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Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Steps of the nursing process

A

Assess
Diagnose
Planning
Implementation
Evaluation

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2
Q

Types of health assessment

A
  1. Initial / comprehensive
  2. Ongoing / partial
  3. Focus / problem oriented
  4. Emergency / emergent
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3
Q

Type of health assessment: initial / comprehensive

A

Collection of Subjective data about the clients:
-perception of their health
-perception of their their body parts -perception of their body systems
-past family history
-physical examination

Nurse wants holistic, subjective, objective data.

Initial = FULL head to toe : detailed assessment

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4
Q

Type of health assessment: ongoing or partial

A

Collection of data that happens after the initial comprehensive assessment.

It is a mini overview of the clients body systems and holistic health patterns for a follow up purpose

Allows a nurse to assess and determine if any changes need to be made to the care plan

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5
Q

Type of health assessment: focused/problem oriented

A

Focused does not replace a comprehensive health assessment.

It is performed when a comprehensive database already exists and the patient comes in for something specific that’s not addressed on the comprehensive assessment 

Example going in for ear pain

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6
Q

Type of assessment: emergency

A

A very rapid assessment performed and life-threatening situations.

ABC’s are addressed

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7
Q

Communication techniques

A

A = acknowledge: make sure your patient feels like they exist to you.

I = Introduce: introduce who you are, what department you’re with, and people who are there with you. This is to help build confidence between you and your patient

D = Duration: tell the patient all the details about why you were there. For example, how long it’s going to take, what their wait time will be, expected result time….Make sure you update your patient if these times change. 

E = Explain: what is going to be done and why. What can the patient expect. Answer any questions and try to explain to the best of nursing ability. Make sure the patient has a solid understanding about what’s going on with her care

T = Thank you: make sure to thank your patient

A. I. D. E. T.

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8
Q

Communication styles

A

Nonverbal verse verbal

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9
Q

Communication style: nonverbal

A

Nonverbal is everything you don’t say.

  1. Appearance
  2. Demeanor
  3. Facial expression
  4. Attitude
  5. Silence
  6. Listening

Things not to do:
1. Excessive or insufficient eye contact (know patients culture/ preference)
2. Distractions / distance (eliminate distractions such as tv and outside noise. Be sure to face your patient and get in their level

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10
Q

Communication style: verbal

A

Verbal is everything you say to the patient.

Things to do for verbal:
1. Open ended
2. Closed
3. Laundry list
4. Rephrasing
5. Well placed phrases
6. Inferring
7. Provide information

Things to avoid:
1. Leading questions
2. Bias questions
3. Rushing
4. Reading the questions 

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11
Q

What is the purpose of an assessment

A

To assess the patient and obtain a baseline

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12
Q

Information that is obtained through health history

A

-Biographical data (Name, age, gender, birthday, etc.)
-reasons they are there (chief complaint)
-persistent health concerns (COLDSPA)
-past health history
-family history
-current symptoms
-lifestyle/health practice
-do you smoke?
-poverty?
-religious preferences?

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13
Q

What is PPE?

A

Personal protective equipment

Examples: Mask, gloves, gown, face shield, respirator, Eye protection

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14
Q

When to use PPE

A

Standard procedures require gloves and mask (in CURRENT healthcare clinic)

Types of PPE will vary depending on precaution status

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15
Q

Why use PPE?

A

To protect self and patient from spreading germs, illness, disease

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16
Q

What are the parts of a stethoscope?

A

Damn, earbuds, bell, diaphragm

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17
Q

When do you use the bell of a stethoscope

A

Bell = smaller side

Used For pediatrics or high pitch sounds like murmurs

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18
Q

When do you use the diaphragm of a stethoscope?

A

Diaphragm = large portion

Used for normal heart and lung sounds on adults and low pitch sounds

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19
Q

What are the normal vital sign ranges?

A

These ranges are for a typical adult without any underlying conditions

-Temperature, 96.0 to 99.9°F (36.5 to 37.7°C)
-Pulse: 60 to 100 bpm
-Blood pressure: 120/60
-Oxygen saturation. 92% or higher
-Respiration: 12 to 20 breaths/min

20
Q

Temperature: places to measure temperature

A
  1. Temporal (at temple)
  2. oral (mouth)
  3. axillary (armpit)
  4. tympanic (eat)
  5. rectal (anus)
21
Q

“Normal” Things that can cause a natural rise in temperature

A

-Exercise
-stress
-Ovulation
-pregnancy

22
Q

Pulse: common sites

A
  1. Radial (wrist on thumb side)
  2. carotid (neck)
  3. brachial (elbow pit)
  4. femoral (groin)
  5. popliteal (behind the knee)
  6. pedal (top of foot)
  7. posterior tibial (inside of ankle)
23
Q

Pulse: amplitude

A

-zero = absent
-1+ = weak
-2+= normal
-3+= bounding

24
Q

Respirations: types

A

One respiration includes inhale and exhale

> 12 breaths / min = bradypnea
24 breaths / kin = tachypnea
Dyspnea = difficultly breathing
Apnea = not breathing

25
Q

What is blood pressure?

A

Blood pressure is the amount of pressure that your blood puts on your blood vessels during contraction and relaxation of the heart.

Top number = systolic (Force of blood against walls during contraction)

Bottom number = diastolic (Force of blood against walls during relaxation) 

26
Q

Factors that affect blood pressure

A

Cardiac output: the more blood the heart pumps, the more pressure is in the vessels.

Elasticity: Decrease in elasticity will increase blood pressure.

Blood volume: the higher the blood volume the higher the BP (Filling up a balloon - the more air you add, the more force is being put on walls.

Blood viscosity: the thicker the blood, the harder it is to pump 

27
Q

External factors that affect blood pressure 

A

Caffeine/nicotine
exercise
emotions
pain
temperature

28
Q

What is pain scale: COLDSPA

A

C= characteristics (describe)
O= onset (when did it start)
L= location (where on body, radiate?)
D= duration (does it come and go? Is it constant?)
S= scale/ severity (use pain scale)
P= pattern (does anything make it better or worse)
A= associated factors (is this affecting anything else? Do you have any other associates factors that could be causing)

29
Q

What is SBAR?

A

S - situation
B - background
A - assessment
R - recommendations

30
Q

PPE: types of precautions

A

Standard: HH + gloves (currently includes mask)

Contact: HH + Gloves + gown + mask

Droplet: HH + Gloves + gown + mask, eye protect/ shield

Airborne: HH + Gloves + gown + mask (N95 or Papr), eye protection/ shield

Enhanced: highest lever and varies among employer (donor all)

31
Q

How does pain affect the body?

A

Pain Creates a stress response that triggers the sympathetic nervous system which results in a physiologic response

Fight or flight response

Emotions: anxiety, fear, hopelessness, sleeplessness, thoughts of suicide

Cognitive: confused or altered temperament

Vital signs: Increase in heart rate, respiratory, and blood pressure. Temperature can, but won’t always be affected. There could be a decrease in oxygen saturation

Body changes: Gastric and intestinal, urinary, immune responses all decrease

32
Q

Classifications of pain

A

Acute:
quick onset with short duration

Chronic:
Long lasting, ongoing, could come and go, could be constant. “livable”

Cancer:
Pain associated with sickness/tumor pressing on nerves, bones or body organsc Pain can be from disease or treatments for the disease

Cutaneous:
Surface level. Injury to skin or superficial tissues

Visceral: Internal organs injured *Most common type of

Deep somatic: When stimuli activate pain deeper in The Body (Tendons, joints, bones, and muscles) “achy pain”

33
Q

Pain scale types

A

FLACC : Face, legs, activity, cry, console ability *Used for infants

FACES: Pictures of happy, neutral, sad, crying faces *used for pediatrics

0-10: number scale
0= no pain
2=mild
4=moderate
6=severe
8=very severe
10=worst pain imaginable

34
Q

Assessment for Fiemitus

A

Place both hands on patients back and have patient say, “99, 99, 99”

Assess for vibrations

35
Q

Tell me about the heart

A

-4 chambers: L+R Atrium and L+R ventricle

-located in the mediastinum

-greatest/ largest vessels:
1. Superior and inferior vena cava
(Bring deoxygenated blood into the right side of the heart)
2. Aorta (Pumps oxygenated blood to the rest of the body
3. Pulmonary arteries: take deoxygenated blood away from the heart to the lungs
4. Pulmonary veins: take oxygenated blood from the lungs back into the heart

36
Q

What is the cardiac cycle? 

A

The filling and emptying of the heart “lub -dub”

S1 = lub = closing of mitral and tricuspid valve during a contraction of the heart (systolic)

S2 = dub = AV valves open, ventricles relax, blood fills the heart, atria contract and empties blood into vessels (diastole) 

37
Q

Electrical pathway through the heart

A
  1. SA Node: Sinoatrial node which is located at the top of the right atrium
  2. AV node: atrioventricular note which is located at the bottom of the right atrium (right above the tricuspid valve)
  3. Bundle of HIS
  4. Right and left bundle branches
  5. Purkinje fibers
38
Q

Blood flow through the heart

A
  1. Deoxygenated blood flow into the right atrium from the inferior and superior vena cava.
  2. The tricuspid valve opens and blood flows into the right ventricle
  3. Tricuspid valve closes and the pulmonary valve opens.Blood leaves the ventricle and flows into the pulmonary arteries
  4. Pulmonary arteries take deoxygenated blood out to the lungs to exchange CO2 for O2
  5. Pulmonary veins bring oxygenated blood back into the heart via the left atrium
  6. Mitral valve opens allowing blood to flow from the left atrium into the left ventricle
  7. Mitral valve closes and aortic valve opens. Blood leaves the left ventricle through the aorta which carries oxygenated blood out to the rest of the body 
39
Q

Where to auscultate heart sounds

A

APETM

A: Aortic: Right side of mid sternal line at 2nd intercostal space

P: pulmonic: Left side of mid sternal line at 2nd intercostal space

E: Erbs pint: Left of mid sternal line at 3rd intercostal space

T: Tricuspid: Left of Mid-sternal line at 4th intercostal space

M: mitral: Left of mid-CLAVICULAR line at 5th intercostal space

40
Q

Thorax : area and what is included

A

Area:
Base of the neck (superiorly), below the neck, to the diaphragm inferiorly (above)

Auscultation points:

Front = 10 spots
-start at 1st inter coastal space (right above clavicle *midpoint)
-use stepladder approach moving down, every 2nd Intercoastal spaces along the midclacucular line.

Back = 10 steps
-start at 1st intercostal space (right above clavicle *midpoint)
-use stepladder approach moving down, every 2 intercoastal spaces, keep close to midclavicular line to avoid scapula.
-after passing scapula, move further out in front and back there after.

41
Q

Breath sounds

A

Fine crackles = pop rocks
Coarse crackles = river rocks
Wheezing = whistles
Strider = high pitched wheeze (usually found in babies)
Plural friction rub = sandpaper

42
Q

Assessment findings in respiratory diseases

A

-Decrease in respiratory rate -abnormalities in the shape of the chest
-shortness of breath
-pulse decrease
-blood pressure decrease
-oxygen saturation decrease
-clubbing or fingers
-labored breathing (using accessory muscles)
-chest pain
-cough

43
Q

Respiratory disease examples: COPD

A

Fourth leading cause of death

COPD stands for chronic obstructive pulmonary disease

It is a combination of emphysema and bronchitis

Emphysema: alveoli Are damaged as they can weekend and rupture overtime

bronchitis: Airflow is restricted through the bronchi due to irritation and inflammation. Increased mucus

Preventable and treatable, but not reversible

44
Q

Risk assessment for COPD

A

Smoke exposure
asthma
exposure to dust and chemicals
35 to 40 years old
sometimes genetics

45
Q

COPD assessment findings

A

Barrel chest
low oxygen saturation
shortness of breath
cough with excessive mucus
clubbing fingers

46
Q

Respiratory disease examples: lung cancer

A

Two types:
1) small cell
2) non small cell

Annual screening should be completed for adults who currently or used to smoke

Risk factors:
-Smoke exposure
-air pollution chemical and fungal exposure
-radiation exposure
-lung cancer
-history (personal or family)
-diet

Health Assessment (3 decks)

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