EXAM 1

jessica g.

Created: 2011-09-12
Last Modified: 2011-09-15

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CH.1

Nurse's role in health assessment

four broad goals are within nursing:

to promote health
to prevent illness
to treat human responses to health or illness

4. to advcate for individuals, families, communities, and populations

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nursing roles:

direct and indirect care
advocacy
scholarship and research-provide care on current evidence

health assessment is

gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluation patient care outcomes.

*includes both health history and physical assessment

health history includes

patient's past medical and surgical histories, risk factors, and current symptoms

comprehensive health history

also includes nutrition, development, mental health, social, cultural and spiritual dimentsions, and safety issues

health belief model

considers the relationship b/t a person's beliefs and actions including: host (patient), agent (disease), environment

health promotion model

views individuals as multidimensional and in interaction iwth interpersonal and physical environments as they pursue health

Healthy People

a national model for health promotion and risk reduction developed by USDHHS

*goals: to increase the length and quality of life for Americans and to eliminate health disparities among different segments of the population

primary prevention

preventing problems

ex. immunizations, health teaching, safety precautions

secondary prevention

early diagnosis of health problems and prompt treatment to prevent complications

ex. pap smears, vision and hearing testing, TB testing

tertiary prevention

focuses on preventing complications of an existing disease and promoting health to the highest level

ex. diet teaching for patients with diabetes, inhaler teaching for patients with lung disease

critical thinking in nursing

result oriented
driven by patient, family, and community needs
based on the nursing process, evidence-based thinking and scientific method
requires specific knowledge
is constantly reevaluating

7 steps of diagnostic reasoning

gather assessmnt data- abnormal findings
draw inferences about what the issue is

Verbal communication skills

active listening
restatement
reflection-summary
encouraging elaboration-assists the patients to more completely describe problems
silence
focusing
clarification
summarizing

nontherapeutic response

false reassurance
sympathy
unwanted advice
biased questions
change of subject
distractions
technical language

types of history

emergency-nurses collect the most important info and defer obtaining details until patients are stable.

focused-question that relate to the current situation

comprehensive-takes place during an annual physical examination, for sports participation screening, and during a hospital admission

ADLs

activities of daily living

ex. eating, dressing, and grooming

review of systems

series of questions about all body systems that helps to reveal concerns or problems as part of a comprehensive health assessment

components of the medical record

nursing admission assessment
history and physical examination by primary provider
primary provider's orders
POC (plan of care)
flow sheets document vital signs, intake and output and routine assessments
focused assessment sheets
MAR (medical administration record)
lab results
progress results
consultations
discharge or transfer summary

HIPAA

Health Insurance Portability and Accountability Act

*gives patients greater control over their medical records became effective in 2003.

SOAP(IE)nursing progress notes format

*format focuses on a single problem:

Subjective-data

Objective-data

Analysis-of data to identify a problem

Plan- for treating or improving the problem

Interventions

Evaluation

PIE-nursing progress notes format

Problem, Intervention, Evaluation

*incorporates the POC into the progress note

DARnursing progress notes format

Data

Action

Response

*focus system of documentation organization

OASIS

Outcome and Assessment Information Set

*accurately measures the patient's status at various specified points during an episode of care

SBAR

*a shared mental model for improving communication between and among clinicians

Situation: state concisely why you are communicating

Background: describe the circumstances leading up to the current situation

Assessment: give objective and subjective data pertinent to the situation

Recommendation: make suggestions for what needs to be done to manage the problem

hypotension

hypertension

pre- 120-139/ 80-90

stage 1- 140-159/ 90-99

stage 2- >160/ >100

A-delta

large nerve fibers covered with myelin; conduct pain impulses rapidly; sharp, stabbing pain

C fibers

smaller unmyelinated nerve fibers; conduct pain impulses more diffusely and slowly; achy and ongoing

4 steps of nociception

transduction-stimuli cause impulse
transmission-periphery to spinal cord
perception-impulses transmitted to higher areas of the brain are identified as pain
modulation-inhibitory and facilitating input from the brain modulates or influences the sensory transmission at the level of the spinal cord

visceral pain

abdominal organs; crampy or gnawing

somatic pain

from the skin, muscles, bones, and joints; sharp

cutaneous pain

from dermis, epidermis, subcut; burning or sharp

referred pain

specific site and one along the spinal nerve

pain assessment is only what type of data

subjective

*self-report, grimacing, rocking, guarding

objective data collection

stress,

BP, pulse, and respiration increase

muscle tension

pain scales

one-dimensional: measures intensity

*Visual analog scale

*verbal descriptor scale

*numeric pain intensity scale

*combined thermometer scale

multidimensional pain scale-chronic pain, malignant pain or complex medical-surgical pain

*McGill pain questionnaire-experimentally induced circumstances

*brief pain inventory-cancer

*FACES

*FLACC

FLACC

face

legs

activity

cry

consolability

*measure acute postoperative pain in children 2 months to 7yrs old

FACES

uses six faces ranging from happy to sad with tears

children 2 yrs and older can identify pain and point to its location

*between 7-10 yrs. children can begin using numeric rating scale

Ch. 6

acute assessment

extreme anxiety

acute distress,

pallor

cyanosis

change in mental status

*interventions while continuing assessment

*obtain vitals: pulse, BP, oxygen sat.

call rapid response team

stridor

respirations < 10 or >32

oxygen sat. < 92%

pulse < 55 or > 120

systolic BP <100 or > 170

new chest pain

anthropometric measurements

measurements of the human body: height and weight

vital signs

temperature, pulse, respirations, and BP

*pain

**assess medications before vitals

normal temperature-oral

35.9C-38C

96.7-100.5F

*most common and comfortable

rectal and temporal and tympanic temp

.4-.5C

0.7-1F higher than oral

r-most accurate

t-quick, safe

axillary temp

.5C (1F) lower than oral

normal pulse

60-100

normal respirations

12-20

normal blood pressure

120/80

tachycardia

heart rate is >100bpm

bradycardia

asystole

absence of pulse

primary nutrients

carbohydrates

proteins

fats

vitamins

minerals

warer

major electrolytes

carbs

main source of energy

found in starch, fiber, grains, fruits, and vegetables

proteins

functions in cell structure and tissue maintenence

lipids (fats)

triglycerides (fats and oils), sterols (cholesterol), phospholipids (lecithin)

vitamins

metabolism of most nutrients

D-needed for bone strength, and synthesis

B folate-metabolism and cell synthesis; leafy greens, seeks, OJ

B12-only water-soluble vitamin not found in plants; myelination, DNA synthesis

minerals

iron

zinc

calcium

major electrolytes

potassium and sodium

Na+ regulates fluid balance, acid-base balance, muscular irritability

K+ " and skeletal muscle contractility

cultural situions

catholics: avoid meat on Fridays

Hinduism: avoid beef, pork, and alcohol

mormon: avoid coffee, tea, alcohol, tobacco

seventh day adventist: lacto-ovo-vegetarians

Judaism: eat on Kosher meat no crustaceans; avoid consuming meat and milk together

Islam: avoid pork and birds of prey; fast during Ramadan

Buddhism: lacto-ovo-vegetarian

BMI calc. and normal

18.5-24.9

BMI= weight/height2 x 703

ch. 10

SAD PERSONAS

suicide risk assessment

sex

age

depression

previous attempt

ethanol abuse

rational thought loss

social supports lacking

organize plan

no spouse

access to lethal means

sickness

objective assessment for mental health

Appearance

Behavior

Cognitive function

Thought process

MMSE-minimental status

Models of health

biomedical

complementary and alternative medicine CAM

Roy's adaptation

Gordon's functional health

eudaimonistic model of health

biomedical model

health as the absence of disease

Complemetary and Alternative Medicine CAM model

view health in a more holistic way

Roy's adaptation model

health is the patient's ability to adapt, compensate, manage, and adjust to physiologic-physical health-related setbacks

Gordon's functional health model

people are considerably healthy if they can fulfill their social roles by contributing to family and society in meaningful ways

eudaimonistic model of health

emphasizes that wholeness of the individual is essential in maintaining good health: biopsychosocial and spiritual-well being

levels of social assessment

individual

community

societal

Ch. 12

human violence

family violence

violent crime committed by an offender who is related to the victim

ex. intimate partner violence (IPV), child maltreatment, sibling violence, elder abuse

punking/bullying

aggression in which the behavior is inended to harm, is repeated over time, and imbalance of power

when told by a patient or when suspicious of human violence nurses are:

mandated reporters and must tell protective services and document the call

rapport

connection with the patient

order of questions

general open-ended questions to specific

_______ is key to intervention in victims of human violence

safety planning

CH. 13

skin, hair, and nails assessment

layer of the skin

epidermis-first line of defense; does not thin
dermis-supports epidermis, contains blood vessels, nerves, sebaceous glands which support nutritional needs of the epidermis
subcutaneous-provides insulation, storage of caloric reserves, and cushioning against external forces

sebum production _________with increasing age

declines

sweat gland types

1. eccrine-covers most of the body, open directly onto skin surface, and sweat in response to environmental or psychological stimuli

2. apocrine- in the axillae and genital areas; open into hair follicles and become active during puberty, functioning decreases with age

what glands become hyperactive during pregnancy

sweat and sebaceous glands; increase acne and sweating

as skin ages it begins to lose:

elastin, collagen, and subcutaneous fat resulting in overall thinner skin

turgor

measure of skin elasticity

what waves are more likely to cause sunburn

**UVB-skin cancers

which waves have deeper skin penetration

UVA-melanomas, effects of photo-aging

keloid

excess growth of scar tissue at the site of a healed skin injury

occur from acne, burns, chicken pox

erythema

redness

cyanosis

bluish discoloration

brawny

dark leathery appearance

wound healing

inflammatory phase-begins within 30min of injury (2-3days)
proliferative phase-may last up to 4weeks
rmodeling phase-may last as long as 2 years

clubbing

of the nails indicates chronic hypoxia

Ch. 18

thorax and lungs assessment

thoracic cage

sternum and clavicle anteriorly

Lobes of the lungs

Right upper lung RUL

right lower lung RLL

Right middle lung RML

*right bronchii is more angled than the curved left bronchii

Left lower lung LLL

Left upper lung LUL

reference lines

midsternal line

midclavicular line

ant., mid., post. axillary lines

vertebral line

scapular line

fissures

oblique fissure- between RLL and RML; b/t LUL and LLL (T3 spinous process)

horizontal fissure-b/t RUL and RML; not in the left lobes

location of lung base, apex,

base-bottom of lung fields; 6th rib MCL(midclavicular line)

apex-top of lungs; 2-4cm from the inner third of the clavicle

pleural sacs

visceral pleura-lines the lungs

parietal pleura-lines the thoracic wall

pleural space- lubricates the two surfaces to reduce friction

respiratory strength _______with age

declines

lungs lose elasticity, flexibility, and bone density

dyspnea

labored breathing or breathlessness

orthopnea

trouble breathing while lying down

types of sputum

mucoid-bronchitis; clear, white or gray

purulent-bacterial infection; yellow or green

tenacious-dehydration; thick; heart failure; thin and frothy

hemoptysis-bloody sputum

comprehensive assessment techniques

inspection of patient-chest

palpation of chest

chest expansion

tactile fremitus-99

percussion of chest

diaphragmatic excursion

auscultation

auscultation of voice sounds

vesicular sounds

soft, low-pitched, and found over fine airways near the site of exchange;

whispering undertones

*inspiration > expiration

bronchovesicular sounds

found over major bronchi that have fewer alveoli

*inspiration= expiration

bronchial

loud, high-pitched, and found over the trachea and larynx

*inspiration < expiration

crackles

fine-high-pitched, soft crackling sounds (strand of hair)

coarse-low-pitched, moist, longer sounds (velcro)

wheeze

high-pitched musical sounds heard primarily during inspiration

Ronchi

low pitched snoring or gurgling sound that may clear with coughing

common with pneumonia

pleural friction rub

loud, coarse, and low-pitchedgrating or creaking sound (squeaky door)

stridor

loud high-pitched crowing or honking sound louder in upper airway

acute pain

pain of a short dration that has an identifiable cause such as trauma, surger or injury

chronic pain

pain that lasts beyond the normal healing period of 3-6 months; may be no cause

lower back pain or sickle cell pain

neuropathic pain

pain that results from damage to nerves in the peripheral or central nervous system

ex. diabetic peripheral neuropathy, postherapeutic neuralgia

primary lesions

lesions that have not been previously present

ex. macule, pustule, nodule, wheal, vesicle

secondary lesion

lesion that has changed over time

ex keloid, lichen..., scars, fissure,

suspicious lesions

Asymmetry

Border irregularity

Color

Diameter larger than 6mm

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