difficulty walking unassisted
d
The nurse is providing care for a client who embraces the hot/cold theory of health and illness. How would the nurse best categorize this theory?
a. Biomedical or scientific
b. Naturalistic
c. Magicoreligious
d. Spiritual Healing
b
The nurse is working with a new client to obtain a health history. Which behaviors by the nurse would help to facilitate building rapport during this interaction? Select all that apply.
a. Use bias free language when asking questions.
b. Make eye contact throughout interview as culturally appropriate.
c. Position self on client’s level.
d. Assume a calm, relaxed posture.
e. Utilize mostly yes and no questions.
a, b, c, d
Which adjustment in the physical environment should the nurse make to promote the success of an interview?
a. Reduce noise by turning off televisions and radios.
b. Provide dim lighting to make the room cozy and help the patient relax.
c. Arrange seating across a desk or table.
d. Reduce the distance between the interviewer and the patient to 2 feet or less.
a
While completing an interview the nurse is gathering information and asks, “How areyou feeling today? Do you have any complaints?” Based on this questions, the nurse is at which phase of the interview process?
a. Summary
b. Closing
c. Opening or Introduction
d. Working
c or d
Working was the original correct answer but the class overwhelming selectedintroduction to I gave credit for it because you might have been confused from the
textbook. The introduction phase is literally introducing your self and explaining what isgoing to happen. Once you start gathering data (such as “How are you feeling”?) youare in the working phase. If you look at the bottom of page 22 in the textbook it saysafter a brief introduction ask an open-ended question, it then says in parentheses seethe following section which is the working phase so I felt like since it might have been alittle confusing in the textbook I would give credit for either
Appearance, Behavior,Cognition, and Thought Process (A, B, C, T)
Components of the Mental Status Exam
A patient who is not fullyalert, is drowsy, and will drift off to sleep during assessment
A lethargic/somnolent patient
Have you ever thought of harming yourself or others?
suicidal screening
Developmental Test for children birth-6 years old
denver II
Components include the 3-item recall test and the clock drawing test
the mini cog
Previous medical history, family history, and reason for seeking care are examples of this.
subjective data
Location, character, severity, timing, aggravating factors
Subjective Data for complaints of pain
ADL is an acronym for
activities of daily living
PQRSTU
Acronym for pain assessment (Provoking, quality, region, severity ,timing, understanding client perception)
ADOLESCENT ASSESSMENT TOOL
HEEADSSS psychosocial scale
Otoscope, speculum, opthalmoscope, penlight
Instruments used for inspection
This assessment technique utilizes the hands to assess temperature, moisture, size, swelling, and tenderness
palpation
Utilizing vibration and sound to assess underlying structures
percussion
Assessment technique utilizing a stethoscope
auscultation
Part of the stethoscope used for high-pitched sounds (normal heart/lung sounds)
diaphragm
During this life phase, the least distressing assessments are performed first
infant
This life phase has a fear of invasive procedures
toddler
When assessing this life phase, provide simple explanations of how the body works
school aged child
In this life phase, you should have parents present and allow the patient to hold/touch instruments
preschool child
In this life phase, you may need to allow for rest periods during your assessment or keep the patient supine if frail
aged adult
Providing privacy, comfort, maintaining eye contact, and removing distractions
Examples of communication facilitators
Posture, facial expression, touch, physical appearance, and eye contact
nonverbal communication
A question that requires more than a yes/no response, allowing the patient to express more information
open ended question
Silence, Clarification, Empathy, and Facilitation
Examples of communication techniques
Using medical jargon, interrupting, leading questions, and providing false reassurance
interviewing traps
When assessing this age group, it is best to examine the patient without family in the room
adolescent
Physical appearance, body structure, mobility, and behavior
4 areas of the general survey
The most common anthropometric measures
height and weight
The tendency to view your own culture/way of life as the most desirable and best
ethnocentrism
Using this part of the stethoscope to hear low pitch sounds.
bell
