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4 broad goals of professional nurses
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Health assessment
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HEALTH ASSESSMENT
| Question | Answer |
|---|---|
| 4 broad goals of professional nurses | to promote health to prevent illness to treat human responses to health or illness to advocate for individuals, families, communities, and population |
| Health assessment | Gather information analyzing and synthesizing making judgments about nursing interventions evaluating patient care outcomes |
| primary prevention | avoid from getting anything immunization, washing hands, education |
| secondary prevention | early identification of illness exams, blood test |
| tertiary prevention | avoid illness from getting worse preventing from recurrence, take medication on time |
| subjective and symptoms | what the patient tells you |
| objective and signs | what you see or notice about patient |
| 3 types of assessment | Emergency Focused Comprehensive |
| emergency assessment | short, life threatening |
| focused assessment | based on patients problem |
| long term care assessment | once a month |
| intensive care assessment | every min or hr |
| 3 major framework of assessment | functional assessment head to toe assessment body system assessment |
| general survey | begins when you first meet client physical appearance mental status mobility behavior |
| vital signs | temp pulse res rate bp O2 pain |
| BP | systolic: ventricular contraction diastolic: ventricular relaxation |
| factors affect BP | age gender race diurnal medication personal habits pain emotions obesity |
| KOROTKOFF sound | phase 1: sharp thuds, start of systolic bp phase 2: blowing sound phase 3: crisp thud phase 4: sounds become muffled phase 5: end of sound, ends at diastolic bp |
| false high BP measurement | arm above heart level loose cuff narrow cuff deflating very slow re-inflating without deflating completely not waiting 1-2 min before repeat |
| false low BP measurement | hand below heart level cuff too wide manometer higher than heart deflating to fast not inflating enough pressing firmly on diaphragm |
| BP in adult | normal 120/80 prehypertensive 120-139/80-89 stage 1 hypertension 140-159/ 90-99 stage 2 hypertension more than 160/100 |
| Temperature | regulated by hypothalamus |
| factor affect Temp | age diurnal variation: decrease in morning, increase in late afternoon and evening menstrual cycle: decrease exercise: increase stress: increase |
| sites of temp | axillary: 96.7-98.5 6-9 min oral: 97.7-99.5 2-3 min rectal: 98.7-100.5 2-3 min tympanic: 98.2-100 2-3 sec temporal: 98.7-100.5 |
| Normal HR | adult: 60-100 newborn: 120-170 1 yr: 80-160 3 yr: 80-120 6 yr: 75-115 10 yr: 70-110 |
| orthostatic hypotension | drop in BP as you stand |
| signs and symptoms of hypertension | HA flushing ringing in the ear nose bleed |
| sign and symptoms of hypotension | increase HR dizziness cool clammy |
| hyperthermia | very high fever |
| hypothermia | very low fever |
| febrile | fever |
| afebrile | without fever |
| factor affect pulse | increase with exercise, fever, and stress decrease with male, age, and athletes |
| bradycardia | slow pulse |
| tachycardia | fast pulse |
| respiration | ventilation: movement of gases diffusion: movement of oxygen and carbon perfusion: distribution of red blood cells |
| tachypnea | fast respiration |
| bradypnea | slow respiration |
| apnea | no respiraiton |
| dyspnea | difficult breathing |
| orthopnea | difficult breathing lying down |
| preinteraction | review of medical record before interviewing the patient |
| factor affect interview | physical setting nurse behaviors type of questions and how they are asked personality and behavior of clients |
| active listening | concentrate on clients response don't formulate next question don't make assumptions |
| facilitation | encourage client to continue talking |
| clarification | gather more information about conflicting |
| restatement | repeating what client says using different words |
| reflection | repeating a phrase client just said to indicate interest |
| confrontation | inconsistencies between what client reports |
| interpretation | sharing conclusions |
| summary | orders data to clarify sequence of events |
| techniques that diminish data collection | using medical terminology expressing value judgments interrupting the client or changing the subject being authoritarian using why question |
| symptom analysis | C: characteristics O: onset L: location D: duration S: severity P: precipitating factor A: alleviating/ aggravating factors T: treatment |
| pruritus | itching |
| turgor | skin elasticity |
| edema | accumulation of fluid in intracellular spaces |
| nail | flat/slightly rounded(convex) nail base angle 160 capillary refill 1-2 sec |
| cyanosis | blue |
| pallor | white |
| jaundice | yellow |
| erythema | redness |
| ecchymosis | bruising |
| telangiectasia | irregular red line caused by dilation of blood vessels |
| cherry angioma | benign tumor, small slightly raised bright red area on face, neck, and trunk |
| purpura | reddish purple, non blancheable |
| petechiae | flat reddish purple, non blancheable |
| capillary hemangioma | port wine stain, stork bite |
| vascular spider | telangiectasia with radiating spider legs, blancheable |
| venous star | telangiectasia, non palpable, flat, bluish star-shaped lesion |
| assessment of mole melanoma | A: asymmetry B: border irregularity C: color uneven D: diameter > 6mm E: evolved or changed over time F: feeling (itch, tingle, sting) |
| primary lesions | macule or patch papule or plaque nodule or tumor vesicle or bulla wheal pustule cyst |
| abnormal nail finding | clubbing hypertrophy thinning/brittleness koilonychia inflammation pitting leukonychia beau's lines |
| types of headaches | migraine cluster tension post traumatic |
| migraine headaches | start anytime young females most susceptible 72 hrs unilateral pain photophobia |
| cluster headaches | painful 30-40 yrs common in men 1/2 to 1 hr repeat daily behind one eye |
| tension headaches | 20-40 yrs bilateral to specific area last for days skeletal muscle of face and jaw tight band around head |
| post traumatic headaches | secondary to head injury common cause motor vehicle accident days to weeks after injury |
| hyperthyroidism | graves disease most common cause 20-40 females |
| hypothyroidism | autoimmune |
| hydrocephalus | abnormal accumulation of CSF |
| microcephaly | head is too small genetic, chromosomal, toxic stimuli |
| macrocephaly | head is too big defective embryonic development or degenerative disease |
| nasal discharge color | clear: normal white: infection viral yellow, green: infection bacteria |
| infant mouth | drooling at 3 month or until able to swallow teeth 6-24 month |
| children mouth | frontal sinuses absent until 7-8 yrs permanent teeth 6 to 18 yrs |
| allergic rhinitis | inflammation of nasal mucosa |
| Epistaxis | nosebleed cause by un-control hypertension |
| candidiasis/thrush | opportunistic infection soft white plaques on tongue, buccal mucosa, posterior pharynx |
| shape ribs | 45 degrees to spine coastal angle less than 90 |
| fine rales/crackles | high pitched crackling collapsed or fluid filled alveoli |
| coarse rales/crackles | loud, low-pitched bubbling collapsed or fluid filled alveoli |
| wheezes | high-pitched blocked airway due to inflammation |
| ronchi | low-pitched, snoring, rattling blocked airway due to inflammation plus fluid |
| stridor | loud, high-pitched crowing upper airway is blocked |
| friction rub | low-pitched grating plueral inflammation |
| infant resp | round thorax nose breathers until 3 months 10-15 sec apnea seesaw breathing |
| grunting | try of force trapped air out of lungs |
| acute bronchitis | inflammation of bronchial tree caused by viruses or bacteria |
| chronic bronchitis | inflammation of bronchial tree productive cough 3 months of 2 successive years |
| pneumonia | infection of terminal bronchioles/alveoli caused by bacteria, fungi, viruses |
| tuberculosis | bacterial infectious disease |
| pleural effusion | fluid in the pleural linning |
| empyema | purulent/pus in pleural lining |
| asthma | hyper reactive airway disease |
| emphysema | abnormal enlargement of air spaces |
| pneumothorax | air entering plural space |
| hemothorax | blood in plural space |
| atelectasis | accumulation of secretions in terminal bronchiole |
| s1 | louder in mitral and tricuspid |
| s2 | louder in aortic and pulmonic |
| s1 and s2 | lub dub |
| veins | take deoxygenated blood to lungs |
| artery | bring oxygenated blood back to the heart |
| apical pulse | point of maximum impulse |
| homan's sign | to assess DVT |
| s3 | ventricular gallop ken-tuck-y |
| s4 | atrial gallop ten-es-see common in older adult |
| murmurs | swishing or blowing sound heard at beginning, middle, pr end of the systolic or diastolic phase |
| strength pulse | 0: absent, not palpable 1+: pulse diminished, barely palpable 2+: easily palpable, normal 3+: full pulse 4+: strong, bounding pulse |
| left side HF | failure of ventricles to pump blood efficiently pulmonary edema precordial movement bilateral pulmonary crackles |
| right side HF | cell necrosis from infarction blood backs up in right atrium systolic murmur dependent peripheral edema |
| venous insufficiency | color: normal or cyanotic temp: normal pulse: normal edema: often marked skin: brown pigmentation around ankles |
| arterial insufficiency | color: pale, dusky red temp: cool pulse: decreased or absent edema: absent or mild skin: thin, shinny |
| ascities | accumulation of fluids |
| peptic ulcer disease | lower end of esophagus, stomach, or duodenum |
| crohn's disease | inflammation mouth to anus, most common terminal in ileum and colon |
| ulcerative colitis | chronic IBD starts in rectum and progresses through large intestine |
| diverticulitis | inflammation of diverticula, herniations through muscular wall in colon |
| viral hepatitis | inflammation of liver |
| cirrhosis | chronic degenerative liver disease, diffuse destruction/regeneration of hepatic parenchymal cell |
| cholecystitis with cholelithiasis | inflammation of gallbladder with gallstone |
| pancreatitis | acute or chronic inflammation resulting from auto digestion of the organ |
| cystitis | urinary bladder infection |
| urethritis | urethra infection |
| pyelonephritis | renal pelvis infection |
| glomerulonephritis | inflammation of renal glomeruli caused by autoimmune process |
| nephrolithiasis | formation of stones in kidney pelvis |
| Barlow-Ortolani maneuver | birth-2 month adduct/abduct test for infants |
| osteoporosis | genetic one side risk for fracture |
| rheumatoid arthritis | genetic both side stiffness ulnar deviation swan neck deformity |
| osteoarthritis | degenerating cartilage joint deformities heberden's bouchard's nodes |
| gout | increase in serum uric acid tophi: round pea-like deposits |
| phalen's and tinels sign test | for carpal tunnel syndrome |
| CN 1-12 | 1 olfactory 2 optic 3 oculomotor 4. trochlear 5. trigeminal 6. abducens 7. facial 8. auditory 9. glossopharyngeal 10. vagus 11. spinal accessory 12. hypoglossal |
| plantar test | to assess Babinski response |
| Glasgow coma scale | assess LOC using 15 points |
| PERRLA | pupils equal round reactive to light and accommodation |
| ptosis | dropping |
| consensual and direct to light | light on left right constrict and light on right left constrict |
| rosenbaum test | to assess CN 2 |
| infants eyes | peripheral vision developed at birth, central vision at 9-12 month 1 month: can fixate, follow light 2-3 month: tears, may see strabismus 3-4 month: fixate, follow n reach for toy 6-12 month: follow a toy in all direction 8 month: distinguish color |
| allen picture card test | 2.5 to 3 yrs |
| snellen's E chart test | 3 to 6 yrs |
| snellen's chart test | 7 to 8 |
| presbyopia | loss of lens elasticity |
| cataract | denaturation of lens protein caused by aging blurred vision can also be cause by trauma to eyes |
| diabetic retinopathy | caused by diabetes mellitus common in 20 to 75 dark spot in vision 2 types background and proliferative |
| glaucoma | damage retina by intraocular pressure leading cause of blindness in USA center is okay and peripheral is bad 2 types: open and closed angle |
| Macular degeneration | caused by hypertension common in 65 and up center is bad and peripheral is okay |
| tinnitus | ringing in ears |
| vertigo | when the room is moving/spinning |
| dizziness | when you are moving/spinning |
| ear is called what | auricle or pinna |
| helix | the hard part of ear |
| cauliflower ear are called what | boxers ear |
| normal tympanic membrane | pearly gray and concave |
| ear assessment | under 3: pull down over 3: pull up adult: pull up and back |
Created by:
anuali
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