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Health Ass. Exam 1
| Question | Answer |
|---|---|
| What is the A in AIDET? | acknowledge - greet the patient by name |
| What is the I in AIDET? | introduce yourself |
| What is the D in AIDET? | duration of assessment |
| What is the E in AIDET? | explain procedure |
| What is the T in AIDET? | thank you |
| What is nursing? | protection, promotion, & optimization of health & abilities, prevention of illness & injury, alleviation of suffering through the diagnosis & treatment of human response, & advocacy in the care of individuals, families, communities, & populations |
| Physical assessment has been an integral part of nursing since... | 1800s |
| Nursing is always... | changing (we must be able to think on our toes and evolve |
| Nurses rely on sense to assess for: | changes in color or temp, use of limbs, body output, muscle strength, etc. |
| Acronym for nursing process: | ADPIE (circular process) |
| What is the A in ADPIE? | assessment |
| What is the D in ADPIE? | diagnosis |
| What is the P in ADPIE? | planning |
| What is the I in ADPIE? | implementation |
| What is the E in ADPIE? | evaluation |
| Assessment is: | collecting subjective and objective data |
| Diagnosis is: | analyzing data to make a collaborative nursing student |
| Planning is: | determining outcome criteria and developing plan |
| Implementation is: | carrying out the plan |
| Evaluation is: | assessing whether outcome criteria have been met and revising the plan as necessary |
| Subjective data: | the patient telling you information/how they feel |
| Objective data: | measurable/hard data or value |
| Can nurses make a medical diagnosis | NO! they can only make a nursing diagnosis (from hard evidence like high BP) |
| Most important phase in nursing process (ADPIE)? | assessment |
| Contributing factors to the need for experts at assessing | limited number of medical students. increasing complexity of care, layered diseases, baby boomers = growing population, increasing number of vulnerable populations, intensifying mental health issues |
| Holistic nursing assessment | collects holistic subjective and objective data to determine a patient's overall level of functioning in order to make a professional clinical judgement (looking at whole patient) |
| Physical medical assessment | focuses primarily on the patient's physiological developmental status |
| 4 basic types of assessments | initial comprehensive (complete), ongoing (partial), focused (problem-oriented), emergent (rapid) |
| initial comprehensive (complete) assessment | complete head to toe assessment with holistic approach - subjective and objective data - takes a good amount of time |
| ongoing (partial) assessment | mini overview as a follow-up, constantly re-assessing abnormal things, not full assessment, just re-evaluating for changes |
| focused (problem-oriented) assessment | specific concern, typically used by physicians |
| emergency (rapid) assessment | immediate, prompt |
| What should you do before assessing a patient? | don't go in cold - review patient's records, hx, etc as well as your own feelings |
| 4 major steps in health assessment? | collection of subjective data, collection of objective data, validation of data and documentation data |
| Collection of subjective data? | biographical information, history of present health concern (physical symptoms related to each body part or system), personal health history, family history, health and lifestyle practices, review of systems |
| Collection of objective data? | physical characteristics, body functions, appearance, behavior, measurements, results of laboratory testing |
| Validation of Assessment data | ensure assessment isn't ended before all data is collected and validate info with patient |
| Documentation of data | forms the database for all healthcare members and ensures valid conclusions can be made |
| Phases of subjective data interview | pre-introductory, introductory, working, summary and closing |
| Pre-introductory phase | review patient's medical record (chart check) before you go into room |
| Introductory phase | AIDET - make sure patient is comfortable and has privacy |
| Working phase | phase of the nurse-patient relationship during which the nurse and patient identify and explore areas that are causing problems in the patient's life |
| Summary and closing phase | summarizing information obtained during the working phase, validating problems & goals with the client, identifying & discussing possible plans to resolve the problem, asking if anything else concerns the patient &if there are any further questions |
| Nonverbal communication | appearance (looking professional), demeanor (act professional), facial expressions (neutral/appropriate), attitude (nonjudgmental), silence (allow time for reflection), listening (open mind and body position) |
| Verbal techniques | open-ended questions, closed-ended questions, laundry list (is pain sharp, dull), rephrasing, well placed phrases (uh huh, yes), inferring, providing information |
| Communication to avoid | excessive or insufficient eye contact, distraction and distance, standing, biased or leading questions, rushing through the interview, reading the question |
| With gerontologic patients, what should you assess first? | hearing |
| If patient is angry, what should you never do? | allow them to get between you and the door |
| 2-point identifier of patient | name and DOB |
| CC should be... | in patient's own words about why they came in |
| history of present health concern acronym | COLDSPA |
| What is C in COLDSPA? | character of symptom |
| What is O in COLDSPA? | onset (when did it begin) |
| What is L in COLDSPA? | location |
| What is D is COLDSPA? | duration |
| What is S in COLDSPA? | severity |
| What is P in COLDSPA? | pattern (what makes it better or worse) |
| What is A in COLDSPA? | associated factors (any related symptoms and feelings) |
| Genogram | used to identify genetic pattern |
| When collecting objective data you should go from | least intrusive to most intrusive |
| With standard precautions you should treat all patients as if... | they have some sort of infection |
| Client approach acronym | IWIPE |
| What is I in IWIPE? | introduce yourself to the patient |
| What is W in IWIPE? | wash your hands |
| What is I in IWIPE? | identify the client |
| What is P in IWIPE? | provide for privacy |
| What is E in IWIPE? | explain the procedure |
| Inspection | visualize everything (begins the second you see the patient) |
| Palpation | to feel |
| Percussion | sound wave production |
| Ausculation | listen |
| Light palpation | depress <1 cm |
| Moderate palpation | depress 1-2cm with dominant hand |
| Deep palpation | depress 2.5-5cm with both hands |
| Bimanual palpation | sandwich a body part |
| Dorsal hand palpation | for temperature |
| Ulnar/palmar surface palpation | vibrations (thrills over heart, remits over lungs) |
| Fingerpads palpation | pulse, texture, size, shape, crepitus (fine discrimination) |
| Percussion purposes | Eliciting pain, determining location or size and shape, determining density, detecting abnormal masses, eliciting reflexes |
| Direct percussion | 1-2 fingertips |
| Blunt percussion | one flat hand fist in other to strike flat hand - to detect organ sensitivity |
| Indirect percussion | strike middle finger of nondominant hand placed over body surface with two fingers of dominant hand |
| Resonance | normal lung (hollow sound) |
| Hyperresonance | lower-pitched, booming sound found when too much air is present such as in emphysema or pneuothorax |
| tympany | puffed cheek, gastric bubble (drum-like sound) |
| dullness | diaphragm, effusion, liver (thud-like sound) |
| flatness | muscle, bone (flat sound) |
| Tubing of stethoscope should not how many inches? | 12 in |
| diaphragm | for high pitched sounds like normal HR, breath and bowel sounds |
| bell | for low-pitched sounds like abnormal heart sounds and bruits |
| Validation of data applies to | patient data and orders received |
| Verbal communication of findings acronym | SBAR |
| What does SBAR stand for? | Situation, background, assessment, recommendation |
| Seven Essential Critical Thinking Characteristics | keep an open mind, use rationale to support opinions/decisions, reflect on thoughts before conclusion, use past clinical experiences to build knowledge, acquire knowledge base that continues to build, be aware of the interactions of others & environment |
| Lethargic | open eyes, answer questions, falls back asleep |
| Obtunded | Opens eyes to loud voice, responds slowly with confusion, unaware of environment |
| Stuporous | awakens to vigorous shake or painful stimuli but returns to unresponsive sleep |
| Comatose | remains unresponsive to stimuli |
| What are CAGE and AUDIT? | tests for alcoholism |
| Score of 15 on Glasgow coma scale | optimal LOC |
| Score of <15 on Glasgow coma scale | some impairment in LOC |
| Score of <7 on Glasgow coma scale | in a coma |
| 30-26 on mini mental health state exam | could be normal |
| 25-30 on mini mental health state exam | mild, early stages |
| 9-10 on mini mental health state exam | moderate, middle stage |
| 9-0 on mini mental health state exam | severe, late stage |
| erik Eriksons infant stage | trust v. mistrust |
| erik Eriksons toddler stage | autonomy v. shame and doubt |
| erik Eriksons preschooler stage | initiative v. guilt |
| erik Eriksons school age stage | industry v. inferiority |
| erik Eriksons adolescent srage | identity v. role of confusion |
| erik Eriksons young adult stage | intimacy v. isolation |
| erik Eriksons middle adult stage | generatively. stagnation |
| erik Eriksons older adult stage | integrity v. despair |
| General survey | 1st part of physical exam, uses all observational skills, provides overall impression of patient's whole being (study of whole person) |
| Significant abnormalities may include | skin color, dress, hygiene, posture and gait, physical development, body build, apparent age, gender |
| Equipment for general survey | thermometer, covers for thermometer, BP cuff, stethoscope, watch for seconds hand, scales for weight/height |
| Orders of measurements/VS | height, weight, BMI, waist/hip ratio, temp, pulse, respirations, BP |
| Anthropometric measurements | height, weight, BMI, waist/hip circumference (measurements of the human) |
| True measurements | T, R, P, BP |
| Final height reached when? | 18-20 years |
| When does height wane? | 5th decade of life when intervertebral discs thin |
| influences on weight | diet, genetics, exercise |
| If you are using a manual scale, what do you need to do first? | level the balance beam at 0 |
| 1 kg = ? lbs | 2.2 lbs |
| Health risk related to obesity | hypertension, dyslipidemia (high total cholesterol), type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, cancer (endometrial, breast, colon) |
| how to measure BMI | weight (kg) / (height m^2) |
| normal BMI | 18.5-24.9 |
| underweight BMI | <18.5 |
| overweight BMI | 25-29.9 |
| obese BMI | over 30 |
| What does BMI estimate? | total body fat |
| Normal waist circumference for women | </= 35 in |
| Normal waist circumference for men | </= 40 in |
| Waist circumference is most common for determining what? | extent of abdominal visceral fat in relation to body fat |
| How to measure waist to hip ratio | waist circumference / hip circumference |
| Where do you measure hips | At the widest point of the hips |
| Healthy waist to hip ratio in men | </= .90 |
| Healthy waist to hip ratio in female | </= .80 |
| Which routes of temp have questionable accuracy | axillary and temporal |
| Normal temp range | 96.9 - 99.5 F (35.9 - 37.5 C) |
| Average temp | 98.6 F (37 C) |
| Tympanic temp is | 0.4-0.5 F higher |
| axillary temp is | 1 F degree lower |
| How long do you have to wait after food/drink for an oral temp? | 15 min |
| How far in do you need to insert a rectal thermometer | 1 inch or less |
| What color is rectal thermometer? | red |
| What thermometer is used for routes other than rectal | blue |
| Geriatric normal body temp is typically | lower than normal |
| What does diurnal variation mean in regards to temp | Temp can fluctuation up to 1.5 degrees throughout the day |
| What should you monitor for with fever? | Dehydration |
| Pulse-heart rate characteristics | rate, rhythm, amplitude, arterial elasticity |
| Normal HR range | 60 -100 bpm in adults |
| rhythm | irrgular or regular |
| amplitude | force: 0-3+ |
| arterial elasticity | straight/springy v. rigid (how does it feel) |
| When do you count pulse for and entire minute | if it is irregular or using apical pulse |
| How long do you count a regular pulse | 30 sec and multiply by 2 |
| Why can you not press too hard when counting pulse? | This could result in occlusion |
| 0 pulse amplitude | absent, unable to palpate |
| 1+ pulse amplitude | weak, diminished (easy to obliterate) |
| 2+ pulse amplitude | normal (obliterate with moderate pressure) |
| 3+ pulse amplitude | bounding (unable to obliterate or requires firm pressure) |
| arrythmia | abnormal heart rhythm |
| bradycardia | slow heart rate, <60 bpm, caused by heart block, sitting or standing long time |
| tachycardia | fast heart rate, <100 bpm, caused by fever, stress, anxiety, exercise, hemorrhage |
| Sinus arrhythmia | pulse speeds and slows with respirations (normal in kids) |
| Normal respiration | 12-20 breaths per minute |
| Rhythm of respiration | regular, in and out |
| depth of respiration | equal, bilateral expansion 1-2 in |
| effort of respirations | should be unlabored and comfortable |
| respirations in newborns | faster: 30 - 40 |
| older adult respirations | 15-22 |
| how does pulse ox work? | sends infrared light into capillaries to measure how much light is reflected off gases |
| normal pulse ox? | 95-100% |
| what can interfere with pulse ox measurement? | nail polish or cold extremeties |
| pulse ox range for pts with COPD | normal around 88% |
| dyspnea | difficulty breathing (tripod position is normal) |
| apnea | cessation of breathing |
| bradypnea | slow breathing |
| tachypnea | rapid breathing |
| orothopnea | difficulty breathing with lying down |
| hypoxia | low blood oxygen (may see cyanosis) |
| cyanosis | blue skin color - low oxygenation of hemoglobin |
| systolic BP | measurement of pressure of blood in arteries when the ventricles are contracted (top number) |
| diastolic BP | measurement of pressure of blood in arteries when ventricles are relaxed (bottom number) |
| how to measure pulse pressure: | systolic-diastolic BP |
| normal pulse pressure | 30-50 mmHg |
| when might pulse pressure widen? | issues such as head injury |
| normal BP | <120/<80 |
| which arm should you measure first? | dominant arm |
| notes when taking BP? | avoid nicotine/caffine 30 min prior, feet flat on floor, no talking, empty bladder |
| what is a normal BP difference between each arm? | about 10 but more than this may be indicative of heart disease |
| BP bladder width should be __% circumference of arm | 40 |
| Stage 1 hypertension blood pressure | 140-169/90-99 |
| Stage 2 hypertension blood pressure | >160/>100 |
| prehypertension BP | 120-139/80-89 |
| mean martial pressure | pressure forcing blood into tissues |
| orthostasis hypotension | low blood pressure that occurs in a standing posture (measure lying, sitting, and standing with waiting 1 min in between), if standing up BP bottoms out more than 20, let physician know |
| what range should children height be? | btw 5th and 95th% on standardized growth charts |
| when does the chest of a child become the same as the head? | around 2 years |
| what is the 5th vital sign? | pain |
| what is pain? | whatever the patient says |
| Pathophysiology pathway | tranduction -> a-delta primary afferent fibers -> transmission -> perception -> modulation |
| acute pain | usually associated with a recent injury, short term |
| chronic pain | persistent; 6 months or more |
| cancer | may be caused by cancer, it's treatment or its metastasis (spread) |
| intractable pain | high resistance to pain relief; hard time getting pain under control |
| cutaneous pain | skin or subcutaneous tissue (burning) |
| visceral pain | internal organs (ache, cramp) |
| deep somatic pain | ligaments, tendons, bones, blood vessels (throb, ache) |
| radiating pain | felt at the source and extending to other areas |
| referred pain | felt in body areas away from pain source |
| phantom pain | felt in nerves left by a missing, amputated, or paralyzed body part |
| neuropathic pain | abnormal processing of pain message from damaged nerves; burning, shooting in nature |
| inflammatory pain | activation of nociceptive pain pathway by mediators released at a site of inflammation (eppendicitis) |
| how can we objectively measure pain? | number and faces scales |
| physical abuse | restraint, pushing, slapping |
| psychological abuse | insults, isolation, threats |
| economic abuse | controlling, money, exploitation |
| sexual abuse | forcing against will |
| categories of violence | intimate partner, child abuse, elder mistreatment |
| how many men experience physical violence? | 1/7 |
| other types of violence | school bullying/violence, hate crimes, human trafficking, war crimes |
| signs of child abuse | malnourished, looks younger than age, evidence of burns, bruise, scars, etc. |
| physical examination to assess abuse | assess dress/hygiene, mental status, VS, skin, head, neck, eyes, abdomen, genitalia, mucoskeletal and neurological system |
| culture | beliefs, customs, and traditions of a specific group of people. This is learned when its passed from generation to generation |
| stereotyping | assuming all members of a group experience things the same way |
| ethnocentrism | belief in the superiority of one's own ethnic group |
| ethnicity | identity with a group of people that share distinct physical and mental traits as a product of common heredity and cultural traditions |
| religion | formal/organized group oriented easily measurable |
| spirituality | informal, self-reflective, and subjective |
| external integumentary structures | skin, hair, nails |
| within the skin | sebaceous and sweat glands |
| how large is the skin? | about 20 square feet |
| epidermis | avascular, 4 distinct layers, replaces itself 3-4 weeks, protection/regulation of water loss |
| what is the epidermis made of? | stratified squamous epithelium |
| stratum germinativum | innermost layer of epidermis in charge of cell regeneration |
| stratum corneum | outermost layers of epidermis-dead keratinized cells/waterproof |
| dermis | highly vascularized, where glands, nerve endings, and hair follicles are |
| dermal papillae | a fingerlike projection of the dermis that may contain blood capillaries of Meissner corpuscles (of touch) |
| sebaceous glands | attach to hair follicles and all, all over body except palms of hands and soles of feet to waterproof skin and hair |
| eccrine sweat glands | directly on skin over entire body that secretes sweat to thermoregulate |
| apocrine sweat glands | "adolescent glands", nonfunctional before puberty in axilla and perineum and interacts with bacteria to produce foul odor |
| subcutaneous (adipose) tissue | support for dermis and epidermis that cushions body, retains heat, stores fat for energy, vascular pathways for nutrients and removal of waste to and from the skin |
| development of skin in newborns | lanugo, vernix caseosa, sebum |
| development of skin in children | epidermis thickens, darkens, and becomes lubricated hair growth accelerates |
| development of skin in adolescents | secretions from apocrine sweat glands and subcutaneous fat deposits increase and secondary sex characteristics |
| lanugo | fine, downy hair of newborn infant |
| vernix caseosa | cheesy substance covering the skin of the fetus made of shed skin cells and sebaceous fluids right after delivery |
| sebum in infants | holds water in skin, thus producing milia |
| milia | tiny bumps in infants that look milky from extra sebum |
| skin development in elderly | loose elasticity, decrease in glands = dry skin, senile purpura, skin breakdown, melanocytes decrease (gray hair), and decrease in adipose tissue |
| senile purpura | discoloration due to increasing capillary fragility |
| liver spots in elderly | clusters of melanocytes on forearms and dorsal side of hands from prolonged sun exposure |
| melasma | increased pigmentation associated with pregnancy |
| vitiligo | localized loss of skin pigmentation characterized by milk-white patches |
| pruritis | itching |
| moles | pigmented nevi |
| pallor | paleness |
| erythmea | redness of skin |
| cyanosis | blueish discoloration of skin |
| jaundice | yellowing skin |
| patch | flat, discolored area on the skin larger than 1 cm (birthmark) |
| striae | stretch marks |
| freckless | macules: flat, melanized patches |
| what is the first step of a kin assessment? | inspection |
| what causes jaundice? | increased bilirubin in infants/liver disease |
| how can you see pallor in individuals with darker skin? | in mucous membranes/inside eyes |
| what can cause erythmea? | injury, irritation, drug allergy, infection, etc. |
| intentional variation of skin | tattoos (in dermis because epidermis is shed) |
| inspections of lesions | anatomic location/distribution, color, elevation, pattern, shape and size, type, exudate (drainage) |
| serosanguineous exudate | thin, watery, and pale red to pink in color |
| purulent exudate | drainage that contains pus usually yellow, green, or brown indicated infection |
| singular/discrete pattern | demarcated lesions that remain separate (bug bites) |
| grouped/clustered lesions | lesions that bunch together in little groups (herpes simplex, impetigo) |
| polycyclic lesion pattern | annular lesions that come in contact with one another as they spread (tinea corporis) |
| confluent lesions | lesions that run together (hives) |
| linear lesions | lesions that forma line (poison ivy, contact dermitis) |
| zosteriform lesion pattern | lesions following a nerve (herpes zoster) |
| generalized lesion pattern | lesions that are scattered all over body (herpes varicella) |
| round/oval (lesion shape) | solid appearance, no central clearing |
| annular lesion | round with central clearing |
| iris lesion | pink macule with purple concentric ring (erythema multiforme) |
| gyrate lesion | snakelike appearance |
| primary lesions | arise from healthy skin |
| secondary lesions | arise from previously abnormal skin |
| vascular lesions | involve blood vessels |
| lesions of aging | seborrheic keratoses and actinic keratoses |
| vascular skin lesion examples | petechiae, purpura ecchymosis, angioma, telangiectasia, vascular spider |
| petichiae | a small red or purple spot caused by bleeding into the skin (flat muscles) |
| pupura | rash of purple spots on skin caused by internal bleeding from small blood vessels- will not blanche |
| ecchymosis | bruising |
| angioma | skin growth, benign tumor |
| capillary hemangioma | abnormal overgrowth of tiny blood vessels |
| telangiectasia | dilated superficial blood vessels |
| vascular spider/venous spider | appears spider/web or star pattern |
| spider veins (varicose veins) | from long period of standing |
| Mongolian spots | areas of deep blue/gray pigmentation most commonly on the sacral aspect of a newborn (goes away btw 3-5 years) |
| cafe au lait spots | light brown birthmarks that can occur anywhere on the body and can go away with sun exposure |
| harlequin color change | skin coloration that occurs in some newborns in response to changes in position - erythema toxicum = common benign rash during first week of life that resolves in 1-2 weeks |
| acrocyanosis | temporary cyanotic condition, usually in newborns resulting in bluish color around the lips, hands, and fingernails, feet and toenails. May last for a few hours and disappear with warming |
| mutis marmorata | benign but if persists could indicate genetic syndromes |
| carotenemia | yellow-orange color in light-skinned people from large amounts of foods containing carotene |
| stork bite | a patch of deep pink skin in infants from nervous simplex- goes away at 8-12 months |
| blackheads | open comedones |
| whiteheads | closed comdeones |
| linea nigra | a dark line appearing on the abdomen and extending from the pubis towards umbilicus during pregnacy |
| chloasma | darkened areas of skin from sun exposure |
| senile lentigines | dark-yellow or brown spots that develop on the skin as aging occurs (liver spots) |
| actinic keratoses | overgrowth of keratin-crusty and scaly appearance; can develop into squamous cell carcinoma |
| xerosis | dry skin |
| acrohordons | skin tags |
| seborrheic keratosis | a benign skin growth that has a waxy or "pasted on" look |
| basal cell carcinoma | pupule > ulcer with raised borders: common slow growing |
| squamous cell carcinoma | patch > ulcer with erythematous base; faster growing |
| melanoma | skin cancer |
| what does ABCDE stand for? | asymmetry, border, color, diameter, evolving |
| Pressure ulcers Stage 1 | erythema and no breakage |
| Pressure ulcers stage 2 | partial-thickness skin erosion with loss of epidermis or also with dermis; superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed |
| Pressure ulcers stage 3 | full-thickness pressure ulcer extending into subcutaneous tissue and resembling a crater. may see subcutaneous fat but not muscle, bone, or tendon |
| pressure ulcers stage 4 | full-thickness pressure ulcer involves all skin layers and extends into supporting tissue; exposes muscle, tendon, or bone, and may slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue) |
| turgor of skin | refers to the elasticity of the skin, pinch skin on dorsal aspect of hand and see if it remains elevated or goes back down, and slowed with dehydration or hypothyroidism |
| alopecia | hair loss |
| hirsutism | excessive hair growth |
| tinea capitis | ringworm of the scalp |
| seborrheic dermatitis | an inflammation that causes scaling and itching of the upper layers of the skin or scalp (dandruff) |
| clubbing nails | angle greater than 180 |
| normal nail angle | less than or equal to 160 |
| capillary refill | a test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure; should be less than or equal to 2 sec |
| Leukonychia | white spots on the nail |
| koilonychia | spoon nails |
| beau's lines | visible depressions running across the width of the natural nail plate |
| paronychia | a fungal/bacterial infection in the folds of skin surrounding a fingernail or toenail |
| onycholysis | lifting the nail plate from the nail bed without shedding, usually beginning at the free edge and continuing toward the lanula area; "course of the black toe" and trauma from repitition |
| easiest way to ask about diet | 24 hr diet recall |
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