Exam 1 Flashcards
1
Q
What is a Health Assessment?
A
Subjective and objective data gathered from physical assessment, lab studies, and imaging from database. Used to make diagnosis and pan of care.
2
Q
What considerations should have for older adults?
A
- Mode of address
- Elderspeak
- Fatigue
- Use of touch
3
Q
Complete health history and physical exam from birth to present
A
Complete Database
4
Q
Mini database that focuses on one problem
A
Focus (problem) Centered Database
5
Q
Used when seeing client for second time and tracks progress, changes, and effectiveness of treatment
A
Follow-Up Database
6
Q
Used for urgent collection of crucial information
A
Emergency Database
7
Q
General Survey
A
Physical Appearance
Body Structure
Mobility
Behavior
8
Q
Nursing Process
A
Assessment
Diagnose
Plan
Implement
Evaluate
9
Q
Subjective Data
A
Anything client tells you about themselves
10
Q
Objective Data
A
Data you can prove or verify with another person or test
11
Q
Physical Assessment
A
- Inspection
- Palpation
- Percussion
- Auscultation
12
Q
Inspection
A
Using eyes, ears, nose, to observe clients whole body and compare sides for symmetry
13
Q
Palpation
A
Using touch to assess skin temp., texture, moisture, organ location/size, swelling, vibration, lumps/masses
14
Q
Percussion
A
Tapping on persons skin with short sharp strokes to assess underlying structure.
15
Q
Percussion Tone: Bone
A
Flat
16
Q
Percussion Tone: Organs
A
Dull
17
Q
Percussion Tone: Healthy Lungs
A
Resonant
18
Q
Percussion Tone: Fluid in lungs or healthy children’s lungs
A
Hyperresonant
19
Q
Percussion Tone: Air-filled Organs
A
Tympanic
20
Q
Auscultation
A
Listening to sounds produced by the body
21
Q
Factors Affecting Temperature
A
- Diurnal Cycle: lowest in morning - peaks afternoon/early evening
- Menstrual Cycle
- Exercise
- Age
22
Q
Adult Pulse
A
50-95 beats per minute
Rhythm: Even tempo
Force: Should not be weak or bounding
23
Q
Documenting Force of Pulse
A
0=Absent
1+=Weak/Thready
2+=Normal
3+=Full/Bounding
Weak=Blood Loss
Full/Bounding= Anxiety, Exercise, or Abnormal Conditions
24
Q
Respirations
A
10-20 Breaths per minute
25
Blood Pressure
Normal: 120/80
Hypertension: higher than 130 and higher than 80
26
Systolic Pressure
Max pressure felt on artery during ventricular contraction - first sound heard when measuring
27
Diastolic Pressure
Resting pressure that blood exerts between each contraction - typically last sound you hear
28
Pulse Pressure
Difference between systolic and diastolic blood pressure readings
29
Mean Arterial Pressure
Systolic plus diastolic blood pressure divided by 2
30
Pain Assessment
Provocation
Quality
Region
Severity
Timing
Understanding
31
Nociceptors
Specialized nerve endings designed to detect painful sensations from periphery and transmit them to CNS
32
Nociceptive Pain
Pain caused by damage to body tissue
33
Neuropathic Pain
Health condition affects the nerves that carry sensations to the brain
34
Referred Pain
Pain felt at particular site but comes from another location where both sites are innervated by same spinal nerve
35
Visceral Pain
Originates from large organs
36
Deep Somatic Pain
Originates from musculoskeletal tissues and body surface
37
Breakthrough Pain
Recurrence of pain before next scheduled dose of medication
38
Cultural Competence
Identifying your own values and beliefs before caring for others
39
Cultural Humility
Understanding the complexity of identities and opening up conversation in a way that attempts to understand a persons identities related tp race, ethnicity, gender, sexual orientation
40
When might you consult a chaplain to support your client?
1. When client receives news of serious illness
2. Person indicates they don't have advanced directive but would like one
3. When someone is coping with a situation where they may have a permanent disability
41
4 Question Screening Tool for Alcohol Abuse
Cut Down
Annoyed
Guilty
Eye-opener
42
Components of Mental Assessment
Appearance
Behavior
Cognition
Thought Process/Content Perceptions
43
Intimacy Vs. Isolation (20-40 years old)
Independence from parents, form intimate bonds with another person, set up/manage a household, make friends and establish social group, begin parental role
44
Generativity Vs. Stagnation (40-65 years old)
Accepting/adjusting to physical changes, reviewing career goals, developing hobby/leisure activities, adjusting to aging parents/ death of a parent, accepting and relating to spouse, attaining desired career performance
45
Integrity Vs. Despair (Starts Age 65)
Adjusting to changes in physical strength/health, affiliating with one's age group, adjusting to retirement/reduced income, arranging safe living quarters, adjusting to death of spouse/family members/friends, conducting life review, preparing for one's own death
46
Components of Culture
Culture is learned, adapted, sharing beliefs, dynamic
47
Types of Cognitive Assessments
1. Time Orientation
2. Place Orientation
3. Three Words Test
4. Serial 7's
5. Repetition
6. Comprehension
7. Reading
8. Writing
9. Connect dots or draw intersecting polygons
48
Nurses Role With Client With Substance Abuse Condition:
Advising and assisting the client regarding substance use and abuse
49
Nutritional Status
Balance between nutrient intake and nutrient requirements - balance affected by physiologic, psychosocial, development, cultural, and economic factors
50
Physiological changes that Affect Nutrition:
Poor Dentition
Decreased vision
Decreased Saliva
Slowed GI Motility
Decreased GI Absorption
Diminished sense of taste and smell
Decreased Energy Requirements
51
Optimal Nutrition
Person has sufficient intake to support body's day to day needs and any increased metabolic needs based on clients circumstances
52
Undernutrition
Nutritional reserves are depleted and/ or nutrient intake is inadequate to meet day to day needs or metabolic demands
53
Overnutrition
When we consume more nutrients especially calories sodium and fat in excess of our body's needs
54
24 hour Food Recall
Nutritional Assessment Test
55
Health Effects of Abuse and Neglect of Older Adults:
Malnutrition
Dehydration
Skin Breakdown
UTI's
Medication Withheld
Injury
Fear
Emotional Distress
56
Subjective Data (Hair, Skin, Nails)
History of skin disease/allergies
Info about moles
Hypo- and hyper-pigmentation
Sores that won't heal
Bruising/Injuries
Rashes/Lesions
Medications
Hair loss/unusual growth/changes in hair texture
Changes in nail shape/color/brittleness
Environmental/Occupational Hazards
Sun Exposure
Insect Bites
Self-care for hair, skin, nails
57
Basal Cell Carcinoma
Most Common Skin Cancer
Slow Growing - face, ears, scalp, shoulders
1. Skin colored papule with pearly translucent top and overlying broken blood vessel
2. Develops round pearly borders with red ulcer or open pore with central yellowing
58
Squamous Cell Carcinoma
Erythematous scaly patches with sharp margins (1cm) - heads and hands
1. Usually develops central ulcer and surrounding erythema
59
Malignant Melanoma
Brown but can be tan, black, pink,-red, purple, or mixed pigmentation
Found on trunk, back of legs, palms, soles and nails
1. Irregular or notched borders and scaling, flaking, or oozing texture
60
Assess for Skin Lesions (ABCDEF)
Asymmetry
Border
Color
Diameter
Elevation
Funny looking
61
Assess for Edema
*Press thumb on skin for 3-4 seconds
0=No edema
1+=Mild pitting, slight indentation no perceptible swelling
2+=Moderate pitting, indentation subsides rapidly
3+=Deep pitting, indentation remains for short time, visible swelling
4+=Very deep pitting, indentation lasts long time, very swollen
62
Stage 1 Pressure Ulcer:
Skin intact and unbroken, localized redness and skin doesn't blanch or turn lighter with pressure
63
Stage 2 Pressure Ulcer:
Partial thickness, skin erosion with loss of epidermis and also dermis. Superficial ulcer looks shallow like abrasion or open blister.
64
Stage 3 Pressure Ulcer:
Full thickness extending into subcutaneous tissue and resembling crater. May see subcutaneous fat but not muscle/bone/tendon.
65
Stage 4 Pressure Ulcer:
Full thickness that involves all skin layers and extends into supporting tissues. Exposed muscle, bones, tendons may show.
66
Tool used to help predict pressure injury risk:
BRADEN scale
67
When you move a part of your body by using your muscles:
Active ROM
68
A part of your body can move when someone or something is creating the movement:
Passive ROM
69
Review All ROM For Body Joints
70
Used to help predict fall risk:
MORSE
71
Sign of chronic oxygen deprivation:
Clubbing
72
Bluish mottled color from decreased skin perfusion:
Cyanosis
73
Sign of dehydration:
Dry mucous membranes
74
Normal change with aging:
Less elasticity and subcutaneous fat
75
Normal finding when assessing capillary refill:
Return to color in less than 3 seconds
76
Body part at highest risk of skin breakdown:
Bony prominence
77
Risk factors on BRADEN scale:
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
