NSG 200 test #1 Flashcards
(127 cards)
1
Q
why is health promotion important
A
Improves the health status of individuals, families, communities, states, and the nation.
Enhances the quality of life for all people.
Reduces premature deaths.
Reduces costs
2
Q
the nurses role in health promotion
A
Get the patient involved
Educate/Teaching
Strategies to improving health:
Improve nutrition
Exercise
Manage stress
Understanding disease process
Identify Unhealthy habits
Smoking, excessive ETOH use, other drugs use
3
Q
health promotion in pregnancies
A
Taking prenatal vitamins/folic acid
Talking to your healthcare provider about current medications
Avoiding alcohol and other drugs
Healthy diet
Exercise
Limiting caffeine
4
Q
health promotion in infancy
A
Bonding
Breast feeding
Sleep patterns
Playful/stimulating activity (developmental stages)
IMMUNIZATIONS
Safety
5
Q
health promotion in children and adolescents
A
Nutrition
Dental Checkups
Exercise
Immunizations
Safety
Peer influences
Body Image
Sexuality
Safety promotion and accidental prevention
6
Q
health promotion in the elderly
A
Nutrition
Dental Checkups
Exercise
Immunizations
Safety
Safety promotion and accidental prevention
falls
restful sleep
7
Q
modifiable risk factors
A
smoking, diabetes, high bp, nutrition, exercise, high cholesterol
8
Q
nonmodifiable risk factors
A
ethnicity, age, gender, family history
9
Q
primary prevention
A
when you are preventing disease, condition, or injury
10
Q
secondary prevention
A
early detection of a potential of a disease before it begins
measuring blood pressure, newborn screening, mammography
11
Q
tertiary prevention
A
treating a disease already present, to defeat its affects and progress
physical therapy, stroke rehab, diabetic treatment, chemo therapy
12
Q
healthy people 2020 determinants
A
health services, biology and genetics, individual environment, social environment, physical environment
13
Q
risks of smoking in pregnancy
A
Risks of Smoking
Birth defects
Premature birth
SIDS
Respiratory issues (both mother and baby)
Infertility issues
Bleeding
14
Q
bad diet and pregnancy
A
Lack key nutrients (both overweight and underweight)
Low birth weight
Obesity (mother & baby)
Diabetes ( mother & baby)
Cardiac disease
Hypertension
Constipation
15
Q
what vitamins should pregnant women be encouraged to take?
A
Folic acid and prenatels
16
Q
risks of children and adolescents smoking
A
More addictive
Affect brain development
Lung impairment-asthma
Decreased physical fitness
Mental health issues
Peer pressure
17
Q
poor diet and exercise in children and adolescents
A
Underweight/overweight
Dental problems
Constipation
Type 2 diabetes
18
Q
older adults risks of smoking
A
Cancer
Diabetes
Cardiovascular disease
Lung disease
19
Q
poor diet and exercise in the elderly
A
Type 2 diabetes
Heart disease
High cholesterol
Osteoporosis
Cancer
Falls
20
Q
common side effects of vaccines
A
Mild swelling & tenderness at the site (can apply a warm or cool compress)
Low grade fever
Mild fatigue
Decreased appetite
Mild headache
Muscle or joint aches
Irritability in children
21
Q
active natural immunity
A
immunity occurs after getting sick or an infection
22
Q
artificial active immunity
A
immunity from a vaccine
23
Q
natural passive immunity
A
Immunity passed on the child from the mother and breastmilk
24
Q
explain the contraindications of live vaccines
A
it is compromised in the immunocompromised such as pregnant women, chemo patients, or radiation.
25
live vaccines
MMR, VAR, HZV, live attenuated flu vaccine
26
contraindications in the live influenza vaccine
egg allergy or guillian barre syndrome
27
gelatin or neomycin allergy
MMR, VRE, HZV
28
phases of the nursing process
Assessment
Diagnosis
Planning
Implementation
Evaluation
29
collecting subjective data
A complete health History
Biographical data
Reasons why they are seeking medical attention
Present health concern
Personal Health History
Family Health History
Review of systems for current health problem (subjective data)
Lifestyle and health practices
description of pain
30
collecting objective data
HR, pulse, respirations, pulse ox, appearance, dress, hygiene, behavior, mood, physical charecteristics, skin color, posture
31
the 4 assessment techniques
inspection, palpation, percussion, auscultation.
32
health history
biographical data
reasons for seeking health care
history of present health concern
past health history
family health history
review of systems
lifestyle and health practices
developmental health
33
COLDSPA
Character, Onset, Locations, Duration, Pattern, Associated factors
34
types of assessment
initial comprehensive assessment, ongoing or partial assessment, focused problem oriented, emergency assessment
35
initial comprehensive assessment
Collection of data about the client’s perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices.
36
ongoing partial assessment
Utilized when focusing on a certain complaint identified in a comprehensive assessment, after the comprehensive data has been established
37
focused/problem oriented assessment
Thorough assessment of a particular client problem, which does not cover areas not related to the problem
38
emergency assessment
Very rapid assessment performed in life-threatening situations.
39
client approach and preparation
Establish nurse–client relationship.
Explain the procedure and the physical assessment that will follow, describing the steps of the examination.
Respect client’s requests and desires.
Explain the importance of the examination.
Leave room while client changes clothes.
Provide necessary container in case of need for sample.
Begin exam with less intrusive procedures.
Explain procedure being performed.
Explain to client why position changes are necessary.
40
pre-introductory phase
In the preintroductory phase the nurse reviews the medical record which may reveal the client's past health history and reason for seeking health care before meeting with the client to assist with conducting the interview.
41
phases of the interview
pre-intorductory
introductory
working
closing
42
normal blood sugar
70-110
43
introductory phase
Introduction of yourself
Explaining the purpose of the interview
Discussing the types of questions that will be asked
Explaining the reason for taking notes
Assuring the client that confidential information will remain confidential
Making sure that the client is comfortable and has privacy
Developing trust and rapport using verbal and nonverbal skills
44
working phase
Collaborating with the client to identify the client’s problems and goals
Listening, observing cues, and using critical thinking skills to interpret and validate information received from the client
Lifestyle and health practices and developmental level
Review of body systems for current health problems
Family history
Past health history
biographical data
History of present health concern
reason for seeking healthcare
45
vaccine recommendations for pregnant women
Tdap 27-36 weeks, flu vaccines, covid vaccines
46
nonverbal communication
Nonverbal Communication
Appearance
Demeanor
Facial Expressions
Attitude
Silence
Listening
47
verbal communication
Verbal Communication
Open-ended questions
Closed-ended questions
Laundry List
Rephrasing
Well-placed phrases
Interfering
Providing Information
48
documentation
Outlines the client’s course of care
Makes accessing this information more easy- for healthcare works, patients and families.
Helps determine eligibility for health reimbursements
Offers a basis for determining the educational needs of the client, family and SO’s
Permanent legal record
49
what vaccine do 12-15 year olds need
Human paploma virus
50
SBAR
S SITUATION: A concise statement of the problem or what is going on now. “Kelly is a 24 year old female who is experiencing sudden onset of headache.”
B Background: Describe events leading up to the situation. “Patient woke up in the middle of the night at 3:00am with the headache. No other complaints prior to that.”
A Assessment: State the subjective and objective data you have collected. “Patient rates pain a 7 on 1-10 scale. Has vomited 3-4 times and continues with nausea. Unable to eat or drink anything. She is lying face down holding her head. She is awake, alert and oriented but does not want to communicate.” Continue on with assessment findings…..
R Recommendation: Suggest what you believe needs to be done for the patient based on your assessment. “Have the physician come see the patient to re-evaluate? Transfer the patient to ICU? Recheck potassium level in 2 hours?” Be specific about patient needs.
51
ages over 65nshould recieve what vaccines
Covid, flu, pneumonia, shingles
52
examination techniques for ABDOMINAL
inspection, auscultation, palpation, percussion
53
what do you need in order to do a good assessment
Room at comfortable
temperature Good lighting
Look and observe
before touching
Completely expose
part being examined
while draping the rest
of client as appropriate
Note characteristics Compare appearance
54
always proceed from ------ to ---------- palpation
light - deep
55
light palpation
Light palpation – less then 1cm depression in a circular
motion. Very light touch to assess for tenderness,
warmth, moisture, etc.
56
moderate palpation
1-2cm depth
57
deep palpation
Deep palpation – depress 2.5 or more cm to feel deep
organs
58
bimanuel palpation
Bimanual palpation – utilizing both hands to compress a
body organ
◦ ONE CM IS EQUAL TO THE DIAMETER OF ONE AAA
BATTERY!
59
Palpation consists of using parts of the hand
to touch and feel for the following
characteristics
• Texture (rough/smooth)
• Temperature (warm/cold)
• Moisture (dry/wet)
• Mobility (fixed/movable/still/vibrating)
• Consistency (soft/hard/fluid filled)
• Strength of pulses
(strong/weak/thready/bounding)
• Size (small/medium/large)
• Shape (well defined/irregular)
• Degree of tenderness
60
percussion purposes
Utilizing tapping to:
Elicit pain
Determining location, size, and shape
Determining density
Detecting abnormal masses
Eliciting reflexes
Used in advanced health assessment – we will discuss
further later on.
61
auscultation purposes
Auscultation is using a stethoscope to elicit sounds such as breath
sounds, heart sounds or bowel sounds.
•Eliminate distracting noise.
•Expose the body part being auscultated.
We will review use of stethoscope with Assessment Techniques!
•Diaphragm, high-pitched sounds (heart/breath/bowel) ;
•Bell, low-pitched sounds (abnormal heart sounds / bruits). Most
likely you will use the diaphragm – it is the larger part of the
stethoscope.
•Place earpieces into outer ear canal angled towards your nose.
•Warm the stethoscope with your hand prior to placing on the
patient.
•NEVER LISTEN THROUGH CLOTHING!
62
vital signs
• Temperature (T)
• Pulse (P)
• Respiratory rate (R or RR)
• Blood pressure (BP)
• Oxygen saturation (O2 sat)
• Pain
63
frequency of assessment
• Admission
• Per policy or orders
• Change in condition
• When medications are given that affect cardiac rate and rhythm
• Pre- and post-op surgery (or invasive procedure)
• In emergency situations
64
normal adult vital signs
T: 36.1-37.2 C or 97-99 F (98.6F “afebrile”)
T: 100.4 or greater = fever
P: 60-100 bpm (beats per minute)
RR: 12-20 bpm (breaths per minute)
BP: 120/80 mm Hg
O2 sats: 95-100%
65
reasons for hyperthermia
Temperature (Hyperthermia)
• Infection
• Heat exhaustion
• Sunburn
• Inflammatory conditions
• Immunizations
• Illicit drugs
• Autoimmune conditions
• Teething
ovulation
exercise
66
hypothermia
Temperature (Hypothermia)
• Inadequate clothing
• Exposure to cold
• Wet clothing
• Aging
67
children and adolescents need what vitamin and mineral
calcium and vitamin D, dairy
68
treat overheating
Increased temperature
• Cool, damp cloth
• Fan, open windows
• Remove clothing/blankets
• Cool bath/shower
• Ice packs
• Administer antipyretics
69
treat decrease in temp
Decreased temperature
• Apply clothing/blankets
• Activity
• Warm bath/shower
• Change damp clothing
• Warming device
70
oral temperature
place in posterior sublingual pocket, hold in place,
71
tympanic temp
hold in the ear, pull the pinna up and back,
72
temporal
scan across forehead
73
rectal
most accurate, used in red only, do not use if patient has diarrhea, colon surgery, heart surgery, heart attack.
74
difference between temps
Tympanic: 0.5-1°F HIGHER than ORAL route
• Normal: 98.0 F-100.9° F (36.7-38.3° C)
Rectal: 0.5-1°F HIGHER than ORAL route
• Normal: 97.4-100.3° F ( 36.3-37.9° C)
Axillary: 0.5-1°F LOWER than ORAL route
• Normal: 95.6-98.5° F (35.4-.7.0° C)
Temporal: 0.5-1° F Lower than ORAL route
• Normal: 97.4-100.3° F (36.3-37.9° C)
75
body temp is the lowest between
4-6am
76
body temp is highest between
in the evening
77
location of pulses
• Temporal
• Carotid
• Brachial
• Radial
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis
78
brachial pulse site
used for babies and small children
79
radial pulse
older pediatrics and adults
80
apical pulse
very accurate, always count for one full minute, best site for newborns, check with an irregular pulse
81
a 12 year old girl is in your office, what kind of vaccinations would you talk to her about
Human paplomma virus
82
carotid pulse
only used in emergencies
83
detecting pulse
• Once you find the pulse, count for 30 seconds and
multiply x 2. This will be your pulse rate per minute. If
the rhythm is irregular, count for a full minute then
verify by assessing the apical pulse.
84
tachycardia
Tachycardia = >100bpm, may occur with fever and certain medications
85
bradycardia
Bradycardia = <60bpm, heart block or dropped rates, may need to auscultate
86
stages of hypertension
• Normal = 120/80
• Elevated = 120-129/greater than 80mmHg
• Stage I hypertension = 130-139/80-89mmHg
• Stage ii = 140/90
Hypertensive = 180/120mmHg
87
what is pulse pressure
• Pulse pressure = systolic minus diastolic
Higher than 50mmHg may indicate cardiovascular disease
88
when measuring pulse you should assess
• Several characteristics should be assessed when measuring radial pulse :
• Pulse rate, rhythm, amplitude, contour, and elasticity
Amplitude is measured as: weak +1, normal +2, bounding +3, 0=no pulse.
89
tachycardia
Tachycardia
• 100-180 BPM
90
bradycardia
• Bradycardia
• Pulse rate below 60 BPM
91
tachypnea
respiration greater than 20
92
bradypnea
less than 12 breaths
93
apnea
less than 10 breaths per minute
94
apical pulse site
Infants & children <2years
old:
4th intercostal space
midclavicular line
Adults: 5th intercostal space
midclavicular line
95
Lub-Dub
“Lub”....
• Closure of the atrial and ventricular heart valves
“Dub”......
• Closure of the pulmonic and aortic valves
96
heart murmur?
Heart Murmur.....
• Defective valves causing hissing sounds when blood squirts blood back through the valves
97
diffusion
• Diffusion• Exchange of oxygen and carbon dioxide
between the alveoli of lungs and circulating
blood
98
perfusion
• Perfusion•
Exchange of oxygen and carbon dioxide
between circulating blood and tissue cells
99
assess for respirations
Observe chest rise and fall to count respirations. (look at chest or lower neck area)
Count for 30 seconds and multiply x 2.
Count respirations while you still have your fingers on pulse assessment. This way the patient is unaware you are
assessing breathing. Respirations have autonomic and voluntary control.
Assess for equal rise and fall of the chest. Both sides should rise and fall symmetrically.
Assess for depth of breathing. (shallow,deep)
Document respirations over one minute. Ex: 16 breath per minute
100
eupnea
Eupnea: normal, unlabored respiration
101
orthopnea
difficulty breathing while laying down
102
dyspnea
difficulty or labored breathing
103
factors affecting blood pressure
• Age, gender, race – African Americans @ highest
risk for hypertension
• Food intake : high sodium intake related to high
blood pressure (hypertension)
• Exercise
• Weight
• Emotional state
• Body position
• Drugs/medications
104
systolic bp
• Age, gender, race – African Americans @ highest
risk for hypertension
• Food intake : high sodium intake related to high
blood pressure (hypertension)
• Exercise
• Weight
• Emotional state
• Body position
• Drugs/medications
105
diastolic bp
A measurement of the pressure of
the blood in the arteries when the
ventricles are relaxed
106
hypotension bp
<90/60
• Orthostatic hypotension
• Symptomatic vs asymptomatic
• What is the biggest safety risk???
107
hypertension is
the silent killer
108
hypotension
• Blood loss
• Dehydration
• Infection
• Pregnancy
• Medications
• Sometimes asymptomatic
109
getting a good bp
• Rest
• Proper position
• Proper cuff size and position
• Estimate systolic pressure
• Pump up cuff to 20-30 mm Hg
above estimate
• Release pressure slowly 2 mm
Hg/second
• First sound=systolic number
• Last sound=diastolic
• Release cuff pressure
110
do not take a blood pressure on a
• Difference between arms
• Avoid
• Stroke side
• Mastectomy
• IV/PICC
• AV fistula
• Hx of DVT in arm
• Open wounds/drainage
111
orthostatic hypotension
Orthostatic hypotension is low blood pressure when standing.
Orthostatic vital signs may be ordered if the patient presents with syncope (fainting) or dizziness.
These patients are at high risk of falls!
1. Lay patient flat for 2-3 minutes then take BP and Pulse.
2. Move the patient to the sitting position and repeat BP / Pulse after 1 minute. Document patient
complaint of dizziness.
3. Move the patient to the standing position and repeat BP / Pulse after 1 minute. Be aware of the patient
becoming dizzy and falling! Stop test if patient feels like they are going to pass out.
Decrease in Systolic BP of 20 mmHg and increase in pulse by 20 bpm is a POSITIVE finding.
112
the fifth vital sign
pain!
Observe posture, facial expression
and general impression. Does the
patient look like they are in pain?
Ask the patient to rate their pain on a
0-10 scale. 0 is no pain, 10 is the worst
pain of their life.
Use COLDSPA
113
measuring infants
Length (Lying)
Use Birth – 24 months
WHO growth chart
Unable to stand
without assistance
114
measuring infants
Able to stand without
assistance
Use 2 – 20 years
CDC growth chart
115
infants weights should double and triple when?
Infants should
double their birth weight @ 6 months weight @ 6 months
and and triple their birth
weight @ 1 year
116
average infant head cm
35cm at birth, HC increases 1cm per month for the first year, 2cm per first 3 months.
117
microcephaly
smaller head
118
macrocephaly
larger head
119
newborn P and R
p: 120-140
r: 30-60
120
infant p and r
p: 100-160
r: 25-35
121
toddler p and r
p: 100-160
122
toddler resp.
20-30
123
preschooler p and r
p: 80-120
r:20-25
124
school age p and r
70-110
r 18-22
125
adolescent p and r
p: 60-90
r:16-20
126
APGAR
appearance, pulse, grimace, activity, respiration
score 0-3 = low
score 4-6 = below normal
score 7+ = normal
127
FLACC SCALE pain
face, legs, activity, cry, consolability
