Test 1 Flashcards
Two components of health assessment
Health history ( interviewing)
Physical assessment ( hands on)
Type of health assessments
Comprehensive, ongoing partial, focused, emergency
Comprehensive assessment
Obtained on admission to the health care facility
- get info, write everything down, ask questions
Ongoing partial assessment
Obtained at regular intervals
- After admission, assess in morning and at a time interval later (ex: every 4 hours)
Focused assessment
Assess a specific problem
- ex: cardiac, respiratory, etc.
Emergency assessment
Assess life- threatening or unstable conditions
- in need of immediate attention, ex: gun shot wound
Subjective data
Anything the patient tells you that you cannot directly observe
- ex: symptoms, feeling, preferences, ideas, values, personal info
Interviewing
- requires professional, interpersonal, interviewing skills
- 2 focuses: establishing rapport and trusting relationship and gathering info
types of info gathered during interview
Developmental, psychological, physiologic, sociocultural, spiritual status
Phases of interview
Pre-introductory, introductory, working and summary/closing
Pre-introductory phase
-review medical records
- reveals information to help assess current needs
- reveals special considerations
- guide nurse in obtaining necessary info
Introductory phase
- 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
Working phase
- 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
Summary and closing phase
- summarize info obtained during working phase
- validate problems and goals
- ask if any other concerns or questions
Objective data
Data directly observed during interaction with the client
- info elicited through physical exam techniques
Collecting objective data (basic knowledge)
- types of operation of equipment needed
- preparing self and client for exam
- properly performing techniques
Performance techniques
Inspection
Palpation
Percussion
Auscultation
Non-verbal communication
Presentable appearance
Demeanor
Facial expression
Attitude
Listening
AVOID:
Excessive/insufficient eye contact
Distraction and distance
Standing
Verbal communication
Open-ended questions
Close ended questions
Validating
Clarifying
Reflective
Sequencing
Directing
AVOID:
Biased or leading questions
Rushing through the interview
Reading off questions
Considerations during interview
Gerontologic variation: age (older adults hearing and sight)
Cultural variation
Emotional variation: depressed, anxious, etc
Analysis Pain
COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors
PQRST
Provocative
Quality
Radiates
Severity
Timing
Supine position
Laying on back
- for skin and abdomen
Standing position
For neuro assessments
Sitting position
Heart and lung exams
Sims position
Laying on left side with right leg bent
- rectum and uterus
Dorsal recumbent position
Laying on back knees up arms up
-vaginal, pelvic, childbirth
Knee-chest position
On knees pull chest to knees
- OBGYN (reposition fetus), some surgeries
Prone position
Laying flat on stomach
-acute respiratory distress syndrome (ARDS), surgery,infants
Lithotomy
On back with legs in stirrups
- OBGYN
Physical assessment inspection
- vision, smell, hearing
- comfortable temp
- lighting
- look/observe before touching
- expose part being examined not rest
-compare symmetric parts
Physical assessment palpation
Light (palms of fingers) or deep (hands)
Feeling for:
Texture
Temp
Moisture
Mobility
Consistency
Strength of pulses
Size
Shape
Tenderness
Palpation finger pads
Pulse, texture, size, consistency, shape, crepitus (rice crispy)
Palpation ulnar or palmar surface
Vibrations
Shrills/thrills
Fremitus
Palpation dorsal surface
Temp
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
Types of percussion
Direct
Blunt: one hand down and hit with other
Indirect or mediate: hand to chest hit fingers with 2 other fingers
Sounds elicited by percussion
Resonance (respiratory)
Hyperresonance
Tympany (stomach)
Dullness
Flatness
Physical assessment auscultation
Requires stethoscope
Classify sounds:
- intensity
- pitch
- duration
- quality
Diaphragm for high pitch bell for low pitch
Vital signs
A measure of the body’s most basic functions
- Temp, Pulse, respirations, blood pressure, sometimes pain, sometimes oxygen sat
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
Normal oral temp
35.8-37.5 Celsius or 96.4-99.5 F
Normal pulse
60-100 bpm
Normal respiration rate
12-20 breaths/min
Normal blood pressure
120/80 or less
Temperature
Reflects the balance between heat the body produces and heat lost from the body to the environment
Core temperature sites
Rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus and urinary bladder
Surface temperature sites
Oral, axillary, temporal, tympanic
Primary source of metabolism
Heat production
What increases metabolism
Hormones, muscle movements, exercise
What is released when additional heat is required
Epinephrine and norepinephrine
Conduction
Transfer of heat from the body directly to another surface
Convection
Dispersion of heat by air currents
Evaporation
Dispersion of heat through water vapor
Radiation
Transfer of heat from one object to another without contact
Diaphoresis
Visible perspiration on the skin
Normal rectal temp
97.4-100.5 F or 36.6-38.1 C
Normal axillary temp
95.6-98.5 F or 35.4-36.9 C
Normal temporal temp
98.7-100.5 F or 36.3-38.1 C
Normal tympanic temp
98.2-100.9 F or 36.8-38.3 C
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
Hormonal changes and temp
- ovulation and menses
- menopause
Exercise/activity and dehydration and temp
On tribute to hyperthermia
Illness and injury and temp
- can cause elevations
- fever
Food/fluid and smoking and temp
Can change the accuracy of oral temp wait 15-30
Circadian rhythms, stress, envi and temp
Can effect temp
Hypothermia
Below 95 F (35 C)
Hyperthermia
Above 104 F (40 C)
Contraindications of Oral temp taking
- under age of 6
- confused/comatose
- on oxygen
- trauma to mouth or favce
Contraindications of rectal temp taking
- constipation/diarrhea
- heart conditions (VEGAS NERVE)
- less than 3 months old
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
Contraindications of axillary temp taking
- sweating
- operator not knowing correct way
Contraindications of tympanic temp taking
- operator
- drainage
- ear infection
- scars
- tubes
Contraindications of temporal temp taking
- operator
- anything covering head
Afebrile
Without fever
Pyrexia
With fever (febrile)
Autonomic nervous system
Controls heart rate
Parasympathetic nervous system
Lowers the heart rate
(Rest and digest)
Sympathetic nervous system
Raises heart rate
(Fight or flight)
Pulse
Measure of heart rate and rhythm
- bounding of blood flowing through various points in the circulatory system
Tachycardia
Greater than 100 bpm
Bradycardia
Lower than 60 bmp
Strength scale of pulse
0 - absent
1 - diminished, weaker than expected
2 - brisk, expected
3- bounding
Dysrhythmia
An irregular heart rhythm, generally with an irregular radial pulse
Pulse deficit
The difference between the apical rate and the radial rate
Regular pulse outside of adults
Newborn: 95-170
Infant: 85-170
Toddler: 70-150
Children: 65-130
Adolescent: 60-115
Peripheral pulses
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Ventilation
The exchange of oxygen and co2 in the lungs through inspiration and expiration
- measure through rate, rhythm and depth
Diffusion
The exchange of oxygen and co2 between the alveoli and the RBC
- measure with pulse oximetry
Perfusion
The flow of RBCs to and from the pulmonary capillaries
- measure with pulse oximetry
Rate of respiration
The number of full inspiration and expiration in 1 minute
Depth of respiration
The amount of chest wall expansion that occurs with each breath (shallow or deep)
Rhythm of respiration
The observation of breathing intervals
Expect regular with an occasional sign (adults)
Normal respiration with age
Newborn: 30-60
Infant: 30-50
Toddler: 20-40
Child: 15-25
Adolescent: 12-20
Diaphragmatic breathers
Breathing with diaphragm and abdomen
Abdominal movements are more pronounced
Males and children
Thoracic breathers
Chest breathing
Chest movements are more pronounced
Women
Considerations of respirations
Pain, anxiety, smoking, body position, medications, neurological injury, illness
Bradypnea
Regular breathing with a rate less than 12/min
Hypoventilation
Shallow breathing pattern with an abnormally low rate
Apnea
Periods where there is no breathing
Ongoing spells can lead to respiratory arrest
Tachypnea
Regular breathing pattern with a rather higher than 20/min
Hyperventilation
Deep breathing pattern with an increases, leads to decreased levels of CO2 and hyperoxygenation
Hyperpnea
Rate, depth and work of breathing increases
Common during exercise
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
Kussmaul respiration
Increased respiratory rate, regular pattern but excessively deep
Normal pulse oximetry range
90-100
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)
Blood pressure
Reflects the force of the blood exerts against the walls of the arteries during cardiac muscle contractions (systole) and relaxation (diastole)
Systolic BP
The peak pressure in the artery at the end of the cardiac cycle while the ventricles are contracting
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
Principal determinants of BP
Cardiac output and systemic (peripheral) vascular resistance
BP = CO X SVR
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
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
Elevated BP
120-129 SBP and less than 80 DBP
Stage 1 hypertension
130-139 SBP and 80-89 DBP
Stage 2 hypertension
Greater than or equal to 140 SBP and greater than or equal to 90 DBP
Orthostatic hypotension
- results from an inadequate physiologic response to postion change
- causes by dehydration, blood loss, neuro, cardiovascular, or endocrine problems,
Hypotension
< 90/60 mmHg
- result of disease
- side effect of meds
- inability of body to maintain or return pressure to normal
Pulse pressure
Difference between systolic and diastolic B
Considerations while taking blood pressure
Age, circadian rhythms, stress, exercise, ethnicity, obesity, family history, sex, meds
Infectious agent
Bacteria, fungi viruses
Reservoir
Natural habitat of the organism
Portal of exit
Point of escape for the organism
Means of transmission
Direct contact, indirect contact, airborne route
Portal of entry
Point at which organism enters a new host
Susceptible host
Must overcome resistance mounted by host’s defenses
Bacteria
Most significant and prevalent infectious agent in hospital settings
- treat with antibiotics
Virus
Smallest of all microorganisms
- treat with antivirals
Fungi
Plant-like organisms present in air soil and water
- athletes food and parasites
Classifications of bacteria
- shape: spherical (cocci), rod (bacilli), corkscrew (spirochetes)
- gram pos or neg
- aerobic or anaerobic
Factors affecting potential to produce disease
- number of organisms
- virulence
- competence of persons immune system
- length and intimacy of contact
Possible reservoirs
Other people
Animals
Soil
Food,water, milf
Inanimate objects
Common portals of exit
- respiratory
- gastrointestinal
- genitourinary tracts
- breaks in skin
- blood and tissue
Incubation period
Organism growing and multiplying
Prodromal stage
Person is most infectious, vague and nonspecific signs
Full stage of illness
Presence of specific signs and symptoms
Convalescent period
Recovery from the infection
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
Cardinal signs of acute infection
Redness
Heat
Swelling
Pain
Loss of function
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
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
Transient bacterial floral
Attached loosely on skin, removable with relative ease
Resident bacterial flora
Found in creases in skin, require friction with brush to remove
4 categories of HAIs
- catheter- associates urinary tract infection CAUTI
- surgical site infection SSI
- central-line associated bloodstream infection CLABSI
- ventilator associated pneumonia VAP
Risk factors for vancomycin- resistant enterococci VRE
- compromised immune system
- recent surgery
- invasive devices
- prolonged antibiotic use
- prolonged hospitalization
Body’s defenses against infection
- body’s normal flora
- inflammatory response
- immune response
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
Personal protection equipment PPE
Gloves gowns masks and protective eyewear
Standard precautions
- used in care of all hospitalized patients
- apply to blood, body fluids, secretions and excretions (not sweat), nonintact skin, mucous membranes
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
Aseptic technique
Includes all activities to prevent or break the chain of infection
Medical asepsis: clean technique
Surgical asepsis: sterile technique
Factors effecting safety
Developmental considerations
Lifestyle
Social behavior
Environment
Mobility
Sensory perception
Knowledge
Ability to communicate
Physical/psych health state
Focus of safety assessments
- the person
- the environment
- specific risk factors ( everyone’s different)
Safety history
- history of falls or accidents
- assistive devices
- history of drug or alcohol abuse
- family support systems and home envi
Safety physical exams
- mobility status
- ability to communicate
- level of awareness
- sensory perception
- identify potential hazards
- domestic violence or neglect?
Factors that contribute to falls
- lower body weakness
- poor vision
- balance issues
- feet and shoe problems
- psychoactive meds
- postural dizziness
- home hazards
Risk factor assessments
Falls
Fires
Poisoning
Suffocation and choking
Firearm injuries
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
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
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
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
Factors influencing mobility
- developmental considerations
- physical/mental health
-lifestyle - attitude/values
- fatigue/stress
- external factors
Physical assessment for mobility
- general ease of movement and gait
- alignment
- joint structure and function
- muscle mass, tone, strength
- endurance
Fowler position
semi sitting position
30 degrees 90 degrees
High Fowler: eating
Protective supine position
Lying on back
Protective side-lying or lateral position
On the side
protective sims position
Left side right leg bent up arms behind back
Protective prone position
Laying on stomach
Lathotomy position
Feet in stirrups (OBGYN)
Pericardium
Outermost later of the heart
Epicardium
Thin outermost layer of the heart
Myocardium
Thick muscular middle layer of the heart
Endocardium
The innermost layer of the heart
Upper chambers of the heart
Right and left atria at the base of the heart
- thin walled, reservoirs for returning blood from the veins
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
Cardiac septum
Blood tight partition that divides the left and right heart
Atrioventricular valves
Tricuspid (right) Mitral (left)
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
Arteries
Carries oxygenated blood from the heart to the body
Carries blood AWAY from heart
Veins
Carry deoxygenated blood TOWARDS the heart
Pulmonary circulation
Right heart pumps deoxygenated blood to the lungs
Systematic circulation
Left heart pumps oxygenated blood to rest of the body
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
Two phase cardiac cycle
Ensures proper circulation by heart contracting and relaxing rhythmically
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”
What closes/opens during systole
Mitral and tricuspid valves close
Aortic and pulmonic valves open (bloods ejected into arteries
Diastole
Ventricles dilate ( energy required effort) drawing blood into them as the atria contract, moving blood from the atria to the ventricles
BASE “dub”
What opens/closes during diastole
Mitral and tricuspid valves open
Aortic valve is closed
Atria contacts as ventricle almost filled
First heart sound
Mitral and tricuspid valves closing
Second heart sound
Aortic and pulmonic valves closing
Third heart sound
Blood moves from atria to ventricles
Fourth heart sound
Complete emptying of atria
Electrical conduction of the heart
Sinoatrial node (SA node) Pacemaker
Atrioventricular node (AV node)
Bundle of His
Purkinje fibers
Cardiovascular health history complaints
Pain (leg arm or chest)
Dyspnea (SOB)
Palpitations (pounding)
Dizziness
Medications
Edema
Nocturnal (sleep schedule)
Pallor
unusual lightness of skin
Look for in inspection phase (cardiac)
Cyanosis
Blueness of skin
Look for in inspection (cardiac)
Inspection for Cardiac exam
Neck vessels, pain, discomfort, cough, fatigue, SOB
Positions of cardiac exam
Sitting, supine (on back with head to 30-45 angle), left lateral recumbent
Auscultation areas for heart
Aortic, pulmonic, erbs point, tricuspid, mitral
Murmurs
Turbulent blood flow with a swooshing or blowing sound
Conditions contributing to murmurs
- increased blood velocity
- structural valve defects
- valve malfunction
- abnormal chamber openings
Neck vessels
Carotid artery and jugular veins
- carotid artery pulse: ventricular systole
Electrocardiogram
Cardiac evalution
Electrolyte lab values
Cardiac evaluation
Usually look for K bc associated with heart
Troponin
Cardiac eval
- protein found in heart (if elevated signifies a problem)
CBC
Cardiac eval (complete blood count)
WBC increase infection
Someone low in hemoglobin or RBC or anemic will have hard time breathing
Cholesterol levels
Cardio eval
Cause blockage in heart
Heart catheterization
Heart eval
Can see arteries and veins and possible blockages
Myocardial infarction
(MI) occlusion of arterial blood flow causing tissue damage
Congestive Heart Failure
(CHF) congestion in pulmonary and or systemic circulation related to inadequate pumping
Thrombus
Blood clot
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
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
Signs of bad vascularity
Pallor
cold
wounds not healing
Lack of hair on lower extremities
Neuropathic
Numbness and tingling
Varicosities
Enlarged veins, alter flow
Identifying varicosities
Circulation (capillary refill on toes greater or less than 3 sec) mobility (wiggle toes) sensation (identify toe you are touching without looking)
Where to use compression
Venous ulcers NOT arterial
Edema
Pitting vs non pitting
Pressing with finger to see if limb “bounces back”
