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Exam 1 Flashcards

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1
Q

Diagnostic Process

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation
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2
Q

Assessment- 2 types of data

A

Subjective- what pt states about himself

Objective- what the health professional observes/assesses

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3
Q

critical thinking

A

developed as the nurse progresses from novice to expert

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4
Q

Thinking like a nurse involves 3 nursing diagnoses:

A
  1. Actual- whats actually happening
  2. Risk- when patient is at risk for something (infection after surgery, sepsis.. etc)
  3. Wellness- how well can the pt cope with daily activities
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5
Q

what determines how a problem is prioritized?

A

the acuity of illness often determines order of priorities

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6
Q

3 levels of setting priorities

A

first-level priority: emergency and life threatening problem

2nd-level priority: when you don’t intervene promptly, pt starts to deteriorate

3rd-level priority: important but not as urgent

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7
Q

what type of health history is taken when patient is admitted into hospital?

A

Complete (total health) database

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8
Q

what type of health history is taken when pt is sent to emergency room?

A

Focused or Problem-Centered Database

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9
Q

What type of health history is taken when pt is discharged and sent to be re-assessed

A

Follow-up database

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10
Q

Type of health history usually taken when happening in emergency situations

A

Emergency Database

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11
Q

health promotion ____

A

encourages patients to do preventative care

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12
Q

The interview process is made up of 2 facrors:

A

Internal and External Factors

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13
Q

Internal factors that should be used during the interview process are:

A
  • liking others
  • empathy
  • listening
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14
Q

External factors that should be used during the interview process are:

A

Privacy
Interruptions
Environment
Note-taking

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15
Q

The 2 most used techniques of communication that can be used in the interview process;

A
  1. Open-ended question: “tell me what you’re in for today”

2. Closed or directed question: “what medication are you taking, rate your pain on a scale of 0-10”

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16
Q

When do you use an open-ended question?

A
  • to facilitate beginning of interview
  • introduce a new section of questions
  • introduce new topic
  • to end an interview and ease into closure
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17
Q

when do you use a closed or directed question?

A
  • need specific info where short answers are rquired

- to force a choice

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18
Q

Common nonverbal skills you project onto patient

A
  • physical appearance
  • posture
  • gestures
  • facial expressions
  • eye contact
  • voice
  • touch
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19
Q

Interpreters are ___

A
  • mandated by law

- NEVER a family member

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20
Q

A complete health history includes 7 aspects:

A
  1. biographic data
  2. source of history
  3. reason for seeking care
  4. present health history/illness
  5. past health information
  6. family history
  7. cultural
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21
Q

What type of assessment is geared towards how the pt takes care of themselves?

A

Functional Assessment

should leave towards the end of the assessment

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22
Q

Assessment Techniques

A

Inspection- look at skin, breathing, smell, use senses
Palpation- always comes after inspection
Percussion- to determines whats beneath a structure
Auscultation- listening to normal body structures

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23
Q

Percussion Sounds:

A

Amplitude- how loud or soft the sound is
Pitch- high vs low pitch (based off of vibration)
Quality- what makes different area of body sound diff.
Duration- how long does sound last?

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24
Q

Percussion Characteristics

A

Resonant- over lungs, normal sound for lung tissue
Hyperresonant- booming sound (lungs) in kids
Tympany- drum like sound, found in abdomen
Dull- muffled thud
Flat- bones

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25
Ausculation is mainly used in what 3 body areas
heart, lungs, abdomen
26
The diaphragm and bell are used for which sounds?
diaphragm- high pitched sound | bell- low pitched sound
27
A general survey includes:
- physical appearance - body structure - mobility - behavior
28
Measurement of Pt includes:
1. Weight 2. Height 3. BMI 4. Waist Circumference
29
Vital Signs:
``` Temperature Pulse Respirations Blood Pressure 5th vital sign: PAIN ```
30
vital signs should be assessed:
Every 4 hours
31
Types of temperature that can be taken
``` Oral- most used, most reliable Axillary Tympanic Temporal Artery Rectal ```
32
Pulse should be taken:
count 30-60 seconds begin at zero use pads of fingers for radial pulse Assess: rate, rhythm, force
33
You should count respirations for how many seconds?
30-60 | 30 if they are healthy, 60 if not so you can observe abnormality
34
how many feet should you be standing from your pt to ensure comfortability?
4-5ft
35
when interviewing adolescents, what should you avoid doing?
long bouts of silence, reflection be aware of your nonverbal communication skills. they are more sensitive to this.
36
HEEADSSS is used as a questionnaire for what patient population and what does it stand for?
adolescents- moves from non threatening questions to personal -Home environment, Education/employment, Activities, Drugs, Sexualtiy, Suicide/depression, safety from injury and violence
37
what are the most common assessment techniques?
inspection, palpation, percussion, Auscultation
38
what is defined as concentrated watching and is the first step of assessment
Inspection
39
the step that always follows inspection in the assessment of a new pt
Palpation
40
palpation feels for:
``` texture temp moisture organ location and size swelling vibration or pulsation crepitation lumps or masses tenderness or pain ```
41
fingers- grasping action of fingers and thumb- Dorsa- Palm-
skin texture, swelling, pulsation, lumps position, shape, and consistency of an organ or mass Temperature (back of hand) vibration
42
tapping of the skin with short, sharp strokes to assess underlying structures
Percussion
43
Light palpation: cm? | Deep Palpation: cm?
``` 1cm deep (usually abdomen) start with this then move into deep if needed 5-8cm (deep circular motion in clockwise direction) ```
44
Percussion sounds: 4
Amplitude: volume Pitch: based on vibration speed Quality: different places make different sounds Duration: how long does the sound last?
45
The Resonant sound comes from
the lungs: clear, hollow sound | Sounds dense if theres a tumor or extra mass
46
Hyperresonnant sound comes from
Child's lung (normal) Adult lung (Abnormal) --> emphysema, COPD "Booming" sound
47
Tympany sound comes from
air filled visuc (stomach, intestine) | "drumlike"
48
Dull sound comes from
an organ | "muffled thud"
49
Flat sound comes from
the bone or thigh muscles, tumor. | "dead stop to sound"
50
vital signs should be assessed every ____
4 hours
51
what is the purpose of taking someones vital signs?
to assess cardiovascular & Pulmonary status give you info on if pt is declining include pain scale
52
what are the 4 vital signs>
Temp Puls Respirations BP
53
5 types of temperature:
- Oral- most used/reliable - Axillary- 1 degree lower than normal (Farenheit) - Tympanic- ear - Temporal Artery- wave magic wand, not as accurate - Rectal- closest temp to core body, avoid in cardiac pt
54
What influences a temperature reading?
diurnal cycle- time of day (^ at night) menstruation- 1 degree higher Exercise Age
55
When you're taking the pulse what should you be assessing for?
Rate (50-95 beats per minute) Rhythm Force
56
the pressure exerted against arteries when the heart is contracting
Systolic BP
57
the resting pressure when ventricles are filling between contraction
Diastolic BP
58
Amount of blood ejected from L ventricle per minute
Cardiac Output
59
Factors that affect BP (5)
1. Cardiac Output 2. Vascular Resistance 3. Volume 4. Viscosity 5. Elasticity of arterial walls
60
The Sphygmomanometer measurements
width- 40% of pt's arm | length- 80% of pt's arm
61
To test a patients orthostatic pressure you should follow these 3 steps:
1. Have pt rest supine for 2-3 minutes 2. Take BP with them lying down 3. Assist pt to sitting position and wait 2-3 minutes 4. Take BP with them sitting 5. Stan patient up wait 2-3 minutes 6. Take BP with them standing - Compare diastolic pressures. if there is a decrease of 20 mmHg its considered positive orthostatic BP
62
3 common abnormalities of the blood/heart
1. Arterial Obstruction 2. Coarctation of the aorta 3. Auscultatory Gap
63
Arterial Obstruction
- stenosis or narrowing of artery * difference in systolic BP of 10-15 mmHg between arms - check BP in both arms
64
Coarctation of the aorta
when your arm BP reads higher than your thigh BP * in healthy person BP is always higher in thigh* - congenital narrowing of aorta
65
An Auscultatory gap is common in:
hypertensive clients or older adults | *caused by atheroscelorsis
66
Order of measurement for infants and toddlers:
1. take an apical pulse* 2. watch for respirations in the abdomone 3. Tame temp last ** will cry***
67
Order of measurement for preschoolers:
1. Take BP for 3yrs and older | 2. take temp last
68
School-aged kids can be coaxed to cooperate through:
explanation of what you are doing
69
In older adults, temperature may be ___
lower. | harder to catch a fever and more at risk for hypothermia
70
A normal pulse ox rate is:
92-100%
71
when you are unable to palpate a pulse, what do you do?
- Grab a doppler before documentation that they didn't have a pulse. - if still cant find pulse-- get doctor immediately
72
Chart documentation follows a simple acronym of:
``` SOAP S- subjective data first O- objective data next A- assessement and documentation of info P-- plan, develop a plan and document their work ```
73
What are the types of pain? (4)
1. Acute 2. Chronic (persistent)- assoc. with disease process 3. Malignant- cancer 4. Nonmalignant- arthritis or some type of musculoskeletal condition
74
What are the sources of pain? (4)
1. Deep Somatic- from joint or vessel (ischemia or injury) 2. Cutaneous- scrape or born. skin levele 3. Referred- originates in 1 area but felt in another 4. Neuropathic- damage of nerve fibers (diabetes, shingles)
75
What is the most reliable indicator of pain?
the subjective report given by pt | - allow pt to describe it
76
What are the assessment tools for pain?
- Numeric rating scale - descriptor scale - faces pain scale

Health Assessment (12 decks)

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