Test 1 Flashcards
1
Q
Two components of health assessment
A
Health history ( interviewing)
Physical assessment ( hands on)
2
Q
Type of health assessments
A
Comprehensive, ongoing partial, focused, emergency
3
Q
Comprehensive assessment
A
Obtained on admission to the health care facility
- get info, write everything down, ask questions
4
Q
Ongoing partial assessment
A
Obtained at regular intervals
- After admission, assess in morning and at a time interval later (ex: every 4 hours)
5
Q
Focused assessment
A
Assess a specific problem
- ex: cardiac, respiratory, etc.
6
Q
Emergency assessment
A
Assess life- threatening or unstable conditions
- in need of immediate attention, ex: gun shot wound
7
Q
Subjective data
A
Anything the patient tells you that you cannot directly observe
- ex: symptoms, feeling, preferences, ideas, values, personal info
8
Q
Interviewing
A
- requires professional, interpersonal, interviewing skills
- 2 focuses: establishing rapport and trusting relationship and gathering info
9
Q
types of info gathered during interview
A
Developmental, psychological, physiologic, sociocultural, spiritual status
10
Q
Phases of interview
A
Pre-introductory, introductory, working and summary/closing
11
Q
Pre-introductory phase
A
-review medical records
- reveals information to help assess current needs
- reveals special considerations
- guide nurse in obtaining necessary info
12
Q
Introductory phase
A
- introduce self
- ask them name and DOB
- tell types of questions you will ask
- explain why taking notes, sitting and looking at computer
- confidential
- make sure comfortable and private
- develop trust and rapport
13
Q
Working phase
A
- biographical data (life, kids, married, gender)
- reason for seeking care (chief complaint)
History of present concern - past history
- fam history
- review of body systems (ROS) ask pain head to toe
-lifestyle and health practices and dev level
14
Q
Summary and closing phase
A
- summarize info obtained during working phase
- validate problems and goals
- ask if any other concerns or questions
15
Q
Objective data
A
Data directly observed during interaction with the client
- info elicited through physical exam techniques
16
Q
Collecting objective data (basic knowledge)
A
- types of operation of equipment needed
- preparing self and client for exam
- properly performing techniques
17
Q
Performance techniques
A
Inspection
Palpation
Percussion
Auscultation
18
Q
Non-verbal communication
A
Presentable appearance
Demeanor
Facial expression
Attitude
Listening
AVOID:
Excessive/insufficient eye contact
Distraction and distance
Standing
19
Q
Verbal communication
A
Open-ended questions
Close ended questions
Validating
Clarifying
Reflective
Sequencing
Directing
AVOID:
Biased or leading questions
Rushing through the interview
Reading off questions
20
Q
Considerations during interview
A
Gerontologic variation: age (older adults hearing and sight)
Cultural variation
Emotional variation: depressed, anxious, etc
21
Q
Analysis Pain
A
COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors
PQRST
Provocative
Quality
Radiates
Severity
Timing
22
Q
Supine position
A
Laying on back
- for skin and abdomen
23
Q
Standing position
A
For neuro assessments
24
Q
Sitting position
A
Heart and lung exams
25
Sims position
Laying on left side with right leg bent
- rectum and uterus
26
Dorsal recumbent position
Laying on back knees up arms up
-vaginal, pelvic, childbirth
27
Knee-chest position
On knees pull chest to knees
- OBGYN (reposition fetus), some surgeries
28
Prone position
Laying flat on stomach
-acute respiratory distress syndrome (ARDS), surgery,infants
29
Lithotomy
On back with legs in stirrups
- OBGYN
30
Physical assessment inspection
- vision, smell, hearing
- comfortable temp
- lighting
- look/observe before touching
- expose part being examined not rest
-compare symmetric parts
31
Physical assessment palpation
Light (palms of fingers) or deep (hands)
Feeling for:
Texture
Temp
Moisture
Mobility
Consistency
Strength of pulses
Size
Shape
Tenderness
32
Palpation finger pads
Pulse, texture, size, consistency, shape, crepitus (rice crispy)
33
Palpation ulnar or palmar surface
Vibrations
Shrills/thrills
Fremitus
34
Palpation dorsal surface
Temp
35
Physical assessment Percussion
DO NOT USE ON CARDIAC
Seeing if they are having pain, masses, reflexes
Assessments:
Eliciting pain
Determine loco, size and shape
Determine density
Detecting abnormal masses
Eliciting reflexes
36
Types of percussion
Direct
Blunt: one hand down and hit with other
Indirect or mediate: hand to chest hit fingers with 2 other fingers
37
Sounds elicited by percussion
Resonance (respiratory)
Hyperresonance
Tympany (stomach)
Dullness
Flatness
38
Physical assessment auscultation
Requires stethoscope
Classify sounds:
- intensity
- pitch
- duration
- quality
Diaphragm for high pitch bell for low pitch
39
Vital signs
A measure of the body’s most basic functions
- Temp, Pulse, respirations, blood pressure, sometimes pain, sometimes oxygen sat
40
When do assess vital signs
- on admission
- before invasive procedures (baseline)
- after procedures (came back to baseline)
- before some meds
- activities after surgery (first time standing after hip replacement)
- LOC lose/level of consciousness
41
Normal oral temp
35.8-37.5 Celsius or 96.4-99.5 F
42
Normal pulse
60-100 bpm
43
Normal respiration rate
12-20 breaths/min
44
Normal blood pressure
120/80 or less
45
Temperature
Reflects the balance between heat the body produces and heat lost from the body to the environment
46
Core temperature sites
Rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus and urinary bladder
47
Surface temperature sites
Oral, axillary, temporal, tympanic
48
Primary source of metabolism
Heat production
49
What increases metabolism
Hormones, muscle movements, exercise
50
What is released when additional heat is required
Epinephrine and norepinephrine
51
Conduction
Transfer of heat from the body directly to another surface
52
Convection
Dispersion of heat by air currents
53
Evaporation
Dispersion of heat through water vapor
54
Radiation
Transfer of heat from one object to another without contact
55
Diaphoresis
Visible perspiration on the skin
56
Normal rectal temp
97.4-100.5 F or 36.6-38.1 C
57
Normal axillary temp
95.6-98.5 F or 35.4-36.9 C
58
Normal temporal temp
98.7-100.5 F or 36.3-38.1 C
59
Normal tympanic temp
98.2-100.9 F or 36.8-38.3 C
60
Age and temperature
- Newborns have a larger surface to mass ratio so they loose heat rapidly to environment making it higher
- older clients could have more adapose (fat) making it higher
61
Hormonal changes and temp
- ovulation and menses
- menopause
62
Exercise/activity and dehydration and temp
On tribute to hyperthermia
63
Illness and injury and temp
- can cause elevations
- fever
64
Food/fluid and smoking and temp
Can change the accuracy of oral temp wait 15-30
65
Circadian rhythms, stress, envi and temp
Can effect temp
66
Hypothermia
Below 95 F (35 C)
67
Hyperthermia
Above 104 F (40 C)
68
Contraindications of Oral temp taking
- under age of 6
- confused/comatose
- on oxygen
- trauma to mouth or favce
69
Contraindications of rectal temp taking
- constipation/diarrhea
- heart conditions (VEGAS NERVE)
- less than 3 months old
70
How to take rectal temp
- lay in left lateral sims position
- 1 1/2 inch for adults
- no more than 1 inch for children
- 1/2 inch for infants
71
Contraindications of axillary temp taking
- sweating
- operator not knowing correct way
72
Contraindications of tympanic temp taking
- operator
- drainage
- ear infection
- scars
- tubes
73
Contraindications of temporal temp taking
- operator
- anything covering head
74
Afebrile
Without fever
75
Pyrexia
With fever (febrile)
76
Autonomic nervous system
Controls heart rate
77
Parasympathetic nervous system
Lowers the heart rate
(Rest and digest)
78
Sympathetic nervous system
Raises heart rate
(Fight or flight)
79
Pulse
Measure of heart rate and rhythm
- bounding of blood flowing through various points in the circulatory system
80
Tachycardia
Greater than 100 bpm
81
Bradycardia
Lower than 60 bmp
82
Strength scale of pulse
0 - absent
1 - diminished, weaker than expected
2 - brisk, expected
3- bounding
83
Dysrhythmia
An irregular heart rhythm, generally with an irregular radial pulse
84
Pulse deficit
The difference between the apical rate and the radial rate
85
Regular pulse outside of adults
Newborn: 95-170
Infant: 85-170
Toddler: 70-150
Children: 65-130
Adolescent: 60-115
86
Peripheral pulses
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
87
Ventilation
The exchange of oxygen and co2 in the lungs through inspiration and expiration
- measure through rate, rhythm and depth
88
Diffusion
The exchange of oxygen and co2 between the alveoli and the RBC
- measure with pulse oximetry
89
Perfusion
The flow of RBCs to and from the pulmonary capillaries
- measure with pulse oximetry
90
Rate of respiration
The number of full inspiration and expiration in 1 minute
91
Depth of respiration
The amount of chest wall expansion that occurs with each breath (shallow or deep)
92
Rhythm of respiration
The observation of breathing intervals
Expect regular with an occasional sign (adults)
93
Normal respiration with age
Newborn: 30-60
Infant: 30-50
Toddler: 20-40
Child: 15-25
Adolescent: 12-20
94
Diaphragmatic breathers
Breathing with diaphragm and abdomen
Abdominal movements are more pronounced
Males and children
95
Thoracic breathers
Chest breathing
Chest movements are more pronounced
Women
96
Considerations of respirations
Pain, anxiety, smoking, body position, medications, neurological injury, illness
97
Bradypnea
Regular breathing with a rate less than 12/min
98
Hypoventilation
Shallow breathing pattern with an abnormally low rate
99
Apnea
Periods where there is no breathing
Ongoing spells can lead to respiratory arrest
100
Tachypnea
Regular breathing pattern with a rather higher than 20/min
101
Hyperventilation
Deep breathing pattern with an increases, leads to decreased levels of CO2 and hyperoxygenation
102
Hyperpnea
Rate, depth and work of breathing increases
Common during exercise
103
Cheyenne-strokes respiration
Irregular rate and depth of respiration that follow a cyclical pattern (shallow to normal, increased rate to slowing again) ending with an apnea period
104
Kussmaul respiration
Increased respiratory rate, regular pattern but excessively deep
105
Normal pulse oximetry range
90-100
106
Pulse oximetry
Measures oxygen saturation of the blood (the percent of hemoglobin that is bound with oxygen in the arteries is the precent of saturation of hemoglobin)
107
Blood pressure
Reflects the force of the blood exerts against the walls of the arteries during cardiac muscle contractions (systole) and relaxation (diastole)
108
Systolic BP
The peak pressure in the artery at the end of the cardiac cycle while the ventricles are contracting
109
Diastolic BP
During ventricular diastole, when the ventricles relax and exert minimal pressure against arterial walls
Represents the minimum amount of pressure exerted on the arteries
110
Principal determinants of BP
Cardiac output and systemic (peripheral) vascular resistance
BP = CO X SVR
111
Determinants of cardiac output
the amount of blood pumped by the heart in one minute
Heart rate
Contractility
Blood volume
Venous return
And increase in any increase CO and BP and vis versa
112
Systemic vascular resistance SVR
The amount of constriction or dilation of the arteries and diameter of blood vessels
Increase SVR increase BP and vis versa
113
Elevated BP
120-129 SBP and less than 80 DBP
114
Stage 1 hypertension
130-139 SBP and 80-89 DBP
115
Stage 2 hypertension
Greater than or equal to 140 SBP and greater than or equal to 90 DBP
116
Orthostatic hypotension
- results from an inadequate physiologic response to postion change
- causes by dehydration, blood loss, neuro, cardiovascular, or endocrine problems,
117
Hypotension
< 90/60 mmHg
- result of disease
- side effect of meds
- inability of body to maintain or return pressure to normal
118
Pulse pressure
Difference between systolic and diastolic B
119
Considerations while taking blood pressure
Age, circadian rhythms, stress, exercise, ethnicity, obesity, family history, sex, meds
120
Infectious agent
Bacteria, fungi viruses
121
Reservoir
Natural habitat of the organism
122
Portal of exit
Point of escape for the organism
123
Means of transmission
Direct contact, indirect contact, airborne route
124
Portal of entry
Point at which organism enters a new host
125
Susceptible host
Must overcome resistance mounted by host’s defenses
126
Bacteria
Most significant and prevalent infectious agent in hospital settings
- treat with antibiotics
127
Virus
Smallest of all microorganisms
- treat with antivirals
128
Fungi
Plant-like organisms present in air soil and water
- athletes food and parasites
129
Classifications of bacteria
- shape: spherical (cocci), rod (bacilli), corkscrew (spirochetes)
- gram pos or neg
- aerobic or anaerobic
130
Factors affecting potential to produce disease
- number of organisms
- virulence
- competence of persons immune system
- length and intimacy of contact
131
Possible reservoirs
Other people
Animals
Soil
Food,water, milf
Inanimate objects
132
Common portals of exit
- respiratory
- gastrointestinal
- genitourinary tracts
- breaks in skin
- blood and tissue
133
Incubation period
Organism growing and multiplying
134
Prodromal stage
Person is most infectious, vague and nonspecific signs
135
Full stage of illness
Presence of specific signs and symptoms
136
Convalescent period
Recovery from the infection
137
Factors affecting host susceptibility
Intact skin and mucus membrane
Normal pH
WBC
Age, sex, race, hereditary
Immunization
Fatigue, climate, nutritional and general heath
Stress
Invasive or indwelling medical devices
138
Cardinal signs of acute infection
Redness
Heat
Swelling
Pain
Loss of function
139
Lab data indicating infection
- elevated WBC count (norm: 5,000-10,000)
- increase in specific WBC
- elevated erythrocyte sedimentation rate
- presence of pathogens in urine, blood, sputum or draining cultures
140
Five moments for hand hygiene
- before touching a patient
- before a clean or aseptic procedure
- after a body fluid exposure risk
- after touch a patient
- after touching patients surroundings
141
Transient bacterial floral
Attached loosely on skin, removable with relative ease
142
Resident bacterial flora
Found in creases in skin, require friction with brush to remove
143
4 categories of HAIs
- catheter- associates urinary tract infection CAUTI
- surgical site infection SSI
- central-line associated bloodstream infection CLABSI
- ventilator associated pneumonia VAP
144
Risk factors for vancomycin- resistant enterococci VRE
- compromised immune system
- recent surgery
- invasive devices
- prolonged antibiotic use
- prolonged hospitalization
145
Body’s defenses against infection
- body’s normal flora
- inflammatory response
- immune response
146
Factors determining use of sterilization and disinfection methods
- nature of organism present
- number of organisms present
- type of equipment
- intended use of equipment
- available means
- time
147
Personal protection equipment PPE
Gloves gowns masks and protective eyewear
148
Standard precautions
- used in care of all hospitalized patients
- apply to blood, body fluids, secretions and excretions (not sweat), nonintact skin, mucous membranes
149
Transmission based precautions
- in addition to standard for patients with suspected infections with pathogens that can be transmitted by airborne, droplets or contact routes
- use PPE whenever entering room
150
Aseptic technique
Includes all activities to prevent or break the chain of infection
Medical asepsis: clean technique
Surgical asepsis: sterile technique
151
Factors effecting safety
Developmental considerations
Lifestyle
Social behavior
Environment
Mobility
Sensory perception
Knowledge
Ability to communicate
Physical/psych health state
152
Focus of safety assessments
- the person
- the environment
- specific risk factors ( everyone’s different)
153
Safety history
- history of falls or accidents
- assistive devices
- history of drug or alcohol abuse
- family support systems and home envi
154
Safety physical exams
- mobility status
- ability to communicate
- level of awareness
- sensory perception
- identify potential hazards
- domestic violence or neglect?
155
Factors that contribute to falls
- lower body weakness
- poor vision
- balance issues
- feet and shoe problems
- psychoactive meds
- postural dizziness
- home hazards
156
Risk factor assessments
Falls
Fires
Poisoning
Suffocation and choking
Firearm injuries
157
Safety devices to prevent falls
- Guard rails in beds ( are a unless asked for so cannot be up without dr order and must be renewed every 24 hrs and checked every hour)
- breaks on beds
- sticky socks
158
RACE
R- rescue anyone in immediate danger
A - active the fire code and notify appropriate person
C - confine the fir by closing doors and windows
E - evacuate patients and others to safe area
159
Safety event reports
- must be completed after any accident or incident
- describe the circumstances
- details of patients response
- completed y nurse immediately after
- not part of medical record and should not be mentioned in documentation
160
Physical hazards associated with restraints
- Increased poss for serious injury due to fall
- skin breakdown
- contractures (weakened muscles and stiffness)
- incontinence (hard to get to BR)
- depression
-delirious
- anxiety
Aspiration
- death
161
Factors influencing mobility
- developmental considerations
- physical/mental health
-lifestyle
- attitude/values
- fatigue/stress
- external factors
162
Physical assessment for mobility
- general ease of movement and gait
- alignment
- joint structure and function
- muscle mass, tone, strength
- endurance
163
Fowler position
semi sitting position
30 degrees 90 degrees
High Fowler: eating
164
Protective supine position
Lying on back
165
Protective side-lying or lateral position
On the side
166
protective sims position
Left side right leg bent up arms behind back
167
Protective prone position
Laying on stomach
168
Lathotomy position
Feet in stirrups (OBGYN)
169
Pericardium
Outermost later of the heart
170
Epicardium
Thin outermost layer of the heart
170
Myocardium
Thick muscular middle layer of the heart
170
Endocardium
The innermost layer of the heart
170
Upper chambers of the heart
Right and left atria at the base of the heart
- thin walled, reservoirs for returning blood from the veins
170
Lower chambers of the heart
Right and left ventricle at the apex of the heart
- thick walled and pumps the blood to the lungs and throughout the body
170
Cardiac septum
Blood tight partition that divides the left and right heart
170
Atrioventricular valves
Tricuspid (right) Mitral (left)
171
Semilunar valves
Between ventricles and great vessel, organ system
regulate blood flow between the ventricals and arteries
- pulmonic: between the right ventricle and the pulmonary artery
- aortic: between the left ventricle and the aorta
172
Arteries
Carries oxygenated blood from the heart to the body
Carries blood AWAY from heart
173
Veins
Carry deoxygenated blood TOWARDS the heart
174
Pulmonary circulation
Right heart pumps deoxygenated blood to the lungs
175
Systematic circulation
Left heart pumps oxygenated blood to rest of the body
176
Path through heart
Inferior and superior Vena cava - right atrium - tricuspid valve - right ventricle - pulmonary valve - pulmonary artery - lungs - left atrium - mitral valve - left ventricle - aorta - rest of body
177
Two phase cardiac cycle
Ensures proper circulation by heart contracting and relaxing rhythmically
178
Systole
Ventricles contract causing blood to eject from the left ventricle into the aorta and from the right ventricle into the pulmonary artery
APEX “lub”
179
What closes/opens during systole
Mitral and tricuspid valves close
Aortic and pulmonic valves open (bloods ejected into arteries
180
Diastole
Ventricles dilate ( energy required effort) drawing blood into them as the atria contract, moving blood from the atria to the ventricles
BASE “dub”
181
What opens/closes during diastole
Mitral and tricuspid valves open
Aortic valve is closed
Atria contacts as ventricle almost filled
182
First heart sound
Mitral and tricuspid valves closing
183
Second heart sound
Aortic and pulmonic valves closing
184
Third heart sound
Blood moves from atria to ventricles
185
Fourth heart sound
Complete emptying of atria
186
Electrical conduction of the heart
Sinoatrial node (SA node) Pacemaker
Atrioventricular node (AV node)
Bundle of His
Purkinje fibers
187
Cardiovascular health history complaints
Pain (leg arm or chest)
Dyspnea (SOB)
Palpitations (pounding)
Dizziness
Medications
Edema
Nocturnal (sleep schedule)
188
Pallor
unusual lightness of skin
Look for in inspection phase (cardiac)
189
Cyanosis
Blueness of skin
Look for in inspection (cardiac)
190
Inspection for Cardiac exam
Neck vessels, pain, discomfort, cough, fatigue, SOB
191
Positions of cardiac exam
Sitting, supine (on back with head to 30-45 angle), left lateral recumbent
192
Auscultation areas for heart
Aortic, pulmonic, erbs point, tricuspid, mitral
193
Murmurs
Turbulent blood flow with a swooshing or blowing sound
194
Conditions contributing to murmurs
- increased blood velocity
- structural valve defects
- valve malfunction
- abnormal chamber openings
195
Neck vessels
Carotid artery and jugular veins
- carotid artery pulse: ventricular systole
196
Electrocardiogram
Cardiac evalution
197
Electrolyte lab values
Cardiac evaluation
Usually look for K bc associated with heart
198
Troponin
Cardiac eval
- protein found in heart (if elevated signifies a problem)
199
CBC
Cardiac eval (complete blood count)
WBC increase infection
Someone low in hemoglobin or RBC or anemic will have hard time breathing
200
Cholesterol levels
Cardio eval
Cause blockage in heart
201
Heart catheterization
Heart eval
Can see arteries and veins and possible blockages
202
Myocardial infarction
(MI) occlusion of arterial blood flow causing tissue damage
203
Congestive Heart Failure
(CHF) congestion in pulmonary and or systemic circulation related to inadequate pumping
204
Thrombus
Blood clot
205
Fluid volume defect (hypovolemia)
Isotonic fluid loss
Fluid becomes hypertonic drawing fluid from cells in interstitial space leaving them depleted ad unable to function
Causes BP to decrease HR to increase
206
Fluid volume excess (hypervolemia)
Excess of isotonic fluid
Kidney malfunction and infective heart pumping may cause, results in the accumulation of fluids in lungs and dependent parts of body
Causes BP increase HR increase and cough, SOB, fluid in lungs
207
Signs of bad vascularity
Pallor
cold
wounds not healing
Lack of hair on lower extremities
208
Neuropathic
Numbness and tingling
209
Varicosities
Enlarged veins, alter flow
210
Identifying varicosities
Circulation (capillary refill on toes greater or less than 3 sec) mobility (wiggle toes) sensation (identify toe you are touching without looking)
211
Where to use compression
Venous ulcers NOT arterial
212
Edema
Pitting vs non pitting
Pressing with finger to see if limb “bounces back”
213
