health assesment exam 1

what is clinical judgement model used for

assessing/judging a patients situation

list the 6 components of clinical judgement (rapgte)

recognize cues

analyze cues

prioritize hypothesis

generate solutions

take action

evaluate outcomes

ABC stands for

airway, breathing, circulation

what is ADPIE

nursing process

ADPIE (steps of nursing process)

Assessment

Diagnosis

Planning

Implementation

Evaluation

what are the 3 steps of the patient centered interview

orientation, working phase, termination phase

What is PICOT

question asking model

what does PICOT stand for

Population

Intervention

Comparison

Outcome

Time

AIDET stands for

acknowledge, introduce, duration, explanation, thank you

what is a primary source

information obtained directly by patient

secondary information

information from chart, family members, other healthcare workers

objective data

information that is seen, heard, felt, or smelled by yourself as the nurse

subjective data

what the person says about himself/herself during history taking

list 3 interview techniques

open ended questions, observation, back channeling

what is back channeling?

prompts such as "go on, I understand"

3 types of assessments

emergency, comprehensive, focused

explain a comprehensive assessment

detailed health history and physical examination of all body systems

activities of daily living

Daily basic tasks fundamental to everyday functioning like hygiene, elimination, dressing

chief complaint definition

main reason for a patients visit

instrumental activities of daily living

daily tasks that allow patients to function independently like, paying bills, preparing meals

main health care needs definition

used to classify what needs the patient feels are most important to address

medication reconciliation definition

comparison of a list of current medications with a previous list

sign definition

Objective data found by the nurse during assessment

symptom definiton

Subjective data that the patient reports (like "I feel dizzy")

what is the joint commission? (TJC)

accrediting agency for health care places, reports data on serious errors

What is the function of the National Database of Nursing Quality Indicators (NDNQI)?

find out how nursing workforce factors like staffing, influence patient outcomes

assessment

hands on data collection

What is cortical bone?

compact bone

What is cancellous bone?

spongy bone

3 types of muscle

skeletal, cardiac, smooth

what acronym can we use to assess pain

PQRST

what does PQRST stand for (questions for assessing pain)

Precipitating cause

Quality

Region

Severity

Timing

palliative definition

relieves the pain

preceptive definition

causes more pain

Wong-Baker FACES scale

A visual pain rating scale, such as Wong-Baker FACES, involves six faces with different expressions, this test is best for:

children

numeric pain scale

the numeric pain scale is best for:

adults

Pain Assessment in Advanced Dementia Scale (PAINAD) is best for:

chronically confused/disoriented patients

PAINAD scale

Adult Non-Verbal Pain Scale (NVPS) is best for:

Patients on ventilators/intubated or Inability to speak

NVPS scale

acute pain lasts between a few seconds to ___ months

6

chronic pain lasts ___ months or longer

6

list 3 objective indicators of pain

pale, fainting, guarding area of pain

EAT stands for ____ ____ ___, and can ONLY BE DONE BY A RN

evaluate, assess, teach

function of a tendon

attaches muscle to bone

function of a ligament

attach bones to bones

fascia definition

Layers of connective tissue that provide strength to muscles

bursae definition

sacs of connective tissue found at bony prominences or joints to relieve pressure and decrease friction

long bones

longer than they are wide

short bones

small cube shaped bones

flat bones

thin, flat, slightly curved

joint definition

articulation of two bones

what is a osteoblast

bone forming cells

what is a osteocyte

mature bone cell

what is a osteoclasts function

breaks down bone

capsule definition

encloses joint in fibrous connective tissue

function of a goniometer

measures ROM

Normal Physical Assessment of the Musculoskeletal System should include

full ROM

normal spinal shape

no atrophy

no joint swelling/tenderness

full muscle strength

3 examples of a diagnostic study of the musculoskeletal system

x-ray, MRI, CT scan

lordosis definition

excessive inward curvature of the spine

Kyphosis definition

upper back is abnormally rounded

5 rights of delegation (tcpcs)

right task

right circumstance

right person

right communication

right supervision

what is gender dysphoria

incongruence between assigned gender and experienced gender

list 3 positions you can use for patient assessment

supine, fowlers, prone

what is fowlers position

sitting in bed slightly elevated (like sitting upright in bed)

flexion

Decreases the angle of a joint

extension

increases the angle of a joint

abduction

movement away from the midline

adduction

movement toward the midline

pronation

palm down

supination

Palm up

Circumduction

circular movement at the far end of a limb

rotation

joint movement

inversion

turning sole of foot inward

eversion

turning sole of the foot outward

Dorsiflexion

bending the foot/the toes upward

plantarflexion

pointing the foot/toes down

what are the 4 types of physical assessment

inspection, palpation, percussion, auscultation

what order do you do a abdominal assessment

inspection, auscultation, percussion, palpation

what type of bone is full of bone marrow

cancellous

epiphysis of long bone

ends of long bones

Diaphysis (long bone)

shaft of a long bone

metaphysis

flared portion of a long bone

epiphyseal plate

cartilaginous area between the epiphysis and metaphysis

Periosteum

fibrous connective tissue that covers the bone

sesamoid bones

round bones found near joints

Epimysium

surrounds entire muscle

Perimysium

surrounds fascicles

Endomysium

surrounds each muscle fiber

isometric movements do or do not produce movement

do not

isotonic movements do or do not produce movement

do

2 sources of ATP

phosphocreatine and glycolysis

synovial joint (diarthrodial)

freely movable joint

hyaline cartilage

The most abundant cartilage type in the body; provides firm support with some pliability

fibrous cartilage

very tough form of cartilage

doo tendons and ligaments have a good blood supply

no

how does aging affect bones

increased reabsorption of bone, decreasing bone formation

osteoarthritis

cartilage damage