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NURS314 Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

data base

A

patient medical record and lab studies plus subjective and objective data

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2
Q

first priority

A

abc, vitals

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3
Q

second priority

A

risk of infection, safety and security

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4
Q

third priority

A

anything not first or second priority

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5
Q

when do you form a total health data base?

A

well child check or annual checkup

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6
Q

when do you form an episodic/focused or problem centered data base?

A

specialist-allergies

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7
Q

When do you form a Follow up data base?

A

after an episodic visit

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8
Q

Emergency data base

A

rapid compilation of data with life-saving measures if needed

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9
Q

six Phases of the Nursing Process

A 
Assessment-collect data, review clinical record, health history, physical exam, functional
Diagnosis-
Outcome Identification
Planning
Implementation
Evaluation
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10
Q

steps of cultural competency

A

• Understand one’s own heritage-based values, beliefs,
attitudes, & practices
• Identify meaning of “health” to patient
• Understand how health care system works
• Acquire knowledge about social backgrounds of
patients
• Become familiar with languages, interpretive services,
& community resources available to nurses & patients

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11
Q

list four types of databases

A

Complete (total Health) database-complete health history and full physical exam

Focused or Problem Centered Database-collect a mini database concerning only one main problem, one cue complex, or one body system

Follow up database- used to follow up on short term or chronic health problems

Emergency Database- rapid collection of data with lifesaving measures

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12
Q

a Successful Interview

A
  1. gather complete health data about health state, including description and chronology of any symptoms of illness
  2. Establish Rapport and trust
  3. Teach the person about the health state so the pt can participate in identifying problems
  4. Build rappport for continuing care-refills, follow-ups
  5. Begin teaching for health promotion and disease prevention
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13
Q

Ten Traps of Interviewing

A

False assurance disregards pt needs
Unwanted advice stalls problem solving
Biased questions leading
Talking too much
Using avoidance language avoid reality of situation
Using why questions puts person on defensive
Engaging in distancing-communicates fear-soften reality
Technical or professional Jargon confusing
Interrupting results in ineffective process
Using Authority-promotes dependency and inferiority

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14
Q

Purpose of a Complete Health History

A

establish rapport
collects subjective data
helps to view the client as a whole individual functioning within the environment
Serves as documentation for others

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15
Q

four techniques used in physical assessment

A

inspection-concentrated watching
palpation-
percussion-
ausculation

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16
Q

4 components of a mental status exam

A

appearance
behavior
cognitive function
thought processes and perception

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17
Q

Drug and alcohol assessment tools

A

audit-C
cage (cut down, annyed, guilty, eye-opener)
tweak (tolerance, worry, eye opener, amnesia, kut down)

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18
Q

effects of domestic violence

A 
Women with lifetime 
victimization experience 
were significantly more 
likely to report having
• Asthma
• Irritable bowel syndrome
• Diabetes
Both women & men with 
lifetime victimization 
experience were 
significantly more likely to 
report
• Frequent headaches
• Chronic pain
• Difficulty sleeping
• Activity limitations
• Self-assessed poor 
physical & mental health
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19
Q

CAGE test

A

cage (cut down, annoyed, guilty, eye-opener)

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20
Q

Mental Status Exam

A 
ABCT
Appearance
Behavior
Cognition
Thought Processes
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21
Q

4 Unrelated Words Test

A

this tests the person’s ability to lay down new memories. It is a highly sensivitve and valid memory test. After 5 mins, ask for the recall of the 4 words. then again at 10 then 30 mins. The normal response for persons younger than 60 is an accurate three-four word recall after a 5, 10, and 30 minute delay.

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22
Q

Most abused drug

A

alcohol

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23
Q

assess for IPV

A

at every healthcare encounter for women

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24
Q

Assessment Techniques (IPPA)

A

inspection
palpation
percussion
auscultation

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25
Importance of Skin Assessment
skin is the body's largest organ | guards the body from environomental stressors and adapts to other environmental influences
26
Genogram
``` focus on questions relating to family history of coronary heart disease hypertension stroke diabetes obesity blood disorders breast/ovarian cancer colon cancer sickle cell kidney disease TB ```
27
Health History | Review of Symptom
purpose: 1) evaluate past and present state of health for each body system 2) double check in case any sig data were omitted in the Present Illness Section 3) evaluate health promotion practices
28
Health History: | Family history
identify diseases and conditions for which a patient may be at increased risk
29
Health History: | Past Health
may have residual effects on the current health state.
30
Childhood illnesses
measles, mumps, rubella, chickenpox, pertussis, and strep throat
31
Serious childhood illness that may have sequelae for the person in later years
rheumatic fever, scarlet fever, poliomyelitis
32
Health History: Present health or History of present illness
location, character/quality, quantity/severity, timing (onset, duration, frequency), setting (what brings symptoms on? shoveling snow?), Aggravating/Relieving Factors, Associated Factors (often review medications now), Patient's Perception (how does this affect your daily activities)
33
Health History: Present Health or History of Present Illness PQRSTUVW
PROVOCATION- what brings illness on? QUALITY/QUANTITY-how does it look, feel sound? How intense is it? REGION/RADIATION-where is it? does it spread? SEVERITY SCALE-how bad is it on 1-10? is it getting worse? TIMING- onset, duration, frequency UNDERSTAND PATIENT'S PERCEPTION- what do you think it means? helps you assess patients' levels of anxiety VARIABLES-associated factors WHERE-setting occurred
34
ABCDE of skin assessment
``` asymmetry border irregularity color variation diameter greater than 6 mm elevation or enlargement ```
35
assess skin
``` temperature moisture texture thickness edema mobility and turgor lesions ```
36
cherry angiomas
small, smooth, and slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years.
37
vitiligo
complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices. can occur in all races, although dark skinned people are more severly affected and potentially suffer a greater threat to their body image
38
ashen grey color in dark skin or marked pallor in light skin
anemia, shock, arterial insufficiency
39
pallor of impending shock accompanied by
rapid pulse rate oliguria apprehension restlessness
40
pallor of anemia accompanied by
``` spoon nails fatigue exertional dyspnea rapid pulse dizziness impaired mental function ```
41
erythema
intense redness of the skin from excess blood (hyperemia) in the dialted superficial capillaries. expect to also find fever, local inflammation, and blushing
42
erythemai
polycythemia, venous stasis, carbon monoxide poisoning, and extravascular presence of red blood cells (petechiae, ecchymois, hematoma)
43
cyanosis
bluish, mottled color that signifies decreased perfusion means the tissue do not have enough oxygenated blood.
44
cyanosis accompanied by
(indicates hypoxia) occurs with shock, heart failure, chronic bronchitis, congenital heart disease
45
Jaundice
yellowish skin color indicates rising amounts of bilirubin in blood.
46
jaundice accompanied by
light or clay-colored stool and dark, golden urine
47
hyperthyroidism
skin is smoother and softer, like velvet
48
hypothyroidism
skin feels rough, dry and flaky
49
bilateral edema
consider heart or kidney failure
50
unilateral edema
consider local or peripheral cause
51
What do lesions with blue-green fluorescence indicate?
fungal infections
52
clubbing of nails
occurs with congenital cyanotic heart disease and neoplastic and pulmonary disease. chronic lung inflammation, bronchial tumors, heart defects with left to right shunts. cause fragmented platelets to become trapped in the fingertip vasculature, releasing platelet-derived growth factor and promoting growth of vessels which shows as clubbing
53
mongolian spot in infants
hyperpigmentation at the sacrum but sometimes on the abdomen, thighs, shoulders, or arms due to deep dermal melanocytes. generally fades during the first year
54
cafe au lait spot in infants
a large round or oval patch of light brown pigmentation, but six or more of these spots, each with a diameter more than 1.5 cm are diagnostic of neurofibromatosis, an inherited neurocutaneous disease.
55
harlequin color change in infants
occurs when the baby is in a side-lying position. The lower half of the body turns red and the upper half blanches with a distinct demarcation line down the midline
56
Erythema toxicum in infants
common rash that appears in the first 3-4 days of life. sometimes called the flea bite, consists of timy punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks.
57
Acrocyanosis in infants
a bluish color around the lips, hands, and fingernails and feet and toenails. may last a few hours and disappears with warming
58
Cutis marmorata in infants
transient mottling in the trunk and extremities in response to cooler room temperatures.
59
persistant, generalized cyanosis in infants
indicates distress such as cyanotic congenital heart disease
60
persistent or pronounced cutis marmorata in infants
occurs with down syndrome or prematurity
61
green-brown discoloration of the skin, nails, and cord in infants
occurs with passing of meconium in utero, indicating fetal distress
62
Jaundice in infants
jaundice on the first day of life may indicate a hemolytic disease jaundice after two weeks of age may indicate biliary tract obstruction
63
excessive sweating in children
may accompany hypoglycemia, heart disease, or hyperthyroidism
64
Senile lentigines in seniors
liver spots clusters of melanocytes that appear after extensive sun exposure not malignant
65
Keratoses in seniors
raised, thickened lesions that look crusty, scaly, and warty. Seborrheic keratosis looks dark, greasy, and stuck on do not become cancerous
66
actinic (senile or solar) keratosis
red/tan scaley plaques that increase over the years to become raised and roughened premalignant and may develop into squamous cell carcinoma
67
xerosis
dry skin in seniors
68
acrochordons
skin tags
69
sebaceous hyperplasia
consists of raised yellow papules with a central depression. they have a pebbly look.
70
lymph node: preauricular
in front of the ear
71
lymph node: posterior auricular
mastoid
72
lymph node: occipital
at the base of the skull
73
lymph node: submental
midline, behind the tip of the mandible
74
lymph node: submandibular
halkway between the angle and the tip of the mandible
75
lymph node: Jugulodigastric
under the angle of the mandible
76
lymph node: Superficial cervical
overlying the sternomastoid muscle; chain of two
77
lymph node: deep cervical
deep under the sternomastoid muscle; chain of three. have patient tip head toward the side being palpated
78
lymph node: posterior cervical
in the posterior triangle along the edge of the trapezius muscle
79
lymph node: supraclavicular
just above and behind the clavicle, at the sternomastoid muscle; have the patient hunch the shoulders and elbows forward
80
when lymph nodes are abnormal, where do you look?
upstream of drainage for the source of the problem
81
how to palpate lymph nodes
use gentle, circular motion of fingertips
82
normal lymph nodes feel
movable, discrete, soft, and nontender
83
respect of cultural competent assessment
Realize you must know heritage of yourself & patient Examine patient within cultural context Select simple questions & speak slowly Pace questioning throughout exam Encourage patient to discuss meaning of health & illness with you Check patient’s understanding & acceptance of recommendations Touch patient within boundaries of his or her heritage
84
phases of the interview process
Pre-interaction phase • Beginning phase • Working phase • Closing phase
85
4 types of health history
COmPleTe health history • inTeRvAl health history • PROBlem-fOCused or chief complaint-focused health history • sPeCiAl health history
86
chief complaint
``` A short statement in client’s own words • symptom(s), feeling(s), or need(s) • subjective information • Record exactly as stated & use quotation marks • This is not a diagnosis • “What brought you here today?” ```
87
what characteristics are included in the summary of each client symptom?
pqrstuvw

NURS314 Assessment (2 decks)

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