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NUR 103 Final
final for Health Assessment
| Question | Answer |
|---|---|
| Subjective Data | What the pt tells you |
| Objective Data | What you observe when assessing a pt |
| First Level Priority | 1. Airway 2. Breathing 3. Cardiac/ Circulation 4. Vital sign concerns (e.g. high fever) |
| Second Level Priority | 1. Mental status change (e.g. cinfusion, decreased alertness) 2. Untreated medicalproblems requiring immediate attention 3. Acute pain 4. Acute urinary elimination problems 5. Abnormal laboratory values 6. Risk of infection, safty, or security |
| Third Level Priority | 1. Health problems that do not fit into the first two levels (e.g problems with lack of knowledge,activity, rest, family coping) |
| Nursing Process | 1. Assessment 2. Diagnosis 3. Planning 4.Implementation 5. Evaluation |
| Holistic Health | views the mind, body, and spirit as functioning as a whole within the environment. Health depends on all these factors working together. |
| Health Promotion | promoting healthy life style, preventing or helping stop unhealthy life styles to prevent disease. |
| Pulse | Palpate for 1 min. assess rate, rythm, and force. |
| Normal pulse Rate | 50-90 bpm varies with age |
| Stroke volume | the amount of blood the heart pumps |
| bradycardia | heart rate < 50 bpm |
| Tachycardia | heart rate > 90 bpm |
| Force of pulse | the strength of the hearts stroke volume |
| Assessment | data collection |
| Diagnosis | Comparing findings with normal and abnormal findings after data collection |
| Planning | establishing priorities, developing outcomes |
| Implementation | carryout your plan |
| Evaluation | how the plan worked |
| Pulse sites | Radial, brachial,Carotid, Ulnar, Popliteal, Posterior tibial, Dorsalis pedis, evternal maxillary, superficial temporal, apical |
| Respirations | normally relaxed, regular, automatic, and silent. count for 1 min. |
| Respiration rate adult | 10-20 |
| Respiration rate 16 yr.s | 12-20 |
| Respiration rate 12-14 yr.s | 18-22 |
| Respiration rate 8-10 yr.s | 20-26 |
| Respiration rate 2 yr.s | 25-32 |
| Respiration rate 1 yr. | 20-40 |
| Respiration rate neonate | 30-40 |
| Oral Temperature | leave in place 3-4 min. if afebrile, and 8 min. if ferile. |
| When taking an oral temperature how long should you wait after the pt has ingested somthing hot or cold? | 15 min. |
| With an oral temperature how long do you wait after a pt has smoked? | 2 min. |
| Rectal Temperature | insert 1" for 2 1/2 min. |
| Tympanic Temperature | Insert into ear takes temperature in about 2-3 seconds |
| Normal Temperature range | 96.4- 99.1 degrees F |
| Normal pulse rate in children | 70-120 bpm |
| Normal pulse rate in toddlers | 90-150 bpm |
| Normal pulse rate in newborns | 120-160 bpm |
| Normal Blood pressure (BP) | <120/80 |
| Systolic pressure | is the maxium pressure felt on the artery during left ventricular contraction (is the top #) |
| Diastolic pressure | the elastic recoil,or resting pressure that the blood exerts constantly between each contraction |
| Pulse pressure | the difference between the Systolic and Diastolic |
| Mean Arterial Pressure (MAP) | the pressure forcing blood into the tissues, averaged over the cardiac cycle |
| MAP is determined by what 5 factors? | cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of vessel walls |
| What happens if the cuff size used when taking BP is too narrow? | It gives a false high BP |
| Auscultatory gap | a period when Korotkoff sounds disappear during asculation. |
| Pain | is the fifth vital sign |
| What two processes does pain develop by? | nociceptive and neuropathic |
| nocieptive pain | nerve endings designed to detect painful sensations from the periphery anad transmit them to the CNS. located in the skin, connective tissue, muscle, and the thoracic, abdominal, and pelvic viscera |
| Neuropathic pain | implies and abnormal processing of the pain message from an injury to the nerve fibers. this pain can start 2-3 yr.s after an injury. |
| Acute pain | is short term pain and self limiting usually goes away after an injury heals |
| Chronic Pain | pain that continues for 6 months or more it can last 5 or more years. |
| Where is your pain? | May be localized or occur in multiple sites |
| What does your pain feel like? | is the quality of pain e.g. burning, stabbing, aching, throbbing, firelike, squeezing, cramping, sharp, itching, tingling, shooting, crushing, dull |
| What is the quality of pain in Neuropathic pain? | burning, shooting, and tingling |
| What is the quality of pain in nocieptive pain? | if localized aching if not localized cramping, and from somatic sites throbbing/aching |
| How much pain do you have? Identifies what? | intensity |
| What makes your pain better or worse idntifies what? | allevating and aggreivating factors and effectiveness of current treatment |
| How does the pain limit your function or activities identifies what? | the degree of impairment and quality of life. |
| How do you usually react when you are in pain identifies what? | aids in detection and assessment |
| Pain rating scale | 0-10; 0 being no pain 10 being the worst pain ever |
| culturally competent | implies that the caregivers understand and attend to the total context of the individuals situation, including awarness of immigration status, stress factors, other social factors, and cultural similarities, and differences. |
| Religion | organized system of beliefs concerning the cause, nature, and purpose of the universe, especially beliefin or the worship of God. |
| Spirituality | a persons personal effort to find purpose and meaning in life |
| Who believe in the evil eye? | Mexico, cuba, columbia, brazil, spain, puerto rico, portugal |
| who believes in yin and yang? | China, india, japan, koream philippines, southeast asia |
| Interview Process | introducing the interview, the working phase, closing the interview |
| Physical environment during interview | comfortable room temp., good lighting,reduce noise, remove distracting objects, 4-5 feet in between you and the pt, arrange a face-face equal status seating. |
| Note taking during interview process | unavoidable but may be distracting: breaks eye contact, shifts attention away from the person, can be threatening to the patient,can interrupt the patients narrative flow, impedes observation of the pt nonverbal behaviors |
| open ended questionsduring interview process | use to begin the interview and when a person begins a new topic |
| closed or direct questions during an interview process | elicit 1 or 2 short answer words like yes or no |
| facilitation during interview process | incourages the pt to say more e.g. "mm-hmm, goon,continue. aka general leads |
| silence during interview process | golden after open ended questions gives the pt time to think about what the pt wishes to say |
| reflection during interview process | repeating part of what the person just said |
| empathy during interview process | recognizing a feeling and putting it into words |
| clarification during interview process | use when a pts word choice is not understood |
| confrontaion during interview process | when observing a certain action and giving your feedback about what you see or feel |
| interpretation during interview process | interpreting what the patient has said to try to link events, associations, implies a cause |
| explanation during interview process | sharing factual and objective information |
| summary during interview process | summarizing what the pt has stated. |
| snellen eye chart | 20/30; you can read at 20 feet what the normal eye can read at 30 feet. the higher the denominator the worse the vision |
| difficulty of seeing | floaters, halos, scotoma, night blindess. |
| pain of the eye | sudden onset of eye symptoms is an emergency quality: burning, itching, sharp, stabbing, a foreign body sensation etc... |
| strabismus | is a deviation in the axis of the eye |
| diplopia | is the perception of two images of a single object |
| Glaucoma | is characterized by increased intraocular pressure |
| lacrimation | tearing |
| epiphora | excessive tearing |
| purlulent discaharge of the eye | is yellow and thick |
| otalgia | earache or pain may be caused by disease, virus or bacteria, trauma, or problems with teeth or oropharynx |
| otorrhea | ear drainage may be from infected canal or perforated eardrum |
| external otitis | purlulent, sanguineous, or watery discharge |
| acute otitis media with perforation | purlulent discharge |
| cholesteatomia | ditry/yellow gray discharge |
| presbycusis | hearing loss |
| tinnititus | ringing, crackling or buzzing of the ear. |
| Objective vertigo | feels like room spins |
| subjective vertigo | person feels like he or she spins |
| examining the ear of an adult | pull the ear up and back |
| examining the ear of a child | pull the ear down |
| signs | is a subjective sensation that the person feels from the disorder |
| symptoms | is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports |
| Mental status | is the persons emotional and cognitive function |
| Mental disorders | is apparent when a persons response is much greater than the expected reaction to a traumatic life event. |
| The 4 main headings of mental status assessment | (A,B,C,T)appearance, behavior, cognition, thought process |
| Aphasia | the impairment of language ability |
| Appearance | the pt Posture, body movement, How the pt dresses, and their grooming and hygiene |
| Behavior | The pt level of consciousness, facial expressions, speech, mood and affect. |
| Cognitive function | Orientation, attention span, recent memory, remote memory, new learning |
| Levels of consciousness | 1. alert 2. lethargic or somnolent 3. obtunded 4. stupor or semi-coma 5. coma |
| speech disorders | Dysphonia, dysarthria, Aphasia |
| dysarthria | trouble with articulation |
| global aphasia | the most common and severe spontaneous speech and comprehension is absent or reduced. |
| Broca's aphasia | expressive aphasia. can understand language but cannot express himself using language |
| Wernick's aphasia | receptive aphasia. the person can hear sounds and words but cannot relate them to previous experiences |
| Flat affect | lack of emotional response |
| depression | sad, gloomy, dejected. |
| depersonalizaion | loss of identity feels estranged, perplexed about on identity and meaning of existance |
| elation | joy and optimism, overconfident, increased motor activity |
| euphoria | excessive well being, unusually cheerful or elated, that is inappropriate considering physical and mental condition |
| anxiety | worried, uneasy, apprehensive from the anticipation of danger whose source is unknown |
| fear | worried, uneasy, apprehensive; external danger is known and identified |
| irritability | annoyed, easily provoked, impatient |
| rage | furious, loss of control |
| ambivalence | the existance of opposing emotions toward an idea, object, person |
| lability | rapid shift of emotion |
| inappropriate affect | affect clearly discordant with the content of the persons speech |
| blocking | sudden interruption in train of thought, unable to complete sentence, seems related to strong emotion |
| word salad | incoherent mixtuer of words, phrases, and sentences; illogical, disconnected, includes neologism |
| echolalia | imitation, repeats others words or phrases, often with a mumbling,mocking, or mechanical tone |
| clanging | word choice based onsound, not meaning,includes nonsense rhymes ans puns |
| obsession | unwanted, persistant thoughts or impulses; logic will not purge them from consciousness; experienced as intrusive and senseless |
| compulsion | unwanted repetitive, purposeful act; driven to do it; behavior thought to neutralize or prevent discomfort or some dreaded event |
| hallucination | sensory perceptions for which there are no external stimuli; may strikeand sense: visual, auditory, tactile, olfactory, gustatory |
| schizophrenia | 1. two or more symptoms present for 2 month period:delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms 2. social/ occupational dysfunction 3.continues signs for at least 6 months |
| delirium | maybe due to a general medical condition or substance abuse. is a disturbance of consciousness, changes in thought, develops over a short period of time |
| dementia | caused by disease memory impairment, aphasia, apraxia, agnosia, disturbance is executive functioning |
| manic episode | persisnatly, elevated, expansive, or irritable mood lasting for more than 1 week: low self esteem, decreased need for sleep, more talkative, racing thoughts, distractiblity |
| major depressive disorders | characterized by two or more major depressive episodes |
| panic attack | intense fear or discomfort: palpations, sweating, shaking, shortness of breath, chest pain, nausea, dizziness,hot flashes |
| obsessive compulsive disorder | person as either obsession or compulsion |
| generalized anxiety disorder | excessive anxiety and worry occuring more days than not |
| heavy alcohol use may cause? | alcoholic cardiomyopathy, with an increase in left ventricular mass, dilation of ventricles, and wall thinning. hypertension, tachycardia or atrial fibrillation |
| assessment techniques | inspection (looking), palpation (feeling), percussion (tapping the persons skin), auscultation (listening) |
| Past history of skin disease | allergies, hay fever, psoriasis, atopic dermatitis |
| hypopigmentation | loss of skin color |
| hyperpigmentation | increase in skin color |
| generalized change in skin color suggest systemic illness | pallor (white or pale), jaundice (yellow), cyanosis (blue) |
| seborrhea | oily |
| xerosis | dry |
| pruritus | skin itching |
| Nail Assessment change in nails | shape, color, brittleness. do they bite nails |
| Nail Assessment and environmental or occupational hazards | people at risk outdoor sports, creosote workers, farmers, sailors, roofers, coal workers |
| Edema pitting | leaves a dent in the skin when pressure is applied, has a 4 point scale 1 being mild pitting and 4 very deep pitting. |
| unilateral Edema | considered a local or peripheral cause |
| bilateral edema | problem with heart failure or kidney failure |
| lymphedema | swelling of the lymphnodes |
| decubitus ulcer stage 1 | intact skim appears red but unbroken. localized redness in lightly pigmented skin will blanch dark skin appears darker but does not blanch |
| decubitus ulcer stage 2 | partial-thickness skin erosion with loss of epidermis or also dermis. superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed |
| decubitus ulcer stage 3 | full thickness pressure ulcer extending into the subcutaneous tissue and resemling a crater. may see subcutaneous fat but not muscle, bone, or tendon |
| decubitus ulcer stage 4 | full thickness pressure ulcer involves all skin layers and extends into supporting tissue. exposes muscle, bone, or tendon, and may show slough or eschar |
| confluent | lesions run together |
| petechiae | pinpoint lesions 1-3 mm round and discrete dark red, purple, or brown in color |
| ecchymosis | a purplish patch resulting from extravastion of blood into the skin, >3 mm in diameter |
| purpura | both petechiae and ecchymosis >3 mm flat red to purple, mascular hemorrhage |
| Measles | red-purple maculopapular blotchy rash does not blanch, characterized by koplik spots in mouth elevation of 1-3 mm |
| lyme disease | bullseye, red macular or papular rash |
| kaposi sarcoma | AIDS defining illness faint pink spots on the temple and beard area |
| tinea capitis | scalp ringworms |
| head ache | is it unusually frequent or severe headaches, is it sudden or gradual, is it on one side or all over, throbbing or aching, how long does it last |
| head injury | dizzyness, loss of consciousness, how long unconscious, any other symptoms, where you hit your head, |
| what are you listening for when listening to the lungs? | crackles, pleural friction rub, wheeze, stridor, rhonci |
| heart failure | crackles in lung base, normal vesicular sounds, percussion is resonant, increased respiratory rate, shortnesofbreath on excertion, orthopnea, ankle edema, nocturia. |
| S1 | signals the beginning of systole the first heart sound closure of AV valves |
| S2 | closeure of the SV second heart sound and signals the end of systole closure of SV |
| blood flow of heart | liver,inferior vena cava/superior vena cava,RA,tricuspid valve,RV,pulmonic valve,pulmunary artery, unoxygenated blood to the lungs,oxygenated blood from lungs,pulmonary viens,LA,mitral valve,LV, aortic valve,arota, blood to the body |
| Dyspnea | shortness of breath |
| paroxysmal nocturnal dyspnea | occurs with heart failure made worse by laying down |
| electrical impulses | SA node → AV node → Bundle of his → right and left bundle branches → Purkinje fibers |
| Breast assessment | pain, lumps, discharge, rash, swelling, trauma, breast disease, surgery, self care behaviors |
| Mastalgia | Breast pain |
| galactorrhea | nipple discharge |
| gynecomastia | enlarged male breast |
| Skin of breast | smooth, even colored. note any localized areas of redness, bulging, or dimpling. no edema |
| Breast nipples | should be symmetrical usually protrude some ar flat and inverted (but not fixed). |
| supernumerary nipple | and extra nipple below the breast |
| vertical stripe pattern | best way to detect a breast mass when palpating, start high in the axilla and palpate down the breast in a kind of zig zag pattern moving across the breast ending at the sternal edge |
| is it normal to feel a firm transverse ridge of tissue in the lower quadrants? | yes |
| Lump in the breast | note location, size, shape, consistency, movable, distinctness, nipple placement, skin over the lump, tenderness, lymph nodes |
| Best time to check for breast lumps | 4th- 7th day of menstrual cycle |
| What percent of men get breast cancer | 1% |
| lactation | colostrum changes to milk around the 3rd day breast become engorged, reddened warm and hard. |
| ascites | fluid in the belly. occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. |
| dysphagia | difficulty swallowing |
| pyrosis | heartburn |
| visceral pain in the stomach | may be from internal organs dull, general, poorly localized. |
| parietal pain in the stomach | from inflammation of overlying peritoneum sharp, precisely localized, aggreivated by movement |
| peptic ulcer disease | occurs with use of NSAIDs, alcohol, smoking, and helicobacter pyloi infection |
| pica | an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age for which this behavior is developmentally inappropriate (eg, > 18-24 months). |
| contour of stomach | flat, scaphoid, rounded, protuberant |
| belly button is enverted from what? | ascites, underlying mass, obesity |
| when should examine tender areas in the stomack | last |
| when assessing the belly | inspect, auscultate, percuss, and then palpate |
| hyperactive sounds | loud, high pitched, rushing tinkiling sound |
| where should you always percuss and palpate | the midline area above the super pubic bone |
| hepatomegaly | enlarged liver |
| aging adult and abdominal assessment | increased deposits of fat, less tone, may note peristalsis, easier to palpate |
| rheumatoid artheritis | involves symmetric joints. worse in the morning movement decreases joint pain, stiffness occurs in morning and after periods of rest |
| myalgia | muscle pain |
| what approach should be taken when assessing objective data of the musculoskeletal system? | head to toe, proximal to distal |
| crepitation | is an audible and palpable crunching or grating that accompanies movement. |
| paralysis | is loss of motor function due to a lesion in the neurologic or muscular system or loss of sensory innervation |
| dysmetria | is the inability tocontrol the distance, power, and speed of a muscular action |
| paresthesia | an abnormal sensation |
| dysarthria | difficulty forming words |
| dysphasia | difficulty with language comprehension or expression |
| early indicators of alzheimer | memory loss and cognitive decline |
| asterognosis | the inability to identify objects that are placed in the hand |
| graphesthesia | the ability to read a number by having it traced on the skin |
| clonus | is a set of rapid, rythmic contractions of the same muscle |
| hyperreflexia | is the exaggerated reflex |
| hyporeflexia | is the absence of a reflex |
Created by:
BLanders
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