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NUR3120 HEALTH ASSESSMENT > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

Pressure Ulcer Stage II

A

Partial thickness skin erosion

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2
Q

Definition of Pain

A
  • An unpleasant sensory and emotional experience associated with potential or actual tissue damage or described in terms of damage
  • pain is subjective
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3
Q

Interview Guidelines

A
  • keep intro short/formal
  • address by last name
  • cultural sensitivity
  • explanation of interview
  • make eye contact
  • ask follow up questions
  • avoid bombarding
  • demonstrate appreciation
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4
Q

Nursing Diagnoses for Spiritual Health

A
  • anxiety
  • grief
  • hopeless
  • ineffective family coping
  • altered family processes
  • altered self-esteem or concept
  • spiritual distress
  • potential for enhanced spiritual well-being
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5
Q

Pressure Ulcer Stage IV

A

Full thickness involving all skin layers and extends into supporting tissue

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6
Q

Passive ROM

A
  • performed when patient has limitation
  • anchor the patient’s joint with one hand while your other hand slowly moves it to its limit
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7
Q

Types of Databases

A
  • complete or total health
  • focused or problem centered: mini-database
  • follow-up
  • emergency
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8
Q

Physiological Effects of Pain : GASTROINTESTINAL

A
  • N&V
  • ileus : intolerance of oral intake
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9
Q

Types of Evidence

A
  • patient preferences & values
  • clinical expertise of provider
  • evidence from research & evidence-based theories
  • physical examination & assessment
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10
Q

Basal Cell Carcinoma

A
  • most common skin cancer
  • usually on sun-exposed areas
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11
Q

The Nursing Process : ASSESSMENT

A
  • collect data : objective & subjective
  • use evidence-based assessment techniques
  • document relevant data
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12
Q

Interview Traps

A
  • derails interview
  • creates communication obstacles
  • provides false assurance
  • giving unwanted advice
  • using authority
  • using avoidance language
  • distancing
  • using professional jargon
  • using leading questions
  • talking too much
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13
Q

Types of Data

A
  • subjective data
  • objective data
  • patient record
  • lab & diagnostic testing results
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14
Q

?s Nurses might ask Regarding Spiritual Health

A
  • tell me what life means to you
  • are you in need of religious/spiritual or emotional support
  • is this illness causing any major life changes for you or a loved one
  • have you had any major stress or change in lifestyle recently
  • is there anything we need to know about your religion, culture, or background
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15
Q

Assessment Tool for Substance Abuse : CAGE

A
  • have you ever felt the need to CUT down on your drinking
  • have people ANNOYED you by criticizing your drinking
  • have you ever felt GUILTY about your drinking
  • have you ever felt you needed a drink first thing in the morning, EYE-OPENER, to steady your nerves or get rid of a hangover
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16
Q

Nutritional Developmental Considerations

A

AGING ADULT
- physical/mental health
- social isolation
- chronic alcoholism
- limitations
- poverty
- polypharmacy
- decreased energy
- socioeconomic

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17
Q

Health Effects of Violence, Abuse, & Neglect : IMMEDIATE

A

injuries including: cutaneous injuries, blunt-force trauma, lacerations, cuts or incisions, or strangulation

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18
Q

Blood Pressure

A
  • Normal : 120/80
  • Use left arm when possible
  • 1st sound : systolic
  • 2nd sound : diastolic
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19
Q

Components of Mental Status Exam : BEHAVIOR

A
  • LOC
  • facial expression
  • speech
  • mood & affect
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20
Q

Health History Purpose

A
  • collect data
  • screening tool
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21
Q

Health Effects of Abuse on Elders

A
  • complications from intentional injury
  • infections
  • cardiac complications
  • sexually related complications
  • dehydration
  • malnutrition
  • skin breakdown
  • self neglect
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22
Q

OLDCARTS
(history of present illness)

A

O = onset - acute vs gradual
L = location/radiation
D = duration
C = characteristics
A = aggravating/associated factors
R = relieving factors
T = treatments
S = severity of symptoms

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23
Q

Why assess mental status?

A

To determine if there is a dysfunction with:
- consciousness*
- language
- mood & affect*
- orientation*
- attention*
- memory*
- abstract reasoning*
- thought process & content*
- perception*

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24
Q

Pulse

A
  • Normal : 60-100 bpm
  • regular, 2+
  • irregular rate needs to be counted for a full minute
  • regular rhythm = 30 secs X 2
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25
Body Movements
- flexion & extension - abduction & adduction - pronation & supination - circumduction - rotation - elevation & depression - eversion & inversion - protraction & retraction
26
Vital Signs
- temperature - pulse - respirations - blood pressure
27
4 basic cultural characteristics
- culture is learned - culture is shared - culture is adapted - culture is dynamic
28
Respirations
- normal : 10-20 breaths/min - do not tell pt when performing - 30 secs X 2, unless irregular = one full minute - even & unlabored
29
Physiological Effects of Pain : IMMUNE SYSTEM
- impaired cellular immunity - impaired wound healing
30
Active ROM
- patient does the movements themselves - you can model movement yourself for patient - performed when patient has no limitations
31
Interfering Factors for Auscultation
- extra room noise - cold room = shivering - hairy chest = friction - gown or article of clothing - examiner sounds
32
Objective Data of Nutritional Assessment
- growth & development - body compositions - height & weight - derived weight measures
33
Nutritional Assessment Screenings
- performed @ admission - dietary history - labs - physical exam - 24hr dietary & 3 day recal
34
Verbal vs. Non-Verbal Communication
- Verbal: spoken word, vocalization, voice tone - Non-Verbal: body language, posture, gestures, facial expression, eye contact, foot tapping, touch, chair placement
35
Diagnosing Substance Abuse
- alcohol pattern: social, moderate, severe - alcohol dependence: chronic progressive disease - highly treatable, not curable - if undiagnosed leads to serious complications
36
Pressure Ulcer Stage III
Full thickness extending into subcutaneous tissue
37
Nurses role in treating substance abuse concerns
ADVISE & ASSIST - state that their drinking is unsafe - recommend they stop or cut down - offer to help : referral to counselor of AA
38
Dependence
Physical reliance & expectation of substance
39
Melanoma
- less common than basal and squamous carcinoma - if not detected & treated early can be dangerous - can spread - may begin in or near mole or dark spot
40
Pressure Ulcer Stage I
Intact skin appears red but unbroken, does not blanch
41
Braden Scale
42
Considerations Related to Pain
- developmental factors - aging adult - pain is not a normal process of aging - indicates pathology, injury - underreporting - culture
43
Physiological Effects of Pain : PULMONARY
- hypoventilation - hypoxia - atelectasis : collapse of or part of lung - dcrd cough
44
Tolerance
Using more substance than normal to continue to get desired effect
45
External Factors that affect Communication
- environment/setting - geographical privacy - psychological privacy - interruptions - dress - note taking
46
4 Point Scale for Assessing Edem
0 = absent 1+ = mild, slight indentation 2+ = moderate pitting, indentation rapidly subsides 3+ = deep pitting, indentation remains for a short time & area looks swollen 4+ = very deep pitting indentation that lasts long time
47
Physiological Effects of Pain : CNS
- fear - anxiety
48
Intoxication
Consumed enough substance to receive desired effects
49
Components of Mental Status Exam : COGNITIVE FUNCTION
- orientation - attention span - recent & remote memory - new learning
50
The Nursing Process : EVALUATION
determine if goals met & outcomes achieved
51
Nutritional Cultural Considerations
- unique heritage - cultural patterns - cultural food preferences - religious practices
52
Abuse
Using substances despite having negative consequences
53
Physiological Effects of Pain : MUSCULOSKELETAL
- spasms - joint stiffness - immobility
54
Health Promotion Regarding Musculoskeletal System
- consume a balanced diet: calcium & vit D - avoid activities that cause muscle strain or stress to joints - encourage maintenance of normal weight - participation in regular exercise program - contact HCP if joint or muscle pain occur, or limitations in ROM develop
55
Physical Assessment Skills
- Assessment - Inspection - Palpation - Percussion - Auscultation
56
Components of Mental Status Exam : APPEARANCE
- posture - body measurement - dress - grooming & hygiene
57
Key Subjective Data of Hair, Skin, & Nails Assessment
- hx of skin disease, allergies, surgery, or trauma (tattooing) - changes in pigmentation - changes in moles - excessive dryness or moisture - pruritus (itching)
58
Health Effects of Violence, Abuse, & Neglect : LONG TERM
chronic health problems including significantly more neurologic, gastric, & gynecologic symptoms & chronic pain
59
Mental Status Definition
A person's emotional and cognitive functions
60
Squamous Cell Carcinoma
- less common than basal cell - grows rapidly - usually on hands or head - areas exposed to UV radiation
61
Intimacy vs Isolation (early adulthood)
- young adult; 19-40 - gain independence from parents' home - establish a career & vocation - form an intimate bond - setting up & managing a household - learning to cooperate in a marriage - making friends & establishing a social group - assuming civic responsibility - beginning a parental role - forming a meaningful philosophy of life
62
Components of Spiritual Assessment
- faith/beliefs - life & self responsibility - life satisfaction - fellowship & community - rituals & practice - vocation - expectations
63
Observations of Hair, Skin, & Nails
- excessive bruising - rashes or lesions - medications - hair loss - nail change - environmental or occupational hazards - usual self-care behaviors
64
Integrity vs Despair (late adulthood)
- old age; 65+ - adjusting to changes in physical strength & health - forming a new role as in-law and/or grandparent - affiliating with one's age group - developing postretirement activities that enhance self-worth & usefulness - arranging safe & satisfactory living quarters - adjusting to the death of. spouse, family members, & friends - conducting a life review - preparing for one's own death
65
Nutritional Status Risk Factors for Disease
- lifestyle - poor diet - smoker - hyperglycemia - exercise - alcohol - high BP - waist circumference
66
Open-Ended vs. Closed Questions
- Closed: elicit specific info, 1 or 2 word answers, speed up interview - Open-Ended: elicit a narrative response, feelings, and opinions, client can determine how much to share, useful for starting interview or expanding topic
67
Physiological Effects of Pain : RENAL
- oliguria : abn small amnts of urine outout - urinary retention
68
Temperature
- Normal : 98.6 - wait 15 mins if ate, drank, or smoked
69
ABCDEF Warning Signs for Skin Cancer
A = Asymmetry B = Border irregularity C = Color variation D = Diameter greater than 6mm E = Elevation & enlargement F = Funny looking
70
The Nursing Process : PLANNING
- setting priorities - identify patient centered goals & expected outcomes - plan individualized nurse interventions - SMART
71
PQRSTU
P = Provocative/Palliative Q = Quality/Quantity R = Region/Radiation S = Severity T = Timing/Treatment
72
The Nursing Process : (nursing) DIAGNOSIS
Use clinical judgment about actual or potential health problems to prioritize & plan care
73
Health History Components
- date/time - biographical data - source - reason for seeking care - past health - family history - review of systems - ADLs
74
Purposes of Nutritional Assessment
- identify at risk patients - collect data - establish baseline - nutritional state & support
75
Withdrawal
Discontinued use of substance causes unwanted side effects
76
Substance
product consumed; alcohol, weed, cocaine, sedatives
77
Physiological Effects of Pain : CARDIAC
- tachycardia - hypertension - incrd myocardial oxygen demands - incrd cardiac output
78
Mini-Mental State Exam (MMSE)
- time & place orientation - register/recall 3 words - serial 7s calc - name object - repetition - comprehension - reading - writing a sentence - intersecting polygons
79
Generativity vs Stagnation (middle adulthood)
- middle age; 40-65 - accepting & adjusting to physical changes - reviewing & redirecting career goals - attaining desired career performance - developing hobby & leisure activities - adjusting to aging/death of parents - helping adolescent children int heir search for identity - accepting & relating to spouse a - coping with an empty nest
80
Components of a General Survey
- general obvious physical characteristics - overall impression - physical appearance - body structure - mobility - behavior - age & gender - LOC - skin color - facial features - ROM
81
Indicators of Pain
- complex biopsychosocial phenomenon - most reliable = pt's report
82
The Nursing Process : IMPLEMENTATION
initiate interventions & actions designed to achieve goals & expected outcomes to support/improve health status
83
Physiological Effects of Pain : ENDOCRINE
incrd adrenergic activity
84
Subject Data of Nutritional Assessment
- eating patterns/habits - usual weight - changes: appetite, taste, smell - recent surgery, trauma, burns, infections - chronic illnesses - food allergies or intolerances - alcohol or drug use - family hx
85
Substance Abuse Definition
Excessive use of alcohol and drugs
86
Internal Factors that affect Communication
- listening abilities : passive, active, demanding, ask questions, verbal & nonverbal, no interruptions - self awareness : personal biases, prejudices, stereotypes
87
Components of Mental Status Exam : THOUGHT PROCESSES & PERCEPTIONS
- thought process & content - perceptions - screen for anxiety, depression, suicidal thoughts
88
The nurse is taking a family history. Which specific disease or problem should be included in the assessment?
Mental illness
89
What does the review of systems provide the nurse?
Info regarding health promotion practices
90
When assessing the quality of a client's pain, the nurse should as which question?
What does your pain feel like (PQRST)
91
Acute Pain
Pain the lasts less than 6 months, is short term, self-limiting, often follows a predictable trajectory and dissipates after injury heals
92
Which assessment technique uses the sense of touch to assess texture, temperature, moisture, and swelling?
Palpation

NUR3120 HEALTH ASSESSMENT (3 decks)

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