Final Review Flashcards
(209 cards)
1
Q
holistic health assessment
A
assessing patient as a whole- incorporating mind, body, and spirit
2
Q
purpose of physical assessment
A
- determine level of client functioning (ability to participate in ADL’s)
- identify signs and symptoms that indicate changes in health status
- determine nursing interventions
- determine effectiveness of nursing interventions
- determine health promo opportunities
- determine baseline data
3
Q
physical assessment techniques
A
inspection
palpation
percussion
auscultation
4
Q
inspection
A
- first step when you meet patient
- using senses (eyes, ears, nose) to observe body parts and notice deviations from normal
5
Q
inspection techniques
A
- look before touching
- use good lighting
- only expose area being inspected
- provide warm, private enviornment
- look for size, shape, moisture, color, swelling, odor, sounds, movement, etc.
6
Q
general survey
A
- noticing client as whole to get an idea of the client
- helps guide further assessment to determine health issues/needs
- helps develop a care plan
7
Q
characteristics of general survey
A
A- airway B- breathing C- circulation D- disability E- exposure
A- appearance S- speech E- emotion/ affect P- perception I- insight C- cognition
8
Q
palpation
A
technique used to assess for edema, moisture, temperature, and tenderness
9
Q
palpation technique
A
- clean, warm hands
- short, clean fingernails
- palpate tender areas last
- wear gloves if coming into contact with bodily fluids
10
Q
light palpation
A
- around 1 cm deep
- tells you about skin and structures directly below the skin
11
Q
deep palpation
A
- 3 to 4 cm deep
- tells you about deeper structures under the skin
12
Q
fingertips
A
- moisture
- contour
- conscitency
- pulsations
- texture
13
Q
palm
A
vibrations
14
Q
ulnar edge
A
- vibrations
2. temperature
15
Q
dorsal side
A
temperature
16
Q
circular motion palpation
A
place fingers together and move skin surface over underlying structures in a circular motion
-assessing for consistency, size, shape
17
Q
dipping motion palpation
A
place fingers together and make gentle, quick depressing movements over abdomen
-assess for feces, pregnant uterus, tenderness
18
Q
direct palpation
A
place fingers together and apply direct preassure on skin
- used to palpate blood vessels, skin lesions, masses, muscles
- assess pulse, tenderness, fluid content, blanching
19
Q
grasping (pincher) motion palpation
A
pinch skin with index finger & thumb
- used to assess masses
- assess turgor, thickness, consistency, size, shape, pulsations
20
Q
percussion
A
- tapping over body structures to elicit a sound with a specific pitch, quality, duration, and intensity
- tells you about density, location, size, tenderness of organs
- most commonly used on abdomen
21
Q
ausculation
A
- assess pitch, intensity, timing, rate, duration of body sounds with stethoscope
- can ausculate pulse, chest cavity, abdomen
22
Q
diaphragm use
A
high pitched sounds (heart rate, pulse)
23
Q
bell use
A
low pitched sounds (heart murmurs)
24
Q
Tanner’s Clinical Judgement Model
A
- Noticing
- Interpreting
- Responding
- Reflecting
25
Clinical Judgment
Interpreting clients needs, wishes, and challenges and using previous knowledge, experience, ethical belifs, critical thinking to determine actions that would provide best care
26
family- Potter & Perry
set of relationships/ network of indiviuals who influence each others lives
27
family- Vanier Institute
two/ more people who are bound together by mutal ties of consent, birth/ adoption, and share the following future obligations:
1. care/ support of family members
2. addition to family through procreation/ adoption
3. socialization of children
4. love & nurture
28
T or F: family is whoever the patient says it is
true
- have to consider how other people view family and how your own biases/ belifs about family may impact the care you provide
29
how are families changing?
- aging population: "sandwiched" generation
- increased diversity in families (cultural blending, interacial families, same- sex couples)
- gender roles in families have changed due to social, political, economic factors
- nuclear family on decline
- multigeneritational households
- more single parent households
- more lone person households
- more couples not having kids
30
characteritics of healthy families
- incorporate the need for stability for growth and change
- show hardiness and resiliance in coping
- influence their enviornment
- act as a cohesive unit
- flexible
- willing to accept outside help
31
how does family influence health
- views on health and lifestyle behaviours (what was normalized in your family is what your normalize)
- generational views on health and healthcare are passed down
- relationships in healthcare settings (ex. mom with sick child)
- embedded in SDOH (housing, socioeconomic status)
32
what makes up a community?
- people (members of community)
- place (geographic location)
- function (collective interest/ purpose)
33
characteristics of healthy community
- supportive
- lies on stable economy
- safe
- has sustainable resources
- access to social services (health care, education)
- celebrates culture & history
- adequate housing
- acts as cohesive unit
34
what are routine practices
IPAC practices that are followed with every patient in every health care setting
35
chain of transmission
1. infectious agent
2. resevoir
3. portal of exit
4. mode of transmission
5. portal of entry
6. susceptiable host
36
infectious agent
virus, bacteria, fungi- any microorganism that can make somebody sick
37
resevoir
where infectious agents live
| -people, animals, food, water, surfaces, equipment
38
portal of exit
how infectious agent leaves resevoir
- bodily openings (mouth, vagina, urethra, skin)
- bodily fluids (blood, mucus, excretions)
- open wounds (lesions, surgical wounds, cuts)
39
mode of transmission
how infectious agents spread from one host to another
- contact
- airborne (droplets)
- vectors (mosquitoes)
40
portal of entry
how infectious agent enters new host
- sex
- respiratory tract
- GI tract
- mucous membrane (eyes, ears, mouth)
- broken skin
- artifical openings
- contaminated food/ instruments
41
susceptible host
people who can get infections easily
| -old people, babies, immunocomprimised people
42
whats the best way to break the chain of transmission?
handwashing
43
whats the most important part about proper handwashing
friction
44
why is understanding growth and development important?
- allows you to be able to understand & recognize normal
| - allows nurses to promote health oppurtunities and provide indiviualized care
45
is growth quantitative or qualitative
quantitative- easily measured
46
T or F: development is quantitative
False, development is qualitative (not easily measured) and looks different in different indiviuals
47
what influences growth & development
- family: if you recieved love and nurture growing up
- socioeconomic status
- quality and accessibility to health care
- nutrition
- genetics
- childhood trauma
- choices mothers make during pregnancy (ex. drug use, drinking)
48
Erikson's Developmental Theory
- 8 stages covering lifespan that include differenet psychosocial tasks
- indiviual must move onto next stage even if tasks in previous one have not been completed
49
Trust vs. Mistrust
Stage 1: infancy to 18 months
| - gaining trust in people around me
50
Autonomy vs Shame & Doubt
Stage 2: infancy- 3 years
| -how can I control myself?
51
Initative vs Guilt
Stage 3: 2- 5 years
| -how do I control myself in my enviornment?
52
Industry vs Inferiority
Stage 4: 5- 13 years
| - learning skills necessary to survive and be successful in life
53
Identity vs Role confusion
Stage 5: 13- 21 years
- where do I belong in the world?
- what is my purpose?
- finding out/ exploring who you are
54
Intimacy vs Isolation
Stage 6: 21- 39 years
| - looking to partner up, form meaningful connections, and start families
55
Generavitity vs Stagnation
Stage 5: 39- 65 years
- giving back to community, younger generations
- nurturing all the other stages
56
Ego Integrity vs Despair
Stage 6: 65+
| -looking back on life and feeling fulfillment/ regret
57
Piaget's Development Theory
- 4 stages: infancy- 18
- indiviual must complete tasks in previous stage to move onto next stage
- using previous experiences to move stages
58
Stage 1: infancy- 2 years
Sosiomotor stage
- exploring the world using sensory and motor skills
- object permanance and seperation anxiety
59
Stage 2: 2- 6 years
Preoperational Stage
- able to use symbols (words and images) to represent objects
- doesn't reason logically
- child is still egocentric
- develops ability to pretend
60
Stage 3: 7-12 years
Concrete operational stage
- develops ability to think logically
- understands conversation
61
Stage 4: 12- 18 years
Formal operational stage
| -develops ability to think abstractally and hypothetically
62
Infancy (0-1 years) growth & development
- weight gain & grow in lenght
- hold head up at 2 months
- roll over at 4-5
- crawl and babble at 9 months
63
assessing infants
- reliant on caregiver for information
- observe child- caregiver intercations, note strenghts & challenges, and offer advice/ help
- no head to toe: just assess as quick as possible & whatever is necessary
- least to most invasive so baby doesn't get fussy
64
Early childhood (1-3 years) growth & development
```
Growth:
-exponential growth
-baby teeth grow in
Development:
- 2-3 word sentances
- potty training
- fine & gross motor skills develop
- more control over motor skills (running, jumping, skipping)
```
65
assessing early childhood
- still reliant on caregiver
- scared of HCP
- show them what you're doing on a teddy bear, parent, yourself
- let them see & touch things that aren't dangerous
- incorporate play & be creative
66
Late childhood (3-6 years) growth & development
- psychosocial tasks: creating relationships (friends at pre- school)
- want for privacy: become more self- aware
- know when its appropriate/ not appropriate to do things like go to the bathroom
67
considerations late childhood
- constipation: become self- aware might be embarassed to use bathroom at school
68
assessing late childhood
- involve them in assessment
- explain what you're doing
- don't lie to them
69
School age (6-11 years) growth & development
Growth:
- weight gain and growth
- skeletal growth happens before muscle growth: lanky
Developmental:
- fine motor skills (shoe tying, playing instruments)
- peers at school have big influence on them
- begin to understand discipline, boundaries, consequences
- begin teaching them about healthy lifestyle choices
- increased body- awarness: increased need for privacy
70
assessing school aged
- can begin to rely on them more for information and less on caregivers
- involve them in assessment
71
Adolescents (12- 18 years) growth & development
Growth:
- growth spurts
- weight gain
- puberty
- sex specific changes
Development:
- independce
- begin exploring relationships
- impulsivness
- risk taking
- big need for privacy
- begin exploring sexuality
- peers and belonging are important
72
considerations adolescents
- mental health issues
| - promoting safe sex
73
assessing adolescents
- privacy and confidentiality is particularly important
- rely primairly on them for information
- don't avoid important questions because they're uncomfortable topics
74
Young adults (18- 35 years)growth & development
Growth:
-bodily systems continue growing and developing to fit adult body size
Development:
- forming interdependence on another person
- finding purpose to make life meaningful
- starting families
- building foundations for good health
75
assessing young adults
- prevention of chronic illness
| - health promotion for healthy behaviours and lifestyle choices
76
Middle age (35-65 years) growth & development
Growth:
- aging (hair, skin changes)
- metabolism slows
Development:
- mental health/ self-image changes
- role changes (children moving out of home)
- life reflection
77
assessing middle age
- screening for and preventing chronic illness
- promote sense of fulfillment by giving back to community\
- Osteoperosis screenings at 65
- Mamograms at 50
78
Older people (65+) growth & development
Growth:
- body systems age
- immune system diminishes
- more health complications
- impaired cognition is NOT a normal sign of aging
Development:
- loss of autonomy/ independence
- loss of role
- reflecting upon life
- dealing with loss of spouse/ friends/ family
- isolation/ loneliness
79
assessing older people
- hearing impaired: speak slowly, loudly, clearly
- if completley deaf position yourself so they can lip read/ write things down
- vision impaired: explain your actions so you don't startle them & provide therapeutic touch
- if cognitively sharp speak to them in assessment, rely on caregiver if cognitive issues are present
80
ineffective communication consequences
- poor patient outcomes
- misscommunications regarding patient needs, health status, and plan of care
- decreased professional credibility
- increased adverse incidents
81
therapeutic interviewing
interviewing with specific purpose with focus on specific content area
82
active listening
finding meaning behind patients words by noticing non- verbal cues, emotions, word choice, and being fully present in conversation
83
subjective data
what patient tell you
84
objective data
data you collect by assessing (ASEPTIC, physical assessment, vital signs)
85
comprehensive assessment
- head to toe
- pre-op
- admission
- non- emergant situations
- seeing patient for first time
86
focused assessment
only assessing body systems releated to symptoms
87
emergent assessment
- emergency situations
| - only focusing on assessing what is necessary
88
purpose of health history
to collect subjective data
89
components of health history
- demographics (age, sex, gender)
- past medical history
- family history
- surgical history
- medications
- allergies
- reason for seeking care
- sexual history/ sexuality (if relevant)
- human violence history (if relevant)
- lifestyle
- related symptoms
90
what is OLDCARTSS?
```
-used for collecting health history
O: onset
L: location
D: duration
C: character
A: alleviating/ aggrevating factors
R: radiation
T: timing
S: severity
S: self- perception
```
91
Privacy
patients right to decide how their information is collected, used, and disclosed
-about patient
92
Confidentiality
About information
| -includes spoken information and written (charting, records, files, etc.)
93
circle of care
people directly caring for patient who have the right to confidential information
94
personal health information
identifying information about clients
- name, age
- past medical history
- eligibility for health care/ payment
- body part/ substance donation
- health card number
- name of patients substitue decision maker
95
T or F: healthcare facilities own personal health information
False
| -patient owns this info but it is safeguarded in health care facilities
96
T or F: domestic violence can be reported without patient consent
False
97
T or F: child abuse can be reported without consulting patient
True
98
When can elderly abuse be reported?
Only when it occurs in health care facilities (LTC, hospital, retirement centre)
99
T or F: you should immedietly share patient information with the police when asked to do so
False
| -need to follow process to obtain information on patient
100
T or F: Illicit drug use can not be reported
True
101
T or F: Suicidal ideations can be shared if the person is a danger to themselves/ others
True
102
T or F: You are concerned with a seniors eligibility to drive; you allowed to voice your concerns to somone outside of the circle of care
True
| -driving concerns can always be reported as they are a public threat
103
Why do we document?
- communicate patient needs/ health status
- communicate changes in health status
- communicate care plan
- quality assurance
104
good documentation is:
```
factual (avoid using generalized terms)
accurate
conscise
clear
organized
relevant
complete
```
105
What to do if you make a mistake when charting?:
A) erase it/ white it out
B)draw a line through the mistake and inital
C) start all over again
D) leave it and hope no one notices
B
106
What do we do with blank spaces on notes?
Draw a line through them so no one can add to your entry
107
What do soap notes have to include?
Time in milatary time
Date
Title
Bottom right: first inital, last, designation
108
SOAP
S- subjective
O- objective (ASEPTIC)
A- problem/ diagnosis
P- plan/ next steps
109
T or F: You can have good mental health while having mental illness?
True
110
T or F: The absence of mental illness= good mental health
False, you can have poor mental health w/o having mental illness- mental health is a continum
111
Normal adult HR
60-100 BPM
112
Normal adult BP
120/80 mmHg
113
Normal adult RR
12- 20
114
Normal O2 saturation
92- 98%
115
Normal temp range- oral
36.5- 37.5
116
Temp range- axillary
35.9- 37.2
117
Temp range- tympanic
36.0- 37.5
118
Temp range- temporal
36.5- 37.5
119
Bradycardia
Slower than usual heart beat
120
Tachycardia
faster than usual heart beat
121
asystole
no heart beat
122
arrhythmia
extra heart beat
123
factors that increase HR
- exercise
- cardiac/ respiratory illness
- gender (female)
- age (younger)
- pain
- fever
- stress
- hemorrhaging
- meds
124
Apical pulse
- apex of the heart
- located between 4th and 5th intercoastal space mid-lateral line (between 4th/ 5th rib)
- under left nipple (right where bra band is for women)
125
when do we listen for apical pulse
- having trouble hearing radial pulse
- children under 2
- when unusual findings are found at radial pulse
- when we want to double check
126
how to listen for pulse- if regular
count "dub" sounds for 30 seconds- multiply by 2
127
how to listen for pulse- if irregular
go to apical pulse listen for full 60 secs
128
hypertension
high BP
| - 140/90
129
hypotension
low BP
| -90/60
130
orthostatic BP
dramatic changes in BP from changing positions
131
pulse preassure
difference in systolic and diastolic BP
- usually around 40
- not a good sign if increasing
132
factors that increase BP
- age
- gender (men)
- chronic conditions
- stress
- medications
- higher in the morning
133
Febrile
Has fever
134
Afebrile
no fever
135
pyrogen
something that causes fever
136
antipyretic
something that alleivates fever (tylenol, advil)
137
diaphoresis
sweating
138
diaphoretic
act of sweating
139
rigors
shivering caused by fever
140
hypothermia
body temp below 35
141
hyperthermia
body temp above 38
142
bradypnea
slow breathing
143
tachypnea
fast breathing
144
dyspnea
difficulty breathing
145
apnea
absence of breath
146
factors that increase RR
- age (younger= faster RR)
- exercise
- smoking
- anxiety
- hypothermia
- medical conditions (ex. anemia)
147
factors that decrease HR
- medications (opiods)
| - upright body position
148
what is oxygen saturation
indirect measurement of oxygen in blood
149
normal oxygen saturation
92- 98%
150
psychiatric nursing vs mental health nursing
you can specialize in psychiatric nursing but mental health nursing is a part of every speciality of nursing
151
Major mental disorders in Canada
- Anxiety
- Mood disorders
- Personality disorders
- Addicition
- Self harm
- Schizophrenia
152
3 D's of mental health
1. disability
2. duration
3. distress
153
7 characteristics of good mental health
1. interpret reality correctly
2. have ability to control your own behaviour
3. have a healthy self- concept
4. find a sense of meaning/ purpose in life
5. have ability to relate to others
6. have ability to cope/ adapt with change & challenges
7. demonstrate creativity/ productivity
154
DSM-V
book used to diagnosis mental disorders
| -standard set of criteria so people aren't uneccessairly diagnosed with mental illness
155
components of mental health history
- personal health history
- family history
- medications
- suicidal ideations
- violence/ trauma
- substance abuse
- mood
- hallucinations/ psychosis
156
structual stigma
limitations/ restrictions on a population scale (ex. policies) that disadvantage mentally ill people
157
social stigma
stigmatization of mentally ill people in society
| -leads to higher levels of illness, incarcination, unemployment of mentally ill people
158
self- stigma
internalization of stigma and negative comments, feelings, thoughts
159
3 pillars of recovery
1. choice
2. community
3. integration
160
principals of recovery
1. fostering hope
2. enabling choice
3. encouraging responsability
4. promoting dignity and respect
161
normal cognitive changes
- processes become slower
- may take longer to process new info
- slight decline in short term memory
- long term memory & decision making abilities should remain in-tact
162
atypical cognitive changes
- personality changes
- no recall of recent events
- confusion
- dementia
- lack of insight
- impaired judgement
163
3 D's of cognitive decline in elderly
1. Dementia
2. Delerium
3. Depression
164
ADLs
Activities of daily living
| - basic functions (bathing, eating, dressing yourself)
165
IADLs
Instrumental activities of daily living
| -executive functions (cleaning, cooking, grocery shopping)
166
T or F: Dementia is reversible and has a definite pathological/ emotional cause
False
- deleium is reversible and has a cause
- dementia is irreverisble and progresses in a step-like manner
167
T or F: Delerium, dementia, and depression can coexist
True
168
Cognition screening tools
Mini- Mental State Exam (MMSE)
3- min mini cog
MOCA
169
What do you need to score on MMSE to be diagnosed with dementia
below 27
- 20 to 26 is mild dementia
- 10 to 19 is moderate dementia
- below 10 is severe dementia
170
when to screen for dementia
- over 80 yrs old
- after a stroke
- after head trauma
- if indications of cognitive decline are present
- after treatment for delerium/ depression
171
components of cognitive assessment
- medical history
- family history
- review of ADLs & IADLs
- meds
- lab results
- head scans
- functional ability
- related symptoms
- onset
- mood
- hallucinations/ psychosis?
- cognitive screening
- substance abuse
172
When communicating with someone with cognitive impairment:
- repeat instructions if not understood
- sit directly in front of them where they can see you and hear you
- be patient
- don't argue with them
- limit enviormental stimuli
- simple instructions
173
Risks for people with cognitive impairment:
- hygeine
- nutrition
- abuse
- targeted scams
- fires
- driving
- wandering/ getting lost
174
What does the body use proteins for
Muscle growth & repair
175
What does the body use carbs for
energy
176
What does the body uses fats for
insulation/ protection
177
factors influencing nutrition
- medications
- family
- lifestyle choices
- socioeconomic status
- geographical location
- education
- culture
- religion
- ability to go get food
178
infant nutrition recommedations
- breast is best
- vitamin D supplements
- introduction of solid food at 6 months
- whole dairy (fat for brain development)
179
pregnancy nutrition recommedations
- prenatal supplements
- folic acid to prevent neural tube defects
- iron to provide oxygen to baby through RBC
- calcium to promote healthy bones & gums
180
early childhood nutrition recommedations
- transition from breast milk to actual meals
| - introducing a variety of new foods
181
teen nutrition recommedations
- require more protein due to rapid growth
| - SCOFF questionnaire: eating disorder screening
182
nutrition screening tools
SCOFF questionnaire: eating disorders
24- hour food recall
Food diary
Nutrition questionnaires
183
what makes up the integumentary system
hair, skin, nails, sweat glands
184
why is assessing the integumentary system important
reflects the patient's hydration, nutrition, and emotional status
185
risk factors for integumentary system
Vitamin/ mineral deficiency
UV exposure
Preassure ulcers
Infectious diseases
186
health promotion integumentary assessment
- edcuate patients on difference between cancerous and non- cancerous moles
- emphasize steps in skin self- examination
- importance of protection from UV rays (limiting exposure, wearing sunscreen, etc.)
- ABCDE's of skin cancer
187
what is the most common skin disease
melanoma (skin cancer)
188
ABCDE's of melanoma
```
A: asymmetry
B: border
C: colour
D: diameter
E: evolution
```
189
Vesicle
- fluid filled
- blister
- on top of skin
- ex: chicken pox
190
Pustule
- puss filled
- generally raised
- on top of skin
- ex: acne
191
cyst
- under the skin
- can be fluid filled, puss filled, cell- filled, infection filled
- ex: cystic acne
192
Macule
- flat
- less than 1cm in diameter
- ex) freckles
193
Papule
- raised
- less than 1cm in diameter
- ex) insect bite
194
Wheal
- slighty raised
- varies in size and shape
- can be flesh coloured/ red
- ex) rash
195
Scar
-replacement of skin during healing
196
Excoriation
- lesion from scartching
| - ex) cat scratches
197
Ulcers
- loss of skin surface that can extend to dermis
| - ex) preassure ulcers
198
what are secondary lesions
lesions resulting from primary lesions
199
preassure ulcers
breaks in skin caused by extended periods of time where preassure is being put on one area of the body and oxygen, nutrients, circulation are unable to reach it
-usually in boney prominances (elbows, hells, skull)
200
how to prevent preassure ulcers
-frequent repositioning
201
Rule of 9's
-used to estimate how much tissue is affected in people who have suffered burns
202
when describing lesions include:
- colour
- texture
- shape
- borders
- fluid/ solid/ semi-solid
- surface/ under the surface
- location
- morphology
- distribution (localized, regional, generalized)
- size
203
Jaundice
yellow tint to skin
| -may indicate liver disease
204
edema
swelling
205
erythema
redness
206
cyanosis
blue tint to skin
| -indicates deoxygenation
207
pallor
paleness
| -may indicate anemia
208
phototoxicity
drug toxicity resulting from medication
209
photosensitivity
redness/ blistering resulting from medication
