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NUR 103 Final

final for Health Assessment

Subjective Data What the pt tells you
Objective Data What you observe when assessing a pt
First Level Priority 1. Airway 2. Breathing 3. Cardiac/ Circulation 4. Vital sign concerns (e.g. high fever)
Second Level Priority 1. Mental status change (e.g. cinfusion, decreased alertness) 2. Untreated medicalproblems requiring immediate attention 3. Acute pain 4. Acute urinary elimination problems 5. Abnormal laboratory values 6. Risk of infection, safty, or security
Third Level Priority 1. Health problems that do not fit into the first two levels (e.g problems with lack of knowledge,activity, rest, family coping)
Nursing Process 1. Assessment 2. Diagnosis 3. Planning 4.Implementation 5. Evaluation
Holistic Health views the mind, body, and spirit as functioning as a whole within the environment. Health depends on all these factors working together.
Health Promotion promoting healthy life style, preventing or helping stop unhealthy life styles to prevent disease.
Pulse Palpate for 1 min. assess rate, rythm, and force.
Normal pulse Rate 50-90 bpm varies with age
Stroke volume the amount of blood the heart pumps
bradycardia heart rate < 50 bpm
Tachycardia heart rate > 90 bpm
Force of pulse the strength of the hearts stroke volume
Assessment data collection
Diagnosis Comparing findings with normal and abnormal findings after data collection
Planning establishing priorities, developing outcomes
Implementation carryout your plan
Evaluation how the plan worked
Pulse sites Radial, brachial,Carotid, Ulnar, Popliteal, Posterior tibial, Dorsalis pedis, evternal maxillary, superficial temporal, apical
Respirations normally relaxed, regular, automatic, and silent. count for 1 min.
Respiration rate adult 10-20
Respiration rate 16 yr.s 12-20
Respiration rate 12-14 yr.s 18-22
Respiration rate 8-10 yr.s 20-26
Respiration rate 2 yr.s 25-32
Respiration rate 1 yr. 20-40
Respiration rate neonate 30-40
Oral Temperature leave in place 3-4 min. if afebrile, and 8 min. if ferile.
When taking an oral temperature how long should you wait after the pt has ingested somthing hot or cold? 15 min.
With an oral temperature how long do you wait after a pt has smoked? 2 min.
Rectal Temperature insert 1" for 2 1/2 min.
Tympanic Temperature Insert into ear takes temperature in about 2-3 seconds
Normal Temperature range 96.4- 99.1 degrees F
Normal pulse rate in children 70-120 bpm
Normal pulse rate in toddlers 90-150 bpm
Normal pulse rate in newborns 120-160 bpm
Normal Blood pressure (BP) <120/80
Systolic pressure is the maxium pressure felt on the artery during left ventricular contraction (is the top #)
Diastolic pressure the elastic recoil,or resting pressure that the blood exerts constantly between each contraction
Pulse pressure the difference between the Systolic and Diastolic
Mean Arterial Pressure (MAP) the pressure forcing blood into the tissues, averaged over the cardiac cycle
MAP is determined by what 5 factors? cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of vessel walls
What happens if the cuff size used when taking BP is too narrow? It gives a false high BP
Auscultatory gap a period when Korotkoff sounds disappear during asculation.
Pain is the fifth vital sign
What two processes does pain develop by? nociceptive and neuropathic
nocieptive pain nerve endings designed to detect painful sensations from the periphery anad transmit them to the CNS. located in the skin, connective tissue, muscle, and the thoracic, abdominal, and pelvic viscera
Neuropathic pain implies and abnormal processing of the pain message from an injury to the nerve fibers. this pain can start 2-3 yr.s after an injury.
Acute pain is short term pain and self limiting usually goes away after an injury heals
Chronic Pain pain that continues for 6 months or more it can last 5 or more years.
Where is your pain? May be localized or occur in multiple sites
What does your pain feel like? is the quality of pain e.g. burning, stabbing, aching, throbbing, firelike, squeezing, cramping, sharp, itching, tingling, shooting, crushing, dull
What is the quality of pain in Neuropathic pain? burning, shooting, and tingling
What is the quality of pain in nocieptive pain? if localized aching if not localized cramping, and from somatic sites throbbing/aching
How much pain do you have? Identifies what? intensity
What makes your pain better or worse idntifies what? allevating and aggreivating factors and effectiveness of current treatment
How does the pain limit your function or activities identifies what? the degree of impairment and quality of life.
How do you usually react when you are in pain identifies what? aids in detection and assessment
Pain rating scale 0-10; 0 being no pain 10 being the worst pain ever
culturally competent implies that the caregivers understand and attend to the total context of the individuals situation, including awarness of immigration status, stress factors, other social factors, and cultural similarities, and differences.
Religion organized system of beliefs concerning the cause, nature, and purpose of the universe, especially beliefin or the worship of God.
Spirituality a persons personal effort to find purpose and meaning in life
Who believe in the evil eye? Mexico, cuba, columbia, brazil, spain, puerto rico, portugal
who believes in yin and yang? China, india, japan, koream philippines, southeast asia
Interview Process introducing the interview, the working phase, closing the interview
Physical environment during interview comfortable room temp., good lighting,reduce noise, remove distracting objects, 4-5 feet in between you and the pt, arrange a face-face equal status seating.
Note taking during interview process unavoidable but may be distracting: breaks eye contact, shifts attention away from the person, can be threatening to the patient,can interrupt the patients narrative flow, impedes observation of the pt nonverbal behaviors
open ended questionsduring interview process use to begin the interview and when a person begins a new topic
closed or direct questions during an interview process elicit 1 or 2 short answer words like yes or no
facilitation during interview process incourages the pt to say more e.g. "mm-hmm, goon,continue. aka general leads
silence during interview process golden after open ended questions gives the pt time to think about what the pt wishes to say
reflection during interview process repeating part of what the person just said
empathy during interview process recognizing a feeling and putting it into words
clarification during interview process use when a pts word choice is not understood
confrontaion during interview process when observing a certain action and giving your feedback about what you see or feel
interpretation during interview process interpreting what the patient has said to try to link events, associations, implies a cause
explanation during interview process sharing factual and objective information
summary during interview process summarizing what the pt has stated.
snellen eye chart 20/30; you can read at 20 feet what the normal eye can read at 30 feet. the higher the denominator the worse the vision
difficulty of seeing floaters, halos, scotoma, night blindess.
pain of the eye sudden onset of eye symptoms is an emergency quality: burning, itching, sharp, stabbing, a foreign body sensation etc...
strabismus is a deviation in the axis of the eye
diplopia is the perception of two images of a single object
Glaucoma is characterized by increased intraocular pressure
lacrimation tearing
epiphora excessive tearing
purlulent discaharge of the eye is yellow and thick
otalgia earache or pain may be caused by disease, virus or bacteria, trauma, or problems with teeth or oropharynx
otorrhea ear drainage may be from infected canal or perforated eardrum
external otitis purlulent, sanguineous, or watery discharge
acute otitis media with perforation purlulent discharge
cholesteatomia ditry/yellow gray discharge
presbycusis hearing loss
tinnititus ringing, crackling or buzzing of the ear.
Objective vertigo feels like room spins
subjective vertigo person feels like he or she spins
examining the ear of an adult pull the ear up and back
examining the ear of a child pull the ear down
signs is a subjective sensation that the person feels from the disorder
symptoms is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports
Mental status is the persons emotional and cognitive function
Mental disorders is apparent when a persons response is much greater than the expected reaction to a traumatic life event.
The 4 main headings of mental status assessment (A,B,C,T)appearance, behavior, cognition, thought process
Aphasia the impairment of language ability
Appearance the pt Posture, body movement, How the pt dresses, and their grooming and hygiene
Behavior The pt level of consciousness, facial expressions, speech, mood and affect.
Cognitive function Orientation, attention span, recent memory, remote memory, new learning
Levels of consciousness 1. alert 2. lethargic or somnolent 3. obtunded 4. stupor or semi-coma 5. coma
speech disorders Dysphonia, dysarthria, Aphasia
dysarthria trouble with articulation
global aphasia the most common and severe spontaneous speech and comprehension is absent or reduced.
Broca's aphasia expressive aphasia. can understand language but cannot express himself using language
Wernick's aphasia receptive aphasia. the person can hear sounds and words but cannot relate them to previous experiences
Flat affect lack of emotional response
depression sad, gloomy, dejected.
depersonalizaion loss of identity feels estranged, perplexed about on identity and meaning of existance
elation joy and optimism, overconfident, increased motor activity
euphoria excessive well being, unusually cheerful or elated, that is inappropriate considering physical and mental condition
anxiety worried, uneasy, apprehensive from the anticipation of danger whose source is unknown
fear worried, uneasy, apprehensive; external danger is known and identified
irritability annoyed, easily provoked, impatient
rage furious, loss of control
ambivalence the existance of opposing emotions toward an idea, object, person
lability rapid shift of emotion
inappropriate affect affect clearly discordant with the content of the persons speech
blocking sudden interruption in train of thought, unable to complete sentence, seems related to strong emotion
word salad incoherent mixtuer of words, phrases, and sentences; illogical, disconnected, includes neologism
echolalia imitation, repeats others words or phrases, often with a mumbling,mocking, or mechanical tone
clanging word choice based onsound, not meaning,includes nonsense rhymes ans puns
obsession unwanted, persistant thoughts or impulses; logic will not purge them from consciousness; experienced as intrusive and senseless
compulsion unwanted repetitive, purposeful act; driven to do it; behavior thought to neutralize or prevent discomfort or some dreaded event
hallucination sensory perceptions for which there are no external stimuli; may strikeand sense: visual, auditory, tactile, olfactory, gustatory
schizophrenia 1. two or more symptoms present for 2 month period:delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms 2. social/ occupational dysfunction 3.continues signs for at least 6 months
delirium maybe due to a general medical condition or substance abuse. is a disturbance of consciousness, changes in thought, develops over a short period of time
dementia caused by disease memory impairment, aphasia, apraxia, agnosia, disturbance is executive functioning
manic episode persisnatly, elevated, expansive, or irritable mood lasting for more than 1 week: low self esteem, decreased need for sleep, more talkative, racing thoughts, distractiblity
major depressive disorders characterized by two or more major depressive episodes
panic attack intense fear or discomfort: palpations, sweating, shaking, shortness of breath, chest pain, nausea, dizziness,hot flashes
obsessive compulsive disorder person as either obsession or compulsion
generalized anxiety disorder excessive anxiety and worry occuring more days than not
heavy alcohol use may cause? alcoholic cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning. hypertension, tachycardia or atrial fibrillation
assessment techniques inspection (looking), palpation (feeling), percussion (tapping the persons skin), auscultation (listening)
Past history of skin disease allergies, hay fever, psoriasis, atopic dermatitis
hypopigmentation loss of skin color
hyperpigmentation increase in skin color
generalized change in skin color suggest systemic illness pallor (white or pale), jaundice (yellow), cyanosis (blue)
seborrhea oily
xerosis dry
pruritus skin itching
Nail Assessment change in nails shape, color, brittleness. do they bite nails
Nail Assessment and environmental or occupational hazards people at risk outdoor sports, creosote workers, farmers, sailors, roofers, coal workers
Edema pitting leaves a dent in the skin when pressure is applied, has a 4 point scale 1 being mild pitting and 4 very deep pitting.
unilateral Edema considered a local or peripheral cause
bilateral edema problem with heart failure or kidney failure
lymphedema swelling of the lymphnodes
decubitus ulcer stage 1 intact skim appears red but unbroken. localized redness in lightly pigmented skin will blanch dark skin appears darker but does not blanch
decubitus ulcer stage 2 partial-thickness skin erosion with loss of epidermis or also dermis. superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed
decubitus ulcer stage 3 full thickness pressure ulcer extending into the subcutaneous tissue and resemling a crater. may see subcutaneous fat but not muscle, bone, or tendon
decubitus ulcer stage 4 full thickness pressure ulcer involves all skin layers and extends into supporting tissue. exposes muscle, bone, or tendon, and may show slough or eschar
confluent lesions run together
petechiae pinpoint lesions 1-3 mm round and discrete dark red, purple, or brown in color
ecchymosis a purplish patch resulting from extravastion of blood into the skin, >3 mm in diameter
purpura both petechiae and ecchymosis >3 mm flat red to purple, mascular hemorrhage
Measles red-purple maculopapular blotchy rash does not blanch, characterized by koplik spots in mouth elevation of 1-3 mm
lyme disease bullseye, red macular or papular rash
kaposi sarcoma AIDS defining illness faint pink spots on the temple and beard area
tinea capitis scalp ringworms
head ache is it unusually frequent or severe headaches, is it sudden or gradual, is it on one side or all over, throbbing or aching, how long does it last
head injury dizzyness, loss of consciousness, how long unconscious, any other symptoms, where you hit your head,
what are you listening for when listening to the lungs? crackles, pleural friction rub, wheeze, stridor, rhonci
heart failure crackles in lung base, normal vesicular sounds, percussion is resonant, increased respiratory rate, shortnesofbreath on excertion, orthopnea, ankle edema, nocturia.
S1 signals the beginning of systole the first heart sound closure of AV valves
S2 closeure of the SV second heart sound and signals the end of systole closure of SV
blood flow of heart liver,inferior vena cava/superior vena cava,RA,tricuspid valve,RV,pulmonic valve,pulmunary artery, unoxygenated blood to the lungs,oxygenated blood from lungs,pulmonary viens,LA,mitral valve,LV, aortic valve,arota, blood to the body
Dyspnea shortness of breath
paroxysmal nocturnal dyspnea occurs with heart failure made worse by laying down
electrical impulses SA node → AV node → Bundle of his → right and left bundle branches → Purkinje fibers
Breast assessment pain, lumps, discharge, rash, swelling, trauma, breast disease, surgery, self care behaviors
Mastalgia Breast pain
galactorrhea nipple discharge
gynecomastia enlarged male breast
Skin of breast smooth, even colored. note any localized areas of redness, bulging, or dimpling. no edema
Breast nipples should be symmetrical usually protrude some ar flat and inverted (but not fixed).
supernumerary nipple and extra nipple below the breast
vertical stripe pattern best way to detect a breast mass when palpating, start high in the axilla and palpate down the breast in a kind of zig zag pattern moving across the breast ending at the sternal edge
is it normal to feel a firm transverse ridge of tissue in the lower quadrants? yes
Lump in the breast note location, size, shape, consistency, movable, distinctness, nipple placement, skin over the lump, tenderness, lymph nodes
Best time to check for breast lumps 4th- 7th day of menstrual cycle
What percent of men get breast cancer 1%
lactation colostrum changes to milk around the 3rd day breast become engorged, reddened warm and hard.
ascites fluid in the belly. occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.
dysphagia difficulty swallowing
pyrosis heartburn
visceral pain in the stomach may be from internal organs dull, general, poorly localized.
parietal pain in the stomach from inflammation of overlying peritoneum sharp, precisely localized, aggreivated by movement
peptic ulcer disease occurs with use of NSAIDs, alcohol, smoking, and helicobacter pyloi infection
pica an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age for which this behavior is developmentally inappropriate (eg, > 18-24 months).
contour of stomach flat, scaphoid, rounded, protuberant
belly button is enverted from what? ascites, underlying mass, obesity
when should examine tender areas in the stomack last
when assessing the belly inspect, auscultate, percuss, and then palpate
hyperactive sounds loud, high pitched, rushing tinkiling sound
where should you always percuss and palpate the midline area above the super pubic bone
hepatomegaly enlarged liver
aging adult and abdominal assessment increased deposits of fat, less tone, may note peristalsis, easier to palpate
rheumatoid artheritis involves symmetric joints. worse in the morning movement decreases joint pain, stiffness occurs in morning and after periods of rest
myalgia muscle pain
what approach should be taken when assessing objective data of the musculoskeletal system? head to toe, proximal to distal
crepitation is an audible and palpable crunching or grating that accompanies movement.
paralysis is loss of motor function due to a lesion in the neurologic or muscular system or loss of sensory innervation
dysmetria is the inability tocontrol the distance, power, and speed of a muscular action
paresthesia an abnormal sensation
dysarthria difficulty forming words
dysphasia difficulty with language comprehension or expression
early indicators of alzheimer memory loss and cognitive decline
asterognosis the inability to identify objects that are placed in the hand
graphesthesia the ability to read a number by having it traced on the skin
clonus is a set of rapid, rythmic contractions of the same muscle
hyperreflexia is the exaggerated reflex
hyporeflexia is the absence of a reflex
Created by: BLanders