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Health asses exam 1
| Question | Answer |
|---|---|
| 4 Main Goals of Nursing (ANA) | *Promote health *Prevent illness *Treat human responses to health or illness * Advocate** for individuals, families, communities, and populations |
| 4 Core Ethical Principles (Code of Ethics) | *Autonomy: Respecting patient self-determination and healthcare choices. * Beneficence: Doing good / kindness *Nonmaleficence:Doing no harm *Justice:Fair and equal care for all |
| Primary Prevention: | aimed at preventing disease or injury before it occurs in a healthy population ex-vaccines |
| Secondary Prevention: | early diagnosis and prompt treatment of health problems to prevent complications. ex-screening,tests |
| Tertiary Prevention | Preventing complications of an existing, diagnosed disease and restoring optimal function. ex-teaching, diet,. stop it from getting worse |
| 1/3 Emergency Assessment: | Performed during life-threatening or unstable situations using the Airway(obstruction), Breathing(respiration, lungs, o2), Circulatory(heart, bp), Disability(neuro issues), Exposure (assess skin/injureis,keep warm) |
| 2/3 Comprehensive Assessment: | Complete health history and full head-to-toe physical examination (performed upon hospital/facility admission or during annual wellness physicals) |
| 3/3 Focused Assessment: | Problem-oriented; smaller in scope but deeper on 1–2 specific body systems (after treatment to see intervention effectiveness) |
| Functional Assessment (Gordon’s 11 Patterns) | Focuses on how illness impacts a patient's daily quality of life |
| Head-to-Toe Assessment: | most organized and efficient for gathering comprehensive objective physical data * Prevents unnecessary position changes, saves time, and preserves patient modest |
| Body Systems Approach: | Reorganizes assessment findings by systems Promotes critical thinking and diagnostic reasoning used for organizing clinical documentation (SOAP) and communication w pros (SBAR) |
| Maslow’s Hierarchy of Needs: | Physiological needs (airway, oxygen, fluid balance) take priority over safety, love/belonging, and self-esteem |
| Nursing Process (ADPIE): A dynamic, non-linear problem-solving framework: | Assess: Collect data, identify findings Diagnose:Cluster data to determine condition Plan (Identify Outcomes): Form measurable realistic goals implement: Execute interventions and treatments Evaluate:Re-assess effectiveness |
| SOAP | subjective-statements made by patients (pain) objective-findings by nurse (vitals) analysis/assesment-nurses diagnose based on S&O plan |
| SBAR | situation-description of issue/patient background- of patient, what led to this, vital hx assessment- finding, evals, what nurse suspects recommend/request- actions/interventions, request from provider |
| closed loop communication | spoken, acknowledged, confirmed. |
| wellness | method of functioning that max potential, increases by promoting patient health and teaching |
| Therapeutic Communication Techniques | Restatement, Reflection, Elaboration, Silence, Focusing, Clarification, Summarizing |
| Restatement: | Repeating the patient's exact or main words to encourage them to elaborate on the content of what they said. |
| Reflection | Summarizing the main emotional themes or underlying meanings of what the patient said so they can explore their feelings. "u seem nervous about.." |
| Elaboration (Facilitation): | Using short cues like head nods, "um-hum", or "go on" to encourage the patient to keep talking. |
| Silence: | Purposeful pauses (5 to 10 seconds) that give the patient time to gather thoughts, process translation, or decide what to disclose. |
| Focusing | Redirecting the conversation back to a specific, relevant topic when the patient strays off track. |
| Clarification | Asking for the meaning of unclear terms or placing events in chronological order to clear up confusion. |
| Summarizing | Condensing 2 to 3 main findings or themes at the end of the interview phase to ensure mutual understanding. |
| Nontherapeutic Responses | avoid-False Reassurance, Sympathy: Feeling with pt from ur own perspective , Unwanted Advice, Biased/ Leading Questions ( you don't use drugs, do you?), Why Questions, Changing Subject b/c uncomf. Distract/ Interrupt, Technical Language |
| Phases of the Interview Process | Preinteraction, Beginning, Working, Closing |
| Preinteraction Phase | Reviewing existing data in the medical record before meeting the patient. |
| Beginning Phase: | Introducing yourself, asking preferred name, stating the purpose of the interview, and ensuring HIPAA privacy. |
| Working Phase | Active data collection phase. Uses open-ended questions for broad answers in the patient's own words and closed-ended questions for specific facts or yes/no answers. |
| Closing Phase: | Summarizing/ identify main problems, stating next steps, asking if the patient needs anything else, and fulfilling mandated reporting duties. |
| Primary Data Source: | The patient (most reliable unless altered or confused). |
| Secondary Data Sources: | Family members, past records, or charts. |
| Emergency History: | Rapid collection of immediate, life-threatening information only |
| Focused History: | Problem-oriented; targets questions specifically related to the current chief complaint. |
| Comprehensive History: | Complete assessment including demographics, chief complaint, HPI, past history, ROS, and functional status. |
| OLDCARTS: | Onset (start), Location, Duration(of pain), Character(pain description), Aggravating/Alleviating factors(what makes it worse) associated manifestations, Radiation, Timing(daily?when), Severity. |
| PQRSTU | Provocative/Palliative(what triggers/relives/brought it up), Quality/Quantity, (how it feels/intense) Region/Radiation, Severity, Timing, Understanding (patient's perception of cause and impact). |
| after assessment the nurse- | discusses findings, validates problems, determines goals, and develops a plan of care with the client. |
| follow-up assessment | evaluates a specific problem after treatment. |
| When recording the client's reason for seeking care (chief concern), it is preferable to | quote the client's exact words whenever possible. |
| Finger pads palpation- | Fine discrimination: pulses, small lumps, skin texture, edema. |
| Palmar surfaces / finger joints palpation- | Firmness, contour, position, size, pain/tenderness. |
| Palm palpation- | Abdominal assessment. |
| Dorsal hand palpation- | Temperature. |
| Ulnar hand palpation- | Vibratory tremors / air movement. |
| Light Depth | About 1 cm; surface characteristics. |
| Moderate Depth | About 1–2 cm; abdominal organ characteristics; pressure with both hands/palmar fingers. |
| Bimanual deep Depth | About 2–4 cm; deeper assessment with nondominant hand over dominant hand. |
| Percussion | produce sound or elicit tenderness. |
| Auscultation | listen to sounds of movement from organs/tissues to assess function, commonly BP, lungs, heart, and abdomen. |
| Temperature | 36.5–37.0 °C (97.7–98.6 °F), route-dependent. |
| Respirations | 12–20 breaths/min, regular. |
| SpO₂ | 92–99% listed as the normal course range. |
| Blood pressure | SBP 90–120 mm Hg; DBP 60–80 mm Hg; slide lists average 120/80 mm Hg. |
| Rapid-response Mental/appearance | Acute mental-status change; extreme anxiety/acute distress; pallor; cyanosis; agitation/restlessness. |
| Rapid-response Airway/breathing | stridor; respirations <10 or >32/min; increasing work of breathing. |
| Rapid-response Oxygenation | SpO₂ <92%. |
| Rapid-response Pulse | <55 or >120 beats/min. |
| Rapid-response Blood pressure | Systolic BP <100 or >170 mm Hg. |
| Rapid-response Temperature | <35 °C or >39.5 °C (<95 °F or >103.1 °F). |
| Rapid-response Chest pain | New-onset chest pain. |
| 2 “cannot miss” pain presentations | chest pain requiring evaluation for myocardial infarction and a “worst headache of my life” requiring urgent evaluation for possible subarachnoid hemorrhage. |
| Pediatric/nonverbal pain: | use behavioral cues and caregiver baseline; know FLACC = Face, Legs, Activity, Cry, Consolability, and recognize when a FACES-type scale is appropriate. |
| Acute pain | Generally described in the lecture as <6 weeks; recent injury/condition. Poorly managed acute pain can contribute to chronic pain. |
| Chronic pain | Lecture uses roughly 3–6 months as chronicity; may persist and affect multiple aspects of life. |
| Visceral pain | Internal-organ pain; dull/achy, gnawing, twisting, or colicky; often poorly localized. |
| Somatic pain | Musculoskeletal pain from muscles, bones, tendons, or ligaments. |
| Cutaneous pain | Originates in the skin. |
| Referred pain | Felt away from the source; lecture example: myocardial infarction with jaw/arm pain. |
| Phantom pain | Pain perceived in a limb/digit that is no longer present after amputation. |
| Neuropathic pain | Related to nerve injury/disease; burning, shooting, pins-and-needles, hypersensitivity; diabetes given as an example. |
| Nociplastic pain | Pain without an identifiable structural cause on routine testing; examples discussed included fibromyalgia, headaches, and IBS. |
| CRPS Complex Regional Pain Syndrome | described as central/peripheral nervous-system dysfunction with prolonged oversensitivity after injury. |
| Petechiae: | Small, pinpoint reddish-to-purple macules or papules that form in response to physical trauma or capillary damage |
| Purpura: | Larger purplish macules or papules caused by bleeding under the skin, often secondary to clotting disorders or inadequate clotting mechanism |
| Ecchymosis: | A classic flat bruise resulting from physical trauma that damages capillaries, allowing blood to seep into surrounding tissues. As the blood gradually reabsorbs, its color changes from purple/blue to green, yellow, and brow |
| Hematoma | A collection of blood under the skin typically resulting from blunt-force trauma. Unlike a flat ecchymosis, this is palpable (raised/touchable) mass |
| Laceration | A tear or cut in the skin that can be superficial or deep and frequently requires suturing to heal correctly |
| Abrasion | A scrape caused by shear force or friction rubbing against the skin, removing several epidermal layers and exposing the dermis |
| Avulsion | Severe trauma where the skin is forcibly torn away or separated from its underlying structures, leaving a ragged open wound |
| Macule | Flat, discolored spot smaller than 1 cm=Freckles, flat moles, tattoos, stork bites |
| Patch | Flat, discolored spot larger than 1 cm=Vitiligo, melasma, tinea versicolor |
| papule | Small, raised, solid bump smaller than 1 cm=Warts, insect bites, moles |
| Plaque | Raised, solid plateau or cluster larger than 1 cm=Psoriasis, lichen sclerosus |
| Nodule | <1 cm w depth. Solid, palpable mass extending deeper into the dermis |
| Tumor | A large nodule w deeper solid mass= Lipoma, basal cell carcinoma, large nevus |
| Wheal | Raised, red/flesh-colored edematous area caused by fluid leaking into the dermis (transient/varies in shape)=.Hives (urticaria), mosquito bites |
| vesicle | Small blister filled with clear serous fluid=Chickenpox (varicella), herpes simplex (cold sores) |
| Bulla | Large blister filled with clear serous fluid=Partial-thickness burns, bullous impetigo |
| Pustule | Raised lesion filled with purulent fluid/pus=Acne, folliculitis |
| Cyst | Encapsulated, distinct walled-off pouch containing fluid or semisolid material=Epidermal cyst, cystic acne |
| Flat Primary Skin Lesions | Macule(<1cm) vs. Patch >1cm) |
| Raised Solid Primary Skin Lesions | Papule (<1cm) vs. Plaque (>1cm) |
| Clear Fluid Primary Skin Lesions | Vesicle (<1cm) vs. Bulla (>1cm) |
| pustule vs. Vesicle/Bulla: | Pustules contain pus(purulent), whereas vesicles and bullae contain clear serous fluid |
| Contact Transmission | Microorganisms move by direct physical touch or contact with contaminated surfaces, linens, or medical equipment (e.g., MRSA, VRE, *C. difficile*) |
| Droplet Transmission | Pathogens spread through large respiratory droplets generated when an infected patient coughs, sneezes, or talks. These droplets travel short distances (within 6 feet)[Requires surgical mask upon entry; patient wears a mask during transport)* |
| Airborne Transmission: | Pathogens travel in tiny aerosolized particles that remain suspended on air currents over longer distances (e.g., Tuberculosis, Measles, Varicella(Requires an Airborne Infection Isolation Room [AIIR] and a fit-tested N95 respirator) |
| Sharps / Vehicle Transmission: | Infections (such as HIV or Hepatitis) transmitted when bloodborne pathogens enter through skin punctures via used needles or sharp instruments |
| I PASS THE BATON | intro, patient, assessment, situation, safety, background, actions, timing, ownership, next |
| Nociception | The perception of pain by specialized sensory receptors that are located throughout body |
| Four Steps of Nociception | Transduction-Noxious stimuli cause nerve impulse at nociceptors transmission-Signal moves from peripheral nerves up spinal cord to brain perception- Brain identifies signal as pain modulation- Brain sends signals down spinal cord to stop or deal w pain |
| Gate Control Theory of Pain | Gate Opens:Continued painful stimuli depolarize nerve fibers, passing impulses up spinal cord via pain-facilitating substances gate Closes: inhibitory signals release pain-blocking substances , stopping the pain signal at the synaptic junction |
| Lichenification | A secondary skin lesion characterized by leathery, thickened skin with accentuation of normal skin lines (resembling tree bark), caused by chronic, excessive scratching |
| Urticaria (Hives): | Primary skin lesions (edematous wheals) caused by fluid accumulation in the dermis following histamine release during an allergic reaction |
Created by:
mahak
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