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NUR 502 > Exam 1 Blueprint > Flashcards

Exam 1 Blueprint Flashcards

1
Q

Subjective data collection

A
  • what the patient says: chief complaint (CC)
  • health history
  • symptoms
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2
Q

Objective data collection

A
  • what the nurse observes: physical exam
  • lab and diagnostic testing
  • signs
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3
Q

Focused questions for Review of Systems

A

targeted problems

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4
Q

Biased communication

A

be nonjudgmental
safe, judgment-free, and non-discriminatory verbiage on forms
pronouns and names

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5
Q

Verbal and non-verbal communication

A

appropriate verbal communication:
- simple, recognizable and clear words
- use non-stigmatizing language; don’t them to shut down

appropriate nonverbal communication:
- body orientation toward and physical proximity to patient
- eye contact
- head nodding w facial animation
- head nodding w gestures
- posture
- tone & use of voice; use of silence
- use of touch

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6
Q

Communicating with the Hearing and visually impaired

A
  • medical interpreter if needed
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7
Q

Using open-ended and closed-ended questions

A

open-ended questions: patient’s own words; story of symptoms

close-ended questions: yes or no answers; pertinent positives and negatives”

what they are telling us vs what is being shown

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8
Q

Interviewing people with challenging needs

A
  • altered state or cognition: needing to decipher what is true or not
  • angry, aggressive, threatening violence: getting reinforcements if needed
  • flirtatious: suggest someone else be there; restating not appropriate and direct to care
  • discriminatory
  • under drug or alcohol influence: asking what they have taken to better care for them
  • limited intelligence
  • low health literacy
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9
Q

Culture

A

beliefs, values, traits, social norms, communication, and behaviors of that group

characteristics of the culture are learned, shared and adapted

requires humility; continually engage in self-reflection and self-critique

examining cultural beliefs and systems of patients and providers

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10
Q

Social Determinants of Health (SDOH)

A

Education access and quality
Healthcare access and quality
Neighborhood and built environment
Social and Community context
Economic Stability

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11
Q

Clinical Reasoning

A

gathering initial patient information
- health history and physical examination
- additional info:
– prior health records
– comments from fam, caregivers, providers, someone w knowledge of patient
– patient’s symptoms from history
– signed observed in exam, lab and diagnostic tests

organizing and interpreting information to synthesize the problem
generate hypotheses
testing hypotheses until a working diagnosis is selected
planning diagnostic and treatment strategy

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12
Q

Nursing Process

Steps for patient care/Plan

ADPIE

A

ADPIE

Assessment
Diagnosing
Planning
Implementation
Evaluation

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13
Q

Clinical Judgment

Steps after making a POC

A

a decision made regarding a course of action by the nurse
- collect data
- analysis of data
- interpretation of data
- determine priority problem/concern
- apply knowledge to clinical situation
- identify appropriate nursing intervention
– problem solving
– decision making
– critical thinkin

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14
Q

Assessment across the lifespan: Newborns and Infants

A

birth to 30 days; infants - 1 month-1yr
parent/caregiver presence
unable to talk
react to the emotional and physical cues
speak in a calm voice
parents can feed the baby
1-2 hours after feeding
sleeping baby best for heart/lung sounds

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15
Q

OPQRST

A

Onset
Precipitating and Palliating factors
Quality
Region or Radiation
Severity
Timing or Temporal characteristics

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16
Q

OLDCART

A

Onset
Location
Duration
Character
Aggravating or Alleviating factors
Radiation
Timing

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17
Q

Abdominal Assessment - focused questions to ask patients

Adults, Infants, Adolescents, Aging adults

A

About:
- abdominal pain
- appetite
- dysphagia- difficulty swallowing
- food intolerance
- nausea, vomiting, diarrhea
- bowel habits, changes
- past abdominal history
- medications
- nutritional assessment

infants:
- breastfeeding/bottle
- table foods
- often eating/constipation

adolescents:
- weight concerns, activity/exercise
- calories consumed

aging adults:
- grocery acquisition
- meal prep - eat alone?
- bowel habits

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18
Q

RLQ and organs

A

cecum
appendix
right ovary and tube
right ureter
right spermatic cord

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19
Q

RUQ and organs

A

liver
gallbladder
duodenum
head of pancreas
right kidney and adrenal

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20
Q

LUQ and organs

A

stomach
spleen
left lobe of liver
pancreas
left kidney and adrenal
splenic flexure of colon
part of transverse & descending colon

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21
Q

LLQ and organs

A

part of descending colon
sigmoid colon
left ovary and tube
left ureter
left spermatic cord

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22
Q

9 regions of abdomen

A

right hypochondriac
right lumbar
right iliac (or inguinal)

epigastric (top middle)
umbilical
hypogastric (suprapubic)

left hypochondriac
left lumbar
left iliac (or inguinal)

23
Q

Abdominal assessment sequence

(4)

A

Inspection, Auscultation, Percussion, Palpation

24
Q

Inspection - abdomen

A

contour:
- flat
- rounded: slightly distended
- scaphoid: concave, sunken
- protuberant: distended

temperature: warm or cool and clammy
color: bruises, erythema, jaundice, rashes, ecchymoses, Nevi
scars: describe location & size
striae: silver are normal; pink-purple are hallmark of Cushing syndrome
dilated veins: seen in thin individuals; can indicate liver issues
symmetry
umbilicus - inverted/everted
pulsations or movement
visible organs or masses
hair distribution

25
Auscultation - abdomen
hyperactive, hypoactive, absent (established after 5 minutes of continuous listening), borborygmi borborygmus: stomach growling - hyperperistalsis bowel sounds: movement of air and fluid through intestine - high pitched, gurgling, and irregular start in RLQ at ileocecal valve area - bowel sounds normally present here auscultate all 4 quadrants note frequency and character; usually 5-30 per minute occur every 5-20 seconds auscultate for vascular sounds - bruits in aortic, renal, iliac and femoral arteries (not normally heard) - check esp in people w HTN -- occurs w stenosis or occlusion -- pulsatile blowing sounds - AAA
26
Percussion - abdomen
findings associated with dullness and tympany, CVA tenderness (Costovertebral angle tenderness) percuss lightly in all four quadrants to determine distribution of tympany and dullness tympany usually predominates because of gas in GI tract - stomach scattered dullness from fluid and feces are common - heard over solid organs, fluid, areas of consolidation (tumor or mass) assess amount and distribution of air, gas, viscera and masses that are fluid-filled or solid - assess size of liver and spleen hyperresonance: distended abdomen
27
Palpation - abdomen
normal and abnormal findings; kidney and spleen
28
Abnormal findings of abdomen (described in abdominal assessment deck)
appendicitis, ascites (fluid shift/fluid wave), constipation, hernias, abdominal pain, abdominal masses - AAA, distended abdomen, intestinal obstruction, hepatomegaly, cholecystitis (Murphy sign), splenomegaly, pancreatitis
29
Developmental considerations for abdomen assessment
30
SBAR communication
talking to providers and giving info on patient - Situation - this is me on ward X calling about X; concerned about X Background - admitted, history, last vitals, normal condition vs now Assessment - i think problem is X; not sure what is wrong but worried, etc Recommendation - i need you to come see pt; is there anything i can do in meantime
31
Influences of culture
Influences parents' decisions -- causes of illness; healthcare and treatment -- ex. Jehovah's witness defines family responsibility -- care of older adult verbal and nonverbal communication (eye contact) views of healthcare system increased probability of miscommunication when nurse and patient are of different cultural backgrounds
32
Dimensions of Cultural Humility
self-awareness respectful communication collaborative partnerships
32
SDOH: Economic stability
employment, food insecurity, housing instability, poverty
32
Cultural Humility ## Footnote 5 R's
Reflection: approach each encounter with humility & understanding Respect: treat every person with utmost respect; strive to preserve dignity Regard: hold every person in highest regard Relevance: expect cultural humility to be relevant and apply this to practice Resiliency: embody the practice of cultural humility to enhance personal resiliency
33
SDOH: Education
early childhood education and development, enrollment in higher education, high school graduation, language and literacy
34
SDOH: Social and community context
civic participation, discrimination, incarceration, social cohesion
35
SDOH: health and healthcare
access to healthcare, quality, access to primary care, health literacy
36
SDOH: Neighborhood and built environment
access to foods that support healthy eating, patterns, crime and violence, environmental conditions, quality of housing
37
SDOH at patient level
be alert to clinical flags, ask patients about social challenges in a sensitive and caring way, help them access benefits and support services
38
SDOH at practice level
offer culturally safe services, use patient navigators, ensure care is accessible to those most in need
39
SDOH at community level
partnering with local organizations and public health agencies, getting involved in health planning, improving environments for health if possible
40
Assessment across the lifespan: young and school-aged children
young: 1-4yrs school age: 5-10 years health history from parents tantrums play as a way to build rapport with child and parents stuffed animals or drawing use words the child understand sitting or lying on the exam table
41
Assessment across the lifespan: adolescents
want to be treated as adults and to be given respect and choices begin with client sitting on exam table share questions or concerns w you through the use of broad open-ended questions time alone with patient, no parent/caregiver head-to-toe approach
42
Assessment across the lifespan: adult
head-to-toe assessment standard precautions is it a complete or focused assessment (focused - certain problem/complete - usually first time seeing them) explain what you are doing to the patient basic measurements - vitals - height and weight - visual and hearing acuity
43
Assessment across the lifespan: older adults
elicit preferred way of being addressed adjust the environment put the patient at ease enough space in exam room for pt to safely navigate what assessment differences do you expect to find? what is the patient's functional ability?
44
SPICES | assess the care of the older client requiring nursing interventions ## Footnote SPICES
Sleep disorders Problems w eating or feeding Incontinence Confusion Evidence of falls Skin breakdown
45
Clinical Reasoning/Clinical Adjustment
Recognize cues Analyze Cues Prioritize hypotheses Generate Solutions Take Actions Evaluate outcomes
46
Tanner/Lasater
Noticing Interpreting Responding Reflecting
47
NCLEX Client Needs
Safe and Effective Care environment - management of care - safety and infection control Health promotion and maintenance Psychosocial Integrity Physiological Integrity - basic care and comfort - pharmacological and parenteral therapies - reduction of risk potential - physiological adaptation
48
Abdomen midline organs
uterus bladder aorta
49
Prep for abdominal assessment
appropriate lighting, warm room supine position, pillow under head, arms at sides draping patient - raise gown below nipple line above xiphoid process - level of symphysis pubis empty bladder warm hands and stethoscope nails short
50
Abdomen development: infant and children
umbilicus is prominent liver takes up more space at birth & may be palpable urinary bladder located higher less muscular - organs more easily palpated
51
Abdomen development: pregnant women
enlarged uterus intestines displaced upwards and to the right bowel sounds diminished motility may cause constipation skin changes - striae, linea nigra
52
CVA tenderness
indirect percussion to assess kidneys place palm of one hand on patient back, thump with fisted hand - pain with inflammation of kidney - causes: renal colic, pyelonephritis done over 12th rib and costovertebral angle on back

NUR 502 (13 decks)

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