HAP Midterm Flashcards
1
Q
“Normal” oral temperature is
A
35.8º C – 37.3º C (96.4º F – 99.1º F)
2
Q
Vital signs
A
- temperature
- pulse
- respirations
- o2 sat
- blood pressure
- pain
3
Q
Normal pulse rate
A
60-100 beats per minute
4
Q
Pulse
A
Assess rate, rhythm, and force
Rhythm- if regular count for 30 seconds (irregular 1 minute)
Force- 0-4+
5
Q
Respirations
A
Normal adult is 12-20 respirations per minute
Count for 30 seconds and multiply by 2
If irregular, count for a full minute
Also assess depth and effort of breathing
6
Q
Falsely high blood pressure reading
A
Falsely high Person is anxious, angry, just exercised Arm below heart level Supporting own arm Legs crossed Improper cuff size (too small) Deflate too slowly, re-inflate too soon
7
Q
Abnormal 02 saturation
A
Below 90% requires further evaluation
8
Q
Urgent assessment
A
Altered LOC Pulse 120 /minute Systolic BP 170 Diastolic BP > 100 New onset CP Acute significant change from patient’s baseline Sudden increase in respiratory effort needed Respirations 28 /minute Pulse oximetry
9
Q
Pain
A
THE FIFTH VITAL SIGN
Pain is always subjective
Pain is whatever the experiencing person says it is, existing whenever he or she says it does
Cannot base diagnosis of pain exclusively on physical examination findings, although these findings can lend support
Subjective report is most reliable indicator of pain
10
Q
Pain in older adults
A
May have multiple health problems associated with pain
Changes in Functional status may be the presenting behavioral cue of pain
Fear of dependency, further testing or invasive procedures, may impact reporting of pain
During interview establish an empathic and caring rapport to gain trust.
11
Q
Normal Rectal Temperature
A
Rectal temperature is 0.5º C (1.0º F) higher than temporal temp
12
Q
Tachypnea
A
Fast shallow breathing
13
Q
Bradypnea
A
Slow deep breathing `
14
Q
Hyperventilation
A
Fast and deep breathing
15
Q
Hypoventilation
A
Slow and shallow breathing
16
Q
Cheyne-Stokes
A
Sleep apnea then followed by gradual increase and decrease in breathing.
17
Q
COPD
A
longer expiratory phase than inspiratory phase due to air trapping.
18
Q
Culture
A
All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview
19
Q
Ethnicity
A
Social group within a cultural and social system that shares common cultural and social heritage that includes:
•Language, history, lifestyle, religion, or all of these
20
Q
Race
A
is genetic in origin and includes physical characteristics:
•Skin color, bone structure, eye color, and hair color
Individuals from the same racial group are not necessarily from the same culture
21
Q
Religion
A
an organized system of beliefs, rituals, and practices in which an individual participates
22
Q
Spirituality
A
Broader concept that influences interpersonal behaviors and expectations
23
Q
Health
A
Specific to individual and based on experience, upbringing, race/ethnicity, sex, gender identity
24
Q
Biomedical health
A
Absence of diseases
25
Holistic health
the view that the mind, body, and spirit are interdependent and function as a whole within the environment
26
Wellness
“a dynamic process and view of health; a move toward optimal functioning”
A “positive” state of health
27
Health definition
state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity”
28
Role of the professional nurse
* To promote health
* To prevent illness
* To treat human responses to health or illness
* To advocate for individuals, families, communities, and populations
29
Health assessment
Health assessment is a systematic method of collecting and analyzing data
30
Benefits to the nursing process
* Diagnose both actual and potential problems
* Provide a blueprint or plan for patient care
* Systematic
* Dynamic
* Humanistic
* Outcome-focused
31
Primary components of the nursing assessment
```
Health history (subjective data)
•Physical assessment (objective data)
•Other factors
•Psychological, sociocultural, spiritual, economic, lifestyle
•Documentation of data
```
32
Subjective data
Symptoms, history
•Information the patient (or the patient’s family or significant other) tells you
•“I have a headache”
•“My husband says he has a headache
33
Objective information
(signs, physical examination)
•The findings resulting from direct observation using all of your senses (sight, sound, touch, smell)
•Uses techniques of inspection, palpation, percussion, and auscultation
•BP 122/68
•Patient is restless
•WBC 12,000
•Lungs crackles bilaterally
34
Documentation
* Improves plan of care
* Legal document of patient’s health status
* Baseline for
* Evaluation
* Changes and decisions related to
35
Types of assessment
```
Emergency assessment
•Comprehensive health assessment
•Problem-based or focused health assessment
•Episodic assessment
•Shift assessment
•Screening assessment
```
36
Basic critical thinking
Concrete and based on a set of rules; early step in developing reasoning; not enough experience to individualize; weak competencies
37
Complex critical thinking
Analyze and examine choices independently; look beyond expert opinion; thinkers separate self from experts; each solution has benefits and risks
38
Priorities in the assessment
High: life- threatening, or if high concern to patient
| Prioritize patient assessment and care based on clinical experience, knowledge, expertise, and judgement
39
Data organization
Organization and clustering of data
•Allows problems to be more clearly apparent
•Can be based on body system format:
•Cardiovascular, musculoskeletal, etc.
•Can be based on conceptual format:
•Oxygenation, perfusion, mobility
40
Data analysis
Identifying abnormal findings
•Correctly interpreting findings to select appropriate plan of care
•Applying clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems
•After understanding the situation, the nurse responds by determining appropriate interventions
41
Diagnosis
```
Interpret Data
•Identify clusters of cues
•Make inferences
•Validate inferences
•Compare clusters of cues with definitions and defining characteristics
•Identify related factors
•Document the diagnosis
```
42
Format of the nursing diagnosis
PES: P r/t E aeb S
P is for the problem
•E is for the etiology or medical diagnosis (may have a secondary etiology)
•S is for the defining characteristics (signs and symptoms)
43
Medical diagnosis
Disease condition based on specific evaluation of signs and symptoms
44
Nursing diagnosis
Judgment about the patient in response to an actual or potential health problem
45
Collaborative diagnosis
An actual or potential physiological complication that nurses monitor to detect the onset of changes in patient’s status
46
Potential risk nursing diagnosis
Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community
47
Actual nursing diagnosis
Describes human responses to health conditions or life processes that exist in an individual, family, or community
48
Wellness nursing diagnosis
Describes human responses to levels of wellness in an individual, family, or community
49
Health promotion
Behavior motivated by desire to increase well-being and actualize health potential
50
Health protection
Disease prevention
51
Health promotion/ protection
Central component of nursing
•Begins with health assessment—data to identify patient’s health status, practices, and risk factors
•Interpretation of data allows the nurse to target health promotion needs
52
Primary prevention
Optimize health and disease prevention through promotion of healthy lifestyles
53
Secondary prevention
Identify at an early stage to initiate prompt treatment; screening efforts
54
Tertiary prevention
Minimizing the effects of the disease or illness and allowing for the most productive life within limitations
55
Healthy people 2020
* Objectives address most significant preventable threats to health, with goals to reduce threats
* Four overarching goals:
* Attain high quality, longer lives, free from preventable diseases
* Achieve health equity, eliminate disparities, and improve the health of all groups
* Create social and physical environments that promote health for all
* Promote quality of life, healthy development, and healthy behaviors across all life stages
56
Order of assessment
```
Inspection
Palpating
Percussion
Direct
Indirect
```
57
Order of ABDOMINAL assessment
Inspect
Auscultation
Percussion
Palpating
58
Inspection
Observation with eyes as soon as patient is seen
| Breathing rate, color, rate of speech, body position, alertness
59
Palpating
```
Use sense of touch
Temperature- back of hands
Moisture
organ size and location (requires deep palpation)
Swelling
Vibration (base of fingers/ ulnar surface)
Consistency
Pulse
Crepetation
Lumps/ masses
```
60
Percussion
Mapping out location and size of organ, signaling density in order to detect abnormal masses/ fluids/ tenderness, and elicit deep tendon reflexes
61
Indirect percussion
Non- dominant is used as a sound board and dominate hand makes noise. Tap on distal portion of middle finger with dominant hand
62
Direct palpation
Tapping directly on patient that is done in only 2 places: sinuses or costoveterbral angle- on the back behind the kidney to determine tenderness of inflammation
63
Resonant quality
Clear, hollow due to air
64
Resonant location
Normal lung tissue
65
Hyper-resonant quality
Booming
66
Hyper-resonant location
Abnormal lung tissue (barrel chested due to hyperinflation of lung)
Normal child lung
67
Tympany quality
Musical and drum like
68
Tympany Location
Air filled viscus (stomach, intestine)
69
Dull quality
Muffled thud
70
Dull location
```
Dense organ (liver, spleen)
Abnormal tissue
```
71
Flat quality
Dullness
72
Flat location
Large muscle (thigh), bone, tumor
73
Physical appearance
| Definition
How does the patient look?
- Overall
- hygiene, dress
- sexual development
- LOC, A&0
- speech pattern, rate, volume
- skin color
- facial appearance
74
Physical appearance: normal
```
Appears stated age
Facial features, body, and movement are symmetrical
Well groomed
Clean clothing
Sexual development appropriate
Even tone
No lesions
Skin normal for ethnicity
No distress
```
75
Physical appearance ABNORMAL
Pallor
Cyanosis
Jaundice
Mask like (no facial expressions, Parkinson's)
Facial drooping (stroke)
Grimacing
Appears older than stated age
Disheveled
Malordorous
Ill fitting clothes/ loud wild clothes and make up
Delayed or early puberty in pre teens and teens
76
Body structure definition
Length, width, Height of body parts
Nutrition
Symmetry
Posture
77
Normal body structure
```
Normal range for age, gender, genetic heritage
Height should be the same as wingspan
Normal weigh to height
Pubis to ground same as ground to pubis
Even body and fat distribution
Equally proportional bilaterally
Erect posture
```
78
Abnormal body structure
```
Dwarfism
Gigantism
Conjoplastic dwarfism (prevents patient from turning cartilage into bone)
Cache is
Anorexia nervousa
Cushing syndrome
Obesity
Lordosis
Kyphosis
Scoliosis
Tripod position
Marian syndrome
Webbed digits
Polydactly (extra digits)
Atrophy or hypertrophy
```
79
Mobility
How well patient moves, walks and their gait, ROM
| ** think safety and risk of falls**
80
Mobility normal
Shoulder- width base
Proper arm swing, smooth, even, balanced
Smooth coordinated ROM
No involuntary movements
81
ABNORMAL mobility
```
Shuffling
Wide base
Dragging
Limping
Stooped over and leaning
Tremors, jerky
Limited movement
Stiff
Uncoordinated
Tics
Paralysis
```
82
OLD CARTS
```
Onset
Location
Duration
Character
Aggravating/ alleviating factors
Related symptoms
Time
Severity (0-10)
```
83
Cranial nerve 1
Sense of smell/ olfactory
84
Cranial nerve II
Vision/ olifactory
85
Cranial nerves III, IV, VI
Ocular motor
Trochlear and abducens
PERRLA
86
Cranial nerve V
Trigeminal nerve, TMJ,
| Light tough on cheek
87
Cranial nerve VII
Facial movements,
have patient smile, frown, lift up eyebrows
88
Cranial nerve VIII
Acoustic or vistbulochochlear
| Whisper voice test- if 2 words missed further assessment needed
89
Cranial nerve IX and X
GLASSOPHARYNGEAL AND VAGUS NERVES
Depress tongue with depressor and say "ahh"
90
Cranial nerve XI
Spinal/ accessory nerve
Motor
Head movement from side to side and shoulder shrug
91
Cranial nerve XII
HYPOGLOSSAL, MOTOR
Voice, speech, movement
Stick out tongue and say "light, tight, dynamite"
