health assessment final

importance of hand hygiene

before and after patient care

inspection percussion palpitation auscultation

inspection: looking

percussion: tapping and hearing

palpitation: feeling

auscultation: hearing

how nurses define themselves

ANA scope and standards of practice

ANA code of ethics

1. to promote health

2. to prevent illness

3. to treat human responses to health and illness

4. to advocate for individuals, families, communities

nurses vs physicians

physicians focus on physical aspects of disease

• diagnose and prescribe

nurses focus on patient than disease

levels of preventation

primary: prevents problem

secondary: early diagnosis/screening

tertiary: prevent complications of existing disease

steps of nursing process

assessment: recognize cues, gather data

diagnosis: cluster data, prioritize hypothesis

planning: generate solutions, predict outcomes

implementation

evaluation

shift assessment

abbreviated head to toe physical assessment

comprehensive assessment

full head to toe physical assessment and health history

focused assessment

more detailed assessment of 1 body system/region

urgent assessment

ABCS

airway

breathing

circulation

subjective data

from the opinion of the patient

objective data

measured and observed by the nurse

importance of skin tone, speech, LOC, overall appearance

being able to tell between sick and not sick across the room

gcs

glassglow coma scale

assesses level of consciousness

3 = deep coma

15 = fully alert

sick or not sick across the room assessment

airway

• stridorous

• muffled speech

• LOC to protect airway

breathing

• working hard to breathe

• speak full sentences without catching

circulation

• uncontrolled bleeding

• pale or ashen

disability (neurological)

• alert and interactive

• LOC or altered mental status

assessing LOC and orientation

A/O

glassglow coma scale

normal temp range

37 C

98.6 F

normal heart rate ranges

60-100 bpm

normal SPO2 rate ranges

90-99%

88-99% in colorado springs

normal respiratory rate ranges

12-20

normal blood pressure rate ranges

systolic: 90-120

diastolic: higher than 80

circumstances of using a rectal thermometer

infants and toddlers

when someone is unconscious or intubated

reasons for HR to speed up

physical activity

increased metabolic demands

early sign of shock

medications

SNS activation

reasons for HR to slow down

at rest

late sign of shock

parasympathetic nervous system activation

SBP, DBP, MAP

systolic: force exerted when ventricles contract

diastolic: at rest btwn beats

MAP: weighted average btwn SBP and DMP and used to measure brain perfusion

relationship btwn RR and blood acidity

↑ RR = ↑ acidity

↓ RR = ↓ acidity

compensated shock

body working hard to keep perfusion

bp normal, signs of SNS activation

↑ HR, ↑ RR, diaphoresis, sometimes pale skin

decompensated shock

body exhausted compensatory resources

bp ↓

confusion, ↓ urine output, ↑ lactate and creatinine

low SPO2

sepsis criteria

temp: higher than 38, lower than 36

heart rate: greater than 90bpm

tachypnea: greater than 20bpm or PaCO2 less than 32

wbc: less than 4,000 or greater than 12,000

has to have sirs and confirmed/presumed infection

main components of health history

HPI: history of present illness

PMH: past medical history

ROS: review of systems

familt/social/cultural history

PQRST

provocative/palliative

quality

region/radiation

severity

timing

what, when, where, why, how

phases of interview

pre-interaction: review info you already have

beginning: introduce yourself, state purpose, privacy, infection control

working: closed ended questions (directive) + open ended questions (non directive)

closing: would you agree? give preview of interventions

open vs close ended questions

open: can’t be answered with yes or no

closed: yes or no answer

primary vs secondary data

primary from patient

secondary from family, friends, witnesses

nociception steps

transduction

transmission

modulation

perception

modulation is affected in controlling pain

pain definition

whatever the patient says it is

always subjective

opioid production

body produces its own endogenous opioids

• neurotransmitters that modulate and inhibit pain

pain presentations

visceral: deep organ

somatic: muscle, bone

cutaneous: skin

referred: pain felt in location different from where the damage is

• gallbladder in shoulder

• heart pain in arm/neck

skin layers outer to inner

epidermis

dermis

subcutaneous

skin reflection of other body systems

perfusion: pinkish hue

liver: yellow skin in liver failure

hydration/nutrition: skin turgor

respiratory: cyanotic indicates hypoxia around mucous membranes

infectious/allergic rxn: rash, hives

urgent skin assessments

related to oxygenation or circulation

airway issues w allergic rxns if there is widespread hives/itching

acute dehydration, cyanosis, laceration

acute trauma/burns

rash + fevers

• infection protocols → measles or varicella

ABCDE melanoma

asymmetry

border irregularity

color variety

diameter greater than 6mm

evolution over time

flushing vs errythema

flushing: temporary and generalized increased permeability of peripheral capillaries

• exercise, elevated temp, hot climate

errythema: redness caused by injury, irritation, or inflammation

• localized, increased dilation and permeability of vessels

cyanosis

bluish tint

sign of hypoxia (lack of oxygen)

present over lips and mouth

pallor

lack of reddish tint

sign of inadequate perfusion or increased peripheral vascular resistance

jaundice

yellow tint due to liver failure

visible in sclera before skin

lesion

an area of abnormal tissue

• alteration or discontinuity

macule

small flat discoloration

papule

small raised, solid, defined

vesicle

small fluid filled (serous)

pustule

small pus filled (purulent)

petechiae, purpura, ecchymosis

red to purple non-blanchable macular lesion

bleeding under the skin that seeps into surrounding tissue

different sizes of same process

hematoma

collection of blood under the skin usually results from blunt force trauma

laceration

tear in skin any depth of any size

abrasion

shear force or friction against the skin, removing several layers and exposing the dermis

avulsion

trauma forced the skin to separate from underlying structures leaving an open raged wound

burn staging

stage 1: only epidermis, red, no blisters, dry

stage 2: affects dermis, blistered, skin breakdown

stage 3: affects all layers, white and nonblanchable, minimal pain

stage 4: charred skin

ulcer staging

stage 1: non-blanchable erythema of intact skin

stage 2: partial thickness skin loss, exposed dermis

stage 3: full thickness skin loss, exposed subcutaneous layer

stage 4: full thickness skin loss, exposed muscle tendon or bone

categories of braden scale

sensory perception

moisture

activity

mobility

nutrition

friction/shear

pressure ulcer risk interventions

turn every 2 hours

specialty mattress (air)

offload bony prominences

manage moisture

early ambulation, good nutrition

pleural space function

negative pressure

lungs suction to edges of the wall

requires a closed system

inhalation: diaphragm relaxes

exhalation: diaphragm contracts

home and work respiratory risk factors

home: allergens, toxins, second hand smoke, tb risk with group homes

work: fumes → use of protective gear

dyspnea

altered breathing

• shortness of breath

• labored breathing

cough with sputum

(productive cough)

wheezing

asthma, COPD

musical with inhalation

orthopnea

shortness of breath when lying down

• excess fluid accumulates in the lungs with legs are up

“paraoxysmal nocturnal dyspnea”

urgent assessment + interventions for shortness of breath

assessment:

vitals

lung auscultation

interventions:

elevate head of bed

give O2 depending on oxygen sat

inhaler or treatment as ordered

assess anxiety

horizontal landmarks

midsternal line

midclavicular line

anterior axillary line

midaxillary line

posterior axillary line

scapular line

vertebral line

vertical landmarks

intercostal spaces

vertebral number

crackles

small airways popping open (alveoli)

fine: in smaller area of lung

course: severe respiratory edema

wheezes

from narrowed airways

higher pitched, more musical, whistiling

asthma, emphysema

rhonchi

lower pitched, more of a snoring quality

blockages/obstructions in larger airways

bronchitis, pneumonia

lower pitch meaning

larger airways affected

respiratory danger zone assessments

new or worsening dyspnea

decreased LOC

respirations > 32

oxygen sat less than 90% (in 88%)

increased WOB

absent or stridorous breath

absent breath sounds interventions

possible collapsed lung → call rapid response

chest tube

tension pneumothorax needs immediate decompression

stridorous breathing interventions

airway obstruction

call rapid response

intubation is pt can’t protect airway

epinephrine if allergy rxn suspected

basic labs and radiology with altered lung sounds

low O2, high CO2

elevated WBC

gram stain

ct scan for pneumonia, pleural effusion

BNP → congestive heart failure

expected interventions for severe pleural effusion

chest tube

thoracentesis

blood flow

deox from body

sup + inf vena cava

R atrium

tricuspid valve

R ventricle

pulmonary valve

pulmonary arteries

lungs

pulmonary veins

L atrium

mitral valve

L ventricle

aortic valve

aorta

body

S1 and S2

s1 start of systole

• louder in mitral and tricuspid (these valves closing)

s2 start of diastole

• louder in aortic and pulmonic (these valves closing)

why smoking, hypertension, high cholesterol are risk factors

smoking: increases SNS response, raises bp, degrades arterial quality

metabolic: atherosclerosis

jugular vein distention

fluid overload

tricuspid regurgitation

5 points of heart auscultation

aortic

pulmonic

erb’s

tricuspid

mitral

structural issues causing murmurs

stenosis (closing)

regurgitation (leaking)

initial assessments and interventions for acute chest pain

sick or not sick → altered mental state, cap refill, skin undertone

take vital signs

ECG

continous cardiac monitor

type of pain

congestive heart failure exacerbations

assessing fluid overload → lung sounds, edema, JVD

labs → BNP

imaging → chest xray, echocardiogram

interventions → diuretics, other meds

conjunctiva

pink membrane between lid and eye

sclera

white part of eye

auricle

top part where cartilage piercings go

lobule is the lobe

external auditory canal

tube from tympanic membrane from outer ear

sinuses

close to brain, attached to ear via auditory tube

turbinates

3 pairs of turbinates moisturize air coming in

soft, spongy tissue prone to congestion

oropharynx etc

throat

uvula → dangly thing

tonsils → soft tissue lymph nodes

epistaxis → nose bleed

oral cancer risk factor

chewing tobacco

common intervention for sleep apnea

sleeping in different position

CPAP

surgery

interventions for epistaxis

pinch pressure on nose and learn forward

EENT urgent assessments

ludwig’s angina → swelling of tongue

epiglottis → infection of epiglottis

anaphylaxis → throat edema

curtain across vision

change in smell

CNS vs PNS

CNS → brain, spinal cord

PNS → nerves spreading to rest of body

• cranial nerves

• spinal nerves

• autonomic nervous system

major brain structures

cerebrum

cerebellum

brainstem

frontal lobe function

complex cognitive