NRSE 210 Study Guide info

Subjective data

things the patient tells you (ex. describing feelings, pain)

Objective data

Things that can be observed

Steps to the nursing process

A- assessment (collect data)

D- diagnosis (analyze data)

P- planning (set priorities, goals)

I- implement (carry out interventions)

E- evaluation (determine if goals were met/adjust)

Database Types

• complete (full history and physical exam)

• focused/ problem- centered (limited, targeted to one issue)

• follow- up (checking status of identified problem)

• emergency (rapid collection of data)

Prioritization

ABC’s- Airway, breathing, circulation

1st- life threatening

2nd- attention to prevent deterioration

3rd- least threatening and can be addressed later

Types of pain

• visceral- organ pain

• deep somatic- musculoskeletal (joints, tendons, muscles)

• cutaneous- superficial, subcutaneous

• Referred pain- origin of pain is somewhere else than the pain

Pain History Question

P- provoke

Q- quality

R- region

S- severity

T- timing

U- understanding

Health History Sections

1) biographic data

2) source of history

3) reason for seeking care

4) Present health/ history of present illness

5) Past health (surgeries, allergies, medications)

6) Family history

7) RoS (review of systems)

8) Functional assessment

functional assessment

asking questions like self esteem, sleep habits, exercise, nutrient, social life. Assesses patients ability to care for themselves

Communication & interviewing

open ended questions, active listening, clarification, empathy, reflection, summarizing

• Avoid: false reassurance, interrupting, medical jargon

• Phases: introduction, working phase, closing

Phases of the physical exam

• Inspection (need privacy and good lighting)

• Palpation (sense of touch)

  • back of hand- temperature

  • base of fingers- vibrations

  • fingers/ thumb- organ/mass

  • fingertips- texture/ swelling

• Percussion- tapping to assess size, density, location (dull= dense organs) (flat= bones, muscles)

• Auscultation- listening to body sounds

  • Diaphragm- high pitched (bowel, great)

  • Bell- low pitched (heart murmurs)

BP parameters

• Normal: <120/<80

• Elevated: 120–129/<80

• Stage 1 HTN: 130–139/80–89

• Stage 2 HTN: ≥140/≥90

• Hypertensive crisis: ≥180/≥120

systolic

pressure during contraction

diastolic

pressure during relaxation

Pulse Assessment

• adults 60-100

• Infants 110-160

• 0 = absent

• 1+ = weak/thready

• 2+ = normal

• 3+ = full/bounding (seen with fear or exercise)

Tachycardia =100

Bradycardia <50

Respiratory Assessment

adult 12-20

infant 30-60

Temperature Assessment (and conversions)

Adult: 98.6F/ 37C

Infant/ adult fever: 100.4 F/ 40C

• 104°F = 40°C

• 98.6°F = 37°C

• 95°F = 35°C

BMI ranges

underweight <18.5

Normal 18.5- 24.9

Overweight 25-29.9

Obese class 1: 30- 34.9

obese class 2: 35- 39.9

obese class 3: 40+

1 pound = ? kg

.45kg

General Survey

1) physical appearance

2) body structure

3) mobility

4) behavior

Mental Status Cues

ABCT: appearance, behavioral, cognitive, thought process

PHQ-2 and PHQ- 9

PHQ-2: two questions, if > or equal to 2, do a PHQ-9

PHQ-9: nine questions

• 5-9 mild depression

• 10-14 moderate

• 15- 19= moderately severe

• 20- 27= severe

Both tests, each question is rated 0-3

Screening for Depression

GAD- 7

Screening for anxiety, 7 question assessment rated on a 0-3 scale per question

• 0-4 minimal

• 5-9 mild

• 10-14 moderate

• 15+ severe

MMSE

Mini Mental State Exam:

• 11 questions

• testing cognitive function (series of questions, repeated words, active recall)

• Average score is 27

• Max= 30

• No impairment= 24-30

• Mild impairment= 18-23

• Severe Impairment= 0-7