test 1 Flashcards by Breanna Proud

COLDSPA acronym

character
onset
location
duration
severity
pattern
associated factors

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nursing open ended qeustions

can’t be answered with yes or no. requires more detail

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what is health

a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity

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8 dimensions of health

physical, emotional, social, spiritual, environmental, intellectual, financial, occupational

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health assessment

the process used to evaluate the health status of a person

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nursing assessment

focus on patient response to diagnosis or disease

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healthy people 2030

framework to improve overall health of induviduals

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beginning the exam: set the stage

reflect on approach
adjust lighting
check equipment
use precautions

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cardinal techniques of examination

close observation
auscultation
palpation
percussion

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how to conduct an exam

move head to toe, starting with right side

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ADPIE

assessment
diagnosis
planning
implementation
evaluation

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objective data

what you see- signs
physical exam
lab reports
radiologic findings

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subjective data

what patient tells you- symptoms
history
chief complaint
OLDCART

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old cart: onset

when did symptom begin

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old cart: location

where is the sign/symptom located

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oldcart: duration

how long has this been going on

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old cart: characteristic

what does it feel like? severity ?

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old cart: associated manifestations

what else is happening when the patient experiences this? any other symptoms?

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old cart: receiving factors

anything the patient tried to receive the symptoms? did it help

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oldcart; treatments

any interventions the patient has already tried

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what does OLDCART fall under in ADPIE

assessment

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ADPIE - diagnosis

based on real or potential health problems
based on assessment data and problem list

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ADPIE- planning

best course of action for patient
short term and long term goals
be realistic

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ADPIE: implementation

can be completed by patient, family, or health care team
individualized for each patient
relates to nursing diagnosis and planned goals

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ADPIE: evaluation

continues process toward goals helps determine if plan needs revised

steps in clinical reasoning

identify cluster interpret make develop

manual heart rate

radius 30 secs multiply by 2 if irregular count for minute

resp rate

30 secs times 2 with stephoscope labored or unlabored? Even? deep or shallow?

pulse ox

oxygen saturation. wait until you get even waveform

convert F to C

Subtract 32 and multiply by 5/9

celsius to farenheit

multiply by 9/5 and add 32

assessment for pain

include vital signs ask comfort level- get rating can use quotes of patient

normal bp

<120 / <80

prehypertension

120-139 / 80-89

hypertension stage 1

140-159 / 90-99

diabetes or renal bp

150-159 / 90-99

hypertension stage 2

>160 / >100

ausculatory gap

don't hear bp noise - gap

occlusion point

when you stop hearing radial point- add 20-30

normal temp

98.6 F / 37 C

normal resp rate

12-20 no diff breathing

normal oxygen sat

95-100%

nociceptive or somatic pain

related to tissue damage

neuropathic pain

related to injury of PNS or CNS

Idiopathic pain

pain w out identifiable cause

psychogenic pain

many factors influence pain

pre interview HA

review medical and nursing records, set goals, adjust environment

HA introduction

greet patient, put them at ease

HA working phase

listen to patients story, identify and respond, clarify, test diagnostic hypothesis, negotiate a plan

HA termination

summarize, discuss plan

therapeutic communication techniques

active listening, guided questioning, nonverbal communication, empathic responses, validation, reassurance, summarizing, transitions, empowering the patient

things not to do w angry patients

dont take things personally dont isolate yourself w a angry person

for the LGBTQ community

dont assume gender establish birth general and gender identity

for patients with language barrier

work with a qualified interpreter

for patients with personal problems

dont give advice outside of nursing

health history components

chief complaint, history of illness, allergies, medications, childhood illness, adult illness, health maintenance, health patterns

for alcohol consumption

ask them what type of drink, how many they have, when was the last one

when explaining things to patients

dont use medical words to patients, speak basic knowledge

if a patient seems depressed

go into suicidal screening

cultural competence

recognizes the need for a set of skills necessary to care for people of different cultures

3 dimensions of cultural humility

self awareness respectful communication collaborative partnerships

stolls guidelines for spiritual assessment

concept of god or diety sources of hope and strength religious practices relation between spiritual beliefs and health

four physical assessment techniques in order when initiating a health assessment

Inspection palpation percussion auscultation

what to do about silent patients

be attentive and encouraging

what to do about confusing patients

possible mental status exam check responses again seek permission to speak with family members

patients with altered capacity

dont have the ability to make healthcare decisions

what to do about talkative patients

focus on what seems important to the patient set limits where needed

what to do about crying patients

be supportive

helping deaf patient

find out there preferred method of communication

assessing patients hard at hearing

see if they use a hearing aid and if its working dont speak fast eliminate background noise

blind patient

establish contact orient patient to surrounding

poor vision patient

encourage glasses or contacts

genogram

diagram for family history female- circle male- square divorce- connected with 2 lines crossed deeased- line through shape

sensitive topics

sexual history, mental health history, family violence

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. Shins and ankles Groin, hips, and knees Breasts Chest and thorax Cardiovascular

breast, chest & thorax, cardiovascular, groin + hips & knees, then shins and ankles

Which equipment should the nurse use to validate the degrees of joint mobility?

goniometer

far eye sight check

snellen chart

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. What describes this finding

resonance

One of the body’s normal physiologic responses to pain is

diaphoresis

using the diaphragm, the nurse would expect to hear

high pitched sounds

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

FIFE

feelings ideas function expectations