FINAL EXAM: Assessment and Health Promotion

4/29 @0800

Steps of the nursing process (review)

Assessment

Analysis (Nursing dx)

Planning

Implementation

Evaluation

Nonmaleficence (review)

Do no harm

Beneficence (review)

Promoting good for patients

Justice (review)

Be fair when providing care

4 types of assessment

1. inspection- looking carefully at pt

2. Auscultation

3. Palpation

4. Percussion

Tools needed for inspection

• Penlight

• Tape measure 

• Pulse ox

• Items for height and wt measurement

Types of Involuntary movements

• Fasciculation-twitch/quivering
• Myoclonus- muscle jerks/spasms
• Tic
• Tremors

BMI classifications

• Underweight less than 18.5 kg/m

• Healthy weight 18.5 to 24.9 kg/m

• Overweight 25 to 29.9 kg/m

• Obesity 30 and above

Calculation for BMI

BMI = weight (kg) / height (m)²

Pulse locations

Pulse strength scale

• 0 = an absent, impalpable pulse

• +1 = a weak, thready, diminished pulse

• +2 = a normal, brisk pulse (expected finding)

• +3 = an increased, strong pulse

• +4 = a bounding, full volume pulse

Visceral pain

in organs, deep cramping, squeezing (appendicitis) (colitis)

Somatic pain

MS system, muscles, bones, tendons

• throbbing/aching

• broken bones

• trauma

Acute pain

Less than 6mo

• AKA transient pain

PQRST for pain assessment

• Provocation/Palliation. What were you doing when the pain started? What makes it better? What makes it worse? What triggers the pain? What relieves it?

• Quality. Describe the pain. Is it dull or sharp? Is it stabbing, throbbing, or cramping?

• Region. Where is the pain? Does it radiate? Is it localized?

• Severity. How severe is it? Does it interfere with activities? How long does it last?

• Timing. What time did it start? How long does an episode last? Is it sudden or gradual onset? Occur during day? Night?

Tanner’s Clinical Judgment Model

1. Background - on the situation

2. Noticing - what was initially noticed about the situation/as time went on (assessment of skin, ect)

3. Interpreting - what do you think about the situation? Have you ever been in a similar one? What other data do you need (Ex. pt has RLQ pain, you think it is appendicitis)

4. ) Responding: What is your goal for the patient/family/staff? Interventions and nursing response (ex. Applying O2 to a pt with low sat)

5. Reflection in action: What happened? What was the response? (Ex. Pt oxygen improved)

6. Reflection on action: What did you learn from the experience that could improve future practice?

Functional assessement

Determined patients ability to care for self when not experiencing an acute illness

• lifestyle

• living environment

• ADL ability

• Internal factors (stress, activity, sleep, ADLs, spirituality, substance abuse)

• External factors (occupational health, living environment, relationships, maltreatment)

Where to assess for cyanosis on darker skin

Oral mucosa and nail beds, palms and soles

Ecchymosis

A discoloration of the skin resulting from bleeding underneath, commonly known as a bruise.

Expected variations of skin assessment

• acne

• wrinkles

• scars

What might velvety skin be indicative of?

Thyroid disease

Purpura

petechiae and ecchymosis covering an area

• bleeding disorder

ABCDs of skin lesion assessment

Asymmetry: Compare one side of the lesion with the other side. The two halves of the lesion do not look the same. They are not a simple round circle or an oval shape. They look radically different from each other.

Border: The Lesion has an irregular outline

Color: Color variation within the lesion (areas of brown, tan, black, blue, red, white, or a combination of those colors.

Diameter: Diameter of the lesion greater than 6 mm (the size of a pencil eraser) at its largest dimension.

Evolving: Lesions change rapidly in size

Stage 1 pressure ulcer

Non-blanchable reddened area

• do NOT rub

Stage 2 pressure ulcer

Partial loss of dermis (top layer)

• pink wound bed

Stage 3 pressure ulcer

Full thickness tissue loss involving subcutaneous tissue, may expose fat.

Stage 4 pressure ulcer

Full thickness tissue loss with exposed bone, tendon, or muscle.

Assessment of edema

To palpate for pitting, use your thumb or index finger to apply pressure for 3 to 4 seconds

1+ denoting a barely detectable indentation

4+ denoting a depression of 8 mm or more that persists for a long time.

Primary prevention

An intervention completed before there is evidence of injury or disease, reduce risk factors

• Ex: encouraging exercise and healthy eating to prevent obesity

• Ex vaccine clinics

Secondary prevention

During disease process, early screenings

• Ex. check BMI during well checks to determine weight status

Tertiary prevention

After the injury or disease is established. Stop bad from getting worse (sick care, hospitals)

• Ex. help individuals lose weight to prevent long term effects of obesity

Beck-depression inventory

Self screens for depression (17-20=borderline clinical depression and higher is worse)

AUDIT form

Alcohol screening form

15-20=moderate to severe use

DAST

Drug abuse screening - no alcohol or tobacco use

3-5=moderate… higher is worse

Edinburg scale

For postpartum depression

10 or higher=pp depression

Normal resting pupil size

3-5mm

Define flexion, extension, hyperextension, adduction and abduction of the upper extremities

Define flexion, extension and pronation/supination of arms/elbows

Define flexion, extension, hyperextension and lateral flexion of the torso

Describe dorsiflexion, plantar flexion, inversion, eversion, flexion and hyperextension of the feet

How much calcium should one intake per day

1000-1200 mg daily

How much vitamin D should one intake per day

600-800 IU

GCS scale

Eyes: 4

Verbal: 5

Motor: 6

Total: 15

Steps of abdominal assessment

Inspection, auscultation, palpation.

• listen to right lower quadrant first

How many BS per min

5-34

Is voluntary guarding an expected variation

Yes typically caused by lack of relaxation, involuntary guarding is when there is rigidity even with relaxing (for abd assessment)

• have pt exhale

Male v Female urethra lengths

Male: 20 cm (8 inches)

Female: 3-4cm (1-1.5 inches)

Types of feeding tubes

Nasogastric - goes into stomach

Nasojejunal - goes past stomach into jejunum

Nasointestinal - for high aspiration risk pts- short term, usually less than 4 weeks

For duodenal and jejunal feeding tubes, how much extra tubing would you add?

20-30cm (8-12 inches)

How often should the nurse check residual volumes on a feeding tube?

q4-6 hours

If using bag for formula administration through feeding tube, how much formula should you add at one time?

Enough to last about 4 hours

• change the bag every 24 hours

How often should the nurse flush the feeding tube?

Before and after each feeding, after med admin/residual checks and every 4 hours to maintain patency

• 30-50 mL of water

Thoracic vs diaphragmatic breathing

• Thoracic breathing involves using the upper chest and is more common in women

• diaphragmatic breathing engages the diaphragm for deeper, more efficient breaths and is more common in males

orthopnea

Difficulty breathing while laying supine

Barrel chest occurs with what dx

COPD

Cheyene-stokes breathing

“ Start stop” breathing

The pt will have deeper breathing that may quicken, followed by hypoventilation and progress to apnea, a lack of respirations.

Ataxic breathing

unexpected pattern with periods of apnea and irregular breathing at varying depths

• brain injury, meningitis, resp. depression

Pleural friction rub

May be felt on palpation of respiratory system, felt as a “grating” sensation

• can also be heard on auscultation

How often should the pt perform TCDB and IS

TCDB q1h or q2 hours when asleep

IS 4-10 times per hour

Types of breath sounds

• tracheal - high pitch/loud intensity

• bronchial - high pitch/loud intensity

• vesicular - intense and loud airflow in the upper anterior lobes but have a softer intensity with a low pitch throughout the other lobes. These breaths are soft-sounding like wind blowing through trees

• bronchovesicular - especially on the right—have a moderate intensity and pitch

Crackles

fine pops like a rice crispy treat

wheezes

whistling sound

Rhonchi

Low pitched bubbling/snoring sounds

Stridor

High-pitched sound during breathing, often indicating airway obstruction.

Assessment of jugular and carotid arteries

HOB @ 35° to 45° angle

• Position yourself on the pts right side and inspect the neck for its tone, symmetry, veins, and pulsations.

• Ask the pt to turn their head away from you and use your penlight to inspect the jugular vein area for pulsations (located on top of the sternocleidomastoid muscle). It is expected to observe a slight visible pulsation in the jugular area without distention of the veins.

• absent pulsation of the carotid arteries is abnormal

What does JVD indicate?

R sided heart failure

Are visible pulsations in the PMI area normal?

Yes but may not be

• should not be prominent and thrusting (heave/lift)

What should you use the bell vs diaphragm for? (stethoscope)

• The diaphragm is used to listen to high-pitched heart sounds such as S1, S2, and some murmurs.

• The bell of the stethoscope is used to identify unexpected lower-pitched sounds, such as S3 and S4.

Auscultation pattern for heart sounds

APe To Man

Normal nail bed curve

160 degrees

Peripheral arterial disease (PAD)

Reduced blood flow to the limbs (arteries carry blood AWAY from the heart)

• pain with activity

• skin is cool and shiny, pale, hairless

• weak or absent pulses

Peripheral venous disease (PVD)

Veins not taking blood back to heart (blood pooling)

• edema

• skin is warm, thick, brownish, tough

• pulses are present

• pain is worse when standing and improves when sitting or elevating the legs.

Unexpected findings for breast tissue

• Thickened rough skin, unilateral dilated veins, dimpling of the skin, edema, inflammation, or a unilateral rash are all findings associated with breast cancer.

• Peau d’orange is when the breast tissue resembles the skin of an orange. It is caused by edema, which dilates the hair follicles. This finding is associated with breast cancer.

• An inflamed, warm, edematous breast can indicate the presence of an infection in the breast tissue.

Screening for breast cancer

Self exams: should be done 4-7 days after start of menstrual cycle

Mammograms: beginning at age 50 q2 years for average risk and 40 for increased risk

• done until age 74

congenital dermal melanocytosis

Often appears in infants with darker skin on lumbosacral area/near the shoulders… should not be mistaken for bruising.

When are tonsils able to be visualised in children

The tonsils are not usually able to be visualized until 6 to 9 months of age and will appear enlarged throughout childhood.

What pulse should you assess in patients less than 2 years of age instead of the carotid?

Brachial

Heart murmurs in children

In addition to S1 and S2, S3 may be heard in some children.

• An S3 sound occurs during ventricular filling, sounds like the word Kentucky, and can be considered normal in children.

• The presence of S4 on auscultation is always a pathologic finding, and sounds like the word Tennessee. 

Types of pain scales for infants

• neonatal infant pain scale (NIPS) (birth-12mo)

• Riley infant pain scale (RIPS) (up to 12 mo)

• r-FLACC (infant-7 years and for non-verbal)

Types of pain scales for children

• FACES (3-8 years)

• Visual analog scale (7+ years)

• Numerical scale (8+ years)

Palmar grasp reflex

A reflex in infants that causes them to grasp objects placed in their palms

• should be gone by 3mo of age

normal newborn HR

110-160 BPM

normal newborn RR

30-60 breaths per minute

• count for 1 full min

Ear placement on infants

The pinna of the ears should be aligned with an imaginary line drawn horizontally from the outer eye canthus; ears set lower than that line may be associated with genetic disorders.

Ronchi in the newborn

rhonchi presents immediately after delivery and should clear by 48 hr of age

Murmurs in newborns

A soft murmur is expected for the first 24 hr of the newborn’s life

Moro (startle reflex)

With the newborn in the supine position, holding the newborn’s hands, pull the newborn up about 1 to 2 cm from the surface, then quickly let go. The arms abduct, at the shoulder, then extend outward with fingers spread, followed by flexion and abduction.

• This reflex should disappear by 6 months of age. 

Rooting reflex

With stroking of the cheek, the newborn turns to that side and makes a sucking motion

• (should disappear by 3 months of age). 

Stepping reflex

Hold the infant in a vertical position with the feet in contact with a flat surface. The infant lifts the feet alternately as if stepping

• (disappears by 1 to 2 months of age). 

Tonic neck reflex

With infant in supine position, turn the head to one side—the upper and lower extremity on that side extend, while the contralateral extremities flex (fencing posture).

• This reflex disappears by 6 months of age. 

Nevus simplex

‘stork bites’ common in infants, not abnormal

Fine pincer grasp

Usually occurs by 12 mo of age

Fontanel closure times

• The posterior fontanel closes between 6 weeks to 2 months of age.

• The anterior fontanel will close on average in the majority of infants by 18 months of age.

Babinski reflex

Stroke along the lateral portion of the sole of the foot, up across the plantar area. With a positive sign, the toes splay and extend with the particular extension of the great toe.

• This reflex is a typical finding in infants to 1 year of age

• flexion is a negative babinski, should occur s/p 1 year

Nagels ’s rule for determining due date

LMP - 3mo + 7 days

Classic manifestations of preeclampsia

Headache, vision changes, epigastric pain, abd pain, edema of face and hands

With false labor the cervix does not __

Dilate or efface

Fundal height measurment

From weeks 18-30, the fundal height (in cm) is the same as the weeks of gestation

• have pt empty bladder first!

• Symphysis pubis to top of fundus (measure)

Latent phase of labor (1st stage of labor)

Cervix softens/effaces to allow for dilation

Active phase of labor (1st stage of labor)

Cervix dilates, fetal presenting part descends