Test #3 Flashcards
(66 cards)
1
Q
heart: subjective data
A
Chest pain Dyspnea (difficulty breathing) Orthopnea (the need to assume a more upright position to breath) (how many pillows do you need to sleep?) Cough Fatigue Cyanosis or pallor Edema Nocturia (peeing at night) Cardiac history Family cardiac history Personal habits (cardiac risk factors)
2
Q
objective data: neck vessels
A
Carotid arteries
- Auscultate for bruit (patient hold their breath)
- Normal is to hear nothing
- Palpate
- Rate pulse on scale 0-3
- Don’t calculate heart rate from here
Jugular veins
- Inspect for jugular venous pressure (JVP)
- Good for detecting pressure on the right side of the heart
- If you can see it (bulging), that means there is to much pressure in the right atrium and the blood has backed up through the superior vena cava into it
3
Q
objective data: the precordium
A
- inspect anterior chest
- palpate the apical impulse
- palpate across precordium (feel for thrills)
4
Q
cardiac: diaphragm or bell?
A
S1 & S2 = diaphragm
extra heart sounds = bell
5
Q
S1 & S2
A
S1 is louder than S2 at the apex (and vice versa)
S1 coincides with the carotid artery pulse
Listen to S1 and S2 separately
6
Q
extra heart sounds
A
S3 - occurs just after S2 when the mitral valve opens, allowing passive filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant LV.
S4 - occurs just before S1 when the atria contract to force blood into the LV. If the LV is noncompliant, and atrial contraction forces blood through the atrioventricular valves, a S4 is produced by the blood striking the LV.
Murmurs - A heart murmur is a swishing sound heard when there is turbulent or abnormal blood flow across the heart valve
7
Q
peripheral vascular and lymphatic system: subjective data
A
Leg pain or cramps Skin changes on arms or legs Swelling Lymph node enlargement Medications
8
Q
objective data: arms
A
- inspect and palpate skin clubbing cap refill symmetry
-palpate pulses
grading scale
locations
palpate the epitrochlear lymph node
9
Q
modified Allen test
A
Evaluates adequacy of collateral circulation before radial artery is cannulated (e.g. ICU – arterial line, RT – measuring blood gases)
- depress radial and ulnar arteries - person open and closes fist
- normal - blood returns via the ulnar artery
- occluded ulnar artery - no blood return
10
Q
objective data: legs
A
inspect and palpate - Skin and hair (PVD) - Symmetry (edema → blood clots) - Temperature - Calf muscles (gastrocnemius) - Inguinal lymph nodes (groin) (swollen?) palpate pulses locations - Femoral - Popliteal - Dorsalis pedis - Posterior tibialis Edema - Cardiac edema - lowest point and build up, bilateral dependent - Lymph edema - lack of lymphatic drainage, not symmetrical, localized to the area leg veins - Varicose veins - Assess while patient stands - Colour changes Moving from one position to another Blood shifting when you move 10 seconds for colour to return to feet 15 seconds for superficial veins to fill
11
Q
edema scale
A
1+ = mild pitting, slight indentation, no perceptible swelling 2+ = moderate pitting, indentations subside rapidly 3+ = deep pitting, indentation remains for a short time, swelling of leg 4+ = very deep pitting, indentation lasts a long time, gross swelling and distortion of leg
12
Q
nociceptive pain
A
- caused by tissue injury
- described as aching or throbbing
- somatic
- visceral
- referred
13
Q
somatic
A
- Superficial from skin and subcutaneous tissue (cutaneous pain)
- Deep from joints, tendons, muscles, or bone
- Stubbed your toe
14
Q
visceral pain
A
- From direct injury or stretching of large interior organs
- Result of tumour, ischemia, distension, or contraction
- Gallbladder, pancreatitis, IBS, pneumonia, appendicitis
15
Q
neuropathic pain
A
- Caused by lesions or disease affecting somatosensory nervous system
- Results from damage to nerve pathway
- Caused by direct nerve trauma, infections, metabolic problems; may be drug induced
- Described as “burning” or “shooting”
- Manifestations vary among patients
- Amputation (phantom limb pain), shingles, damage to nerve
16
Q
referred pain
A
- Originates in one location but is felt in another site
- Innervated by same spinal nerve
- Abdominal pain, chest pain
17
Q
types of pain
A
Acute pain
- Short term
- Self limiting - only do as much as your pain allows
- Follows a predictable trajectory
- Dissipates after injury heals
Persistent (chronic) pain
- Continues for 6 months or longer
- Malignant (cancer related) or nonmalignant (eg. MSK)
- Does not stop even after tissue has healed
18
Q
pain: considerations for infants and children
A
Higher risk for undertreatment (because of belief that infants do not remember pain)
Leaving untreated pain in infants/children can lead to trauma
Words children may use to report pain
Fear of injections
19
Q
developmental considerations for pain: older adults
A
Pain not a normal process of aging
Pain can create delirium and increase in bad behaviour
Higher incidence related to chronic conditions
20
Q
Andrew Robert Survey
A
- Nurses tend to only believe pain when people look like they are in pain
- We need to look away from what pain appears to be and listen to how the patient describes it (subjective > objective)
- Pain is whatever the experiencing person says it is, existing whenever he says it does
- Failure to ask patients about pain and to accept and act on patients pain reports is probably the most common cause of unrelieved pain and unnecessary suffering
21
Q
OPQRSTUV
A
- Onset: when did it begin? How long does it last? What were you doing when it started? How often does it occur?
- Provocative or palliative: relieved with rest? Previous treatments effective?
- Quality of pain: words to describe pain?
- Region of body: Where? Radiates?
- Severity: How patient would rate on intensity scale?
- Timing and onset of pain: When started? Constant, dull, or intermittent? Changed over time? Pain free periods?
- Understanding of pain: what patients believes is causing pain? Goal for comfort? Medications used?
- Values: what are your beliefs for treating pain? Thoughts, opinions?
- Aggravating
- Associating
- Alleviating
22
Q
acute pain: objective findings
A
- Pain well controlled (Mild to moderate) (Example post surgery)
- Pain tolerance for functioning (Pain control before rehabilitation)
- Side effects of treatment (Nausea, vomiting, pruritis)
- Pain prior to treatments (Dressing changes)
23
Q
objective findings: neuropathic pain
A
Decreases or increases in sensation (Assessed with vibration or pin prick)
Numbness (Loss of sensation)
Inspect skin (Colour, swelling, deformity) (Bottoms of feet for diabetic neuropath)
24
Q
pain assessment: nonverbal behaviours
A
acute
- Guarding, grimacing, vocalizations (moaning), agitation, restlessness, stillness, diaphoresis
- vital sign changes
Chronic
- Person adapts over time to chronic pain
- Bracing, rubbing, decreased activity, sighing, change in appetite, sleeping more
25
misconceptions about pediatric pain
```
Cannot feel pain
Less sensitive to pain
Cannot express pain
Cannot be accurately assessed
Cannot remember pain
```
26
misconceptions about geriatric pain
Pain is a natural part of growing old
Pain is perception/sensitivity decreases with age
If the patient does not report pain, they don't have pain
If the patient appears to be asleep or distracted from pain, they don’t have pain (Sleeping patients can be in pain)
27
substance abuse: paradigms for harm reduction
- Conservative - Harm reduction measures (needle exchange) are seen as temporary with an ultimate goal of abstinence
- Liberal - Informed choice is supported and safety net provided
- Structural - Empowerment, advocacy and emancipation of people using substances are embraced
28
factors influencing substance use
Social practices and acceptability
Affordability
Trauma, violence, chronic pain
Mental health
29
5 A’s for Integrating Knowledge of Substance Use in Health Assessment
- Acquire knowledge; replace erroneous assumptions
- Anticipate harm that may be caused by your practices, reactions, judgements
- Avoid social judgment about substance use, such as seeing a person as “bad”, deviant, or morally weak
- Analyze the impact of policies at levels of organization and society
- Approach ALL patients respectfully
30
substance abuse: screening tools
TWEAK - tolerance, worried, eye opener, amnesia, Kut down)
CAGE - cut down, annoyed, guilty, early
(saying yes to 2 or more is a red flag)
31
substance withdrawal
- Alcohol withdrawal is more dangerous than drugs because you have a high risk of seizures, delirium, psychosis because alcohol is a depressant
- Cocaine withdrawal is more like terrible flu symptoms but less dangerous
- stage 1 (6-12 hours) - tremors, tachypnea, tachycardia, diaphoresis
- stage 2 (12-24 hours) - hallucinations
- stage 3 (24-48 hours) - seizures
- stage 4 (48-72 hours) - delirium, psychosis, hallucinations, hypertension, seizures
32
CIWA
```
For alcohol withdrawal
Giving a benzodiazepine → adjusts seizure threshold
Give multivitamins and thymine = increasing nutrition
Investigating these symptoms
Nausea/vomiting
Tremors
Anxiety
Agitation
Paroxysmal sweats
Orientation and clouding of sensorium
Tactile disturbances
Auditory disturbances
Visual disturbances
Headaches
Generates an overall score that tells you how they need to be medicated appropriately
```
33
COWS
```
For opioid withdrawal
Giving advil, gravol
Symptom management
Resting pulse rate
Sweating
Restlessness
Pupil size
bone/joint aches
Runny nose or tearing
GI upset
Tremor
Yawning
Anxiety or irritability
Gooseflesh skin
```
34
abdominal: subjective data
```
Appetite/Weight Changes
Dysphagia
Food intolerance
Abdominal pain
Nausea/vomiting
Bowel habits
Abdominal history
Medications
Iron - more constipated, darker, harder stool
Substance Use
Nutritional assessment
```
35
acute abdominal pain
```
Acute abdominal pain- Pain < 7 days duration
Can be classified
- Visceral
- Parietal (somatic)
- Referred
Visceral and parietal most common
```
36
visceral abdominal pain
Stretching of fibers around organs
Ischemia and inflammation around organs (earlier signs)
Steady ache to severe colicky pain
Pain localized generally to a spinal cord level
Epigastric pain - stomach, duodenum, biliary tract
Umbilical pain - small bowel, appendix, cecum
Suprapubic pain - colon, GU tract
Pain may be perceived as midline before lateral - Textbook appendicitis
37
parietal pain
Irritation of the fibers on parietal peritoneum
Usually anterior peritoneum (later signs)
Pain localized specifically and laterally
Parietal pain usually follows visceral pain
Tenderness and (involuntary) guarding
Rebound tenderness and rigidity - Appendicitis
38
referred pain
```
Pain distant from involved organ
Usually laterally and rarely midline
Examples
- Subdiaphragmatic irritation - Ipsilateral (same side) shoulder pain
- Liver pain - Right shoulder
- Pancreatic pain - Mid lower back
```
39
guarding
- Voluntary guarding - muscles are tight → hard to palpate
| - Involuntary guarding (rigidity) - trauma, fluid build up, body is eliciting an involuntary protection response
40
Bulbourethral gland
Pea sized, inferior to the prostate, on both sides of the urethra
Secrete clear viscid mucus
41
seminal vesicles
Project like rabbit ears above the prostate
| Secrete fluid that is rich in fructose, which nourishes the sperm
42
subjective data: anus, rectum, prostate
```
Bowel routine
Bristol stool chart, regularity?
Changes in bowel habits
Rectal bleeding or blood in stool
Medications
Rectal conditions
Family history
Self-care
```
43
screening for colorectal cancer
- Canadian Task Force for Preventative Health (2016) recommends screening for men and women aged 50+ years every two years
- People at high risk can be screened at an earlier age
- Fecal occult blood test (gFOBT, iFOBT, or FIT)
- Positive FOBT may be followed up by a colonoscopy, sigmoidoscopy, double contrast barium enema
44
risk factors for prostate cancer
Age >65 years
Family history
Diet high in fats
African ancestry
45
head to toe assessment
- Simultaneous collection of subjective and objective data using a systems approach (incorporate it all together)
- 2 patient identifiers (name, DOB) and compare to name band
- Determine orientation
- Start at top and work down
- Health history - Refer to information from previous shift report
- Assess for pain
- General appearance - Personal hygiene (ability to attend to hair, shaving, etc.)
- Measurement - Vital signs; pulse oximetry; pain level rating at rest, with activity, and following analgesia
46
internal anatomy of breasts
Glandular tissue
Fibrous tissue
Adipose tissue
47
quadrants of the breasts
Upper inner/upper outer
Lower inner/lower outer
Axillary tail of spence
48
axillary lymph nodes
Central
Pectoral (anterior)
Subscapular (posterior)
Lateral
49
objective data: breasts and lymphatics
Breasts - inspection
- General appearance
- Skin
- Lymphatic drainage areas
- Nipple
- Maneuvers to screen for retractions
Axillae - inspection and palpation
- Skin
- Palpation techniques
- Lymph nodes
50
breast exam positions
- retraction = sitting up, lift hands above head
| - supine, laying down = palpation
51
5 D's of Nipples
```
Discharge
Depression
Discolouration
Dermatologic changes
Deviation on one side
```
52
subjective questions: genitourinary
```
Frequency, urgency, and nocturia (peeing at night time)
Dysuria (pain when voiding)
Hesitancy and straining
Urine color/consistency
Past genitourinary history
Sexual activity
STI contact
STI risk reduction
Contraceptive use
Urgency (rushing to bathroom) and nocturia → high risk for falls → make sure area is safe for them to move around
```
53
penis - inspection
Skin and glans
Urethral meatus
Pubic hair
Urethral discharge
54
scrotum - inspection and palpation
```
Skin
Testes
Epididymis
Spermatic cord
Any mass
- Not characteristics
- Transillumination (replaced with ultrasound in some places)
- Perform if mass present
- Scrotal contents not transilluminated
```
55
inguinal lymph nodes
Horizontal chain along groin and vertical chain along upper inner thigh
56
testicular cancer risk factors
Age 15-49
Delayed descent of testicles
Family history
Abnormal development of testicles
57
External genitalia - inspection
```
Skin colour
Hair distribution
Labia majora
Labia minora
Urethral opening
Vaginal opening
Perineum
Anus
```
58
spousal abuse
physical/sexual violence, psychological violence, or financial abuse within current/former marital or common-law relationships, regardless of sex or gender identity
59
interpersonal abuse
Intimate partner violence
Sexual assault
Child maltreatment (is reportable in all provinces)
Elder abuse (reportable in ontario)
60
four levels of sexual assault
Forced sexual activity without physical injury
Sexual assault with a weapon or verbal threats
Sexual assault causing bodily harm
Aggravated sexual assault
61
types of abuse
Physical
Sexual
Neglect
Emotional
62
elder abuse and neglect
Mandatory reporting in Ontario if in nursing home
Physical abuse or neglect, failure to provide basic services, psychological abuse or neglect (failure to provide stimulation), financial abuse or neglect
Inflicted by any persons in a situation of power or trust
In home or institutions
Women at higher risk than men
63
effects of violence on health
- physical injury
- chronic health (Chronic pelvic pain, Unintended pregnancy, STIs, including HIV, Urinary tract infections)
- mental health (depression, etc)
64
health care providers response to abuse
- Greater detection of abuse did not necessarily lead to meaningful responses
- E.g., decreased exposure to violence
- Women report negative experiences with health care providers who focus on physical consequences rather than wider effects and context of IPV
- HCP’s being judgemental, victim blaming, unsympathetic
65
abuse: health care provider should:
- Assume that a majority of patients will have a history of abuse of some form
- Assume some may be currently experiencing abuse
- Provide care that is appropriate for those with histories of abuse, regardless if abuse has been disclosed
- Routinely inquire about home/work life effects on health
66
HCP’s Responses to Child Abuse
- Neglect and emotional abuse most common
- Parents not only possible perpetrators
- Most allegations are not substantiated
- Stress of removal of child from parents
- Nursing role as child “rescuer” at expense of relationship with parents or child/parent relationship
- Children over 11 can usually provide history (Separately if possible)
