Health Assessment Test 1 - Units 1 and 2

Factors that affect pulse oximeter reading

Cold hands, nail polish, long fingernails, tremors, and positioning that affects lung expansion, any issues w/ breathing and perfusion

Bell

smaller piece of stethoscope used to hear soft, low-pitch sounds

Diaphragm

larger piece of stethoscope, used to hear high-pitch sounds

How to measure BP cuff size

between 1.5 and 2 times around the arm, width should be 40% of arm sircumference

If BP cuff is too long…

it may seem lower

If BP cuff is too short…

It may seem higher

Prone

laying flat on stomach

lateral recumbent

laying on side

dorsal recumbent

laying flat on back with knees bent

The nurse is working in a primary care clinic. She walks into the room and the general inspection begins. What is not part of the general inspection?

B. The patient is wearing clothes that are normally worn by females

Expected body temp

between 36 degrees C and 38 degrees C (96.8 degrees and 100.4 degrees)

Oral temperature

nice bc simple, convenient, comfy, and safe, but pt must keep their mouth closed and there can be errors

Tympanic

Fast and easy to use for kids over 6 months and unconscious pts, but it is a special thermometer that is more variable and risks injury

Axillary

safe and easy to use for children or uncooperative or unconscious patient, but doesn’t reflect core temp, one of least accurate sites, slow, and can be affected by sweat

Rectal

accurate core temp, alternative for pt unable to follow directions, but it’s embarrassing, risky for injury, and requires special positioning, it can be affected by diarrhea, rectal disease, and bleeding disorders

Temporal

accurate core temp, fast, safe, no discomfort, but it requires a special device and has errors, head wounds can affect it

These can affect oral temp reading

bradypnea and tachypnea

Newborn and infant BP

SBP: 60-80 mm Hg, DBP: 40-50 mm Hg

1-3 years, toddler BP

SBP - 80s mm Hg, DBP - 40s mm Hg

3-6 years, preschooler BP

SBP - 90s mm Hg, DBP - 40-50s mm Hg

6-12 years, school age BP

SBP - 90-100s mm Hg, DBP - 50-60s mmHg

12-20 years, adolescents, adults, and older adults BP

SBP - <120 mm Hg, DBP - <80 mm Hg

edema of 1+

Trace, 2 mm

edema of 2+

Mild, 4 mm

edema of 3+

Moderate, 6 mm

edema of 4+

8 mm

submental lymphnodes

below chin

submandibular lymph nodes

below jaw

Tonsillar lymph nodes

Jaw bone

Preauricular lymph nodes

in front of ear

Posterior auricular lymph nodes

Behind ear

Occipital lymph nodes

base of skull

Superficial cervical lymph nodes

middle of neck below ear

Posterior cervical lymph nodes

between neck muscles

supraclavicular lymph nodes

above clavicle

Deep cervical chain

neck

Valves

what you’re hearing when auscultating, aortic, pulmonary, tricuspid, mitral

Lub sound

closure of mitral and tricuspid valve, S1 sound

Dub sound

closure of aortic and pulmonic valves, S2 sound

electrical pathway of heart

heart stimulated by its own impulses, impulse comes from SA node in right atrium that initiates and triggers each heart beat, then impulse travels to AV node, then is transferred into branches of Purkinje fibers

Any defect in heart electrical system…

affects electrical pathway and the way it beats, causing dysrhythmia

pulse strength of 0

absent, unable to palpate

pulse strength of +1

Diminished, weaker than expected

pulse strength of +2

brisk, expected

+3 pulse strength

Increased, strong pulse

+4 pulse strength

full volume, bounding

cyanotic

blueness

right upper quadrant

the liver, gallbladder, duodenum

Right lower quadrant of abdomen

appendix, cecum, ascending colon

Left upper quadrant

stomach, spleen, pancreas, part of liver

left lower quadrant

small intestine, large intestine

subjective data

symptoms, what the patient states

objective data

signs, what you can see or observe

50% or below of plate being eaten

is abnormal and needs to be highlighted

24 hour recall

most accurate way to access dietary retake

Normal BMI

18-25

Underweight BMI

lower than 18

Overweight BMI

25-30

Obese BMI

over 30

culture

ideas, customs, and social behavior of a particular people or society

factors affecting psychosocial life

biological, psychological, and social details, functional abilities, self-efficacy, family relationships, Relationships w/ wider social environment, Interpersonal communication, social resources and networks

Things to inquire about when obtaining a complete health history:

stress sources, coping, depression, anxiety, resources, previous/current counseling

General survey components

physical appearance, hygiene, body structure and movement, emotional and mental status, behavior

Inspect physical appearance and hygiene with…

healthy appearance? tremors or facial droop? looks appropriate age? color and condition of skin? odors? well-groomed?

inspect body structure and position with…

stature and height appropriate for age, nutritional status, body symmetry and positioning

Body movement inspection

note how pt moves, any assistive devices? limitations in ROM? Involuntary movements?

inspecting emotional and mental status and behavior

alert, conversing appropriately? appropriate clothes for weather? pt maintaining eye contact as culturally appropriate? appropriate facial expressions?

Universal steps

Perform hand hygiene, ensure privacy, introduce yourself, confirm w/ name and DOB, place equipment near bedside, explain procedure, hand hygiene, perform procedure, hand hygiene again, ensure client is comfy, call light is in reach, bed is low and locked, hand hygiene

Motivational Interviewing

a client-centered strategy and evidence based communication method for nurses to enhance pt’s motivation to change behaviors

NOT about persuading people to change

Principles of Motivational Interviewing

Express empathy, develop discrepancy, roll w/ resistance, support self-efficacy

Developing discrepancy in MI

the motivation for change starts when there’s a difference between present behavior and values and goals of client

Examples of questions to develop discrepancy

how important is it to you to manage your disease? What would make taking the meds more important to you?

Roll w/ resistance

don’t argue for change, no direct opposition, don’t use words like “should”, warn what will happen if disease is ignored

Support self-efficacy

support client’s belief that they can change

OARS framework

For motivational interviewing
Open questions, Affirmations, Reflective listening, Summarizing

Barriers to Change

Complex regimen, forgetfulness or lack of support, lack of confidence in abilities, experiencing fear of side effects, cultural, low health literacy, probs accessing medical care, psych issues

Shifting focus

shift a person’s focus away from a barrier to progress and toward a workable solution

normal temp of babies

36.5-37.5 (97.7-99.5) axillary

1-3 years, toddler temp

37-37.5 (97.9-98.6)

3-6 years, preschooler temp

37 (98.6) oral

6-12 years

37 (98.6) oral

12-20 years, adolescent temp

37 (98.6) oral

adult older than 20

36-38 (98.6-100.4) oral

older than 65 temp

35-36.1 (95.9-99.5) oral

Newborn pulse range

110-160 bpm

1 mo. - 1 year pulse range

90-160 bpm

1-3 years Pulse Range

80-140 bpm

3-6 years pulse range

70-120 bpm

6-12 years pulse range

60-110 bpm

adolescent pulse range

50-100 bpm

adult pulse range

60-100

older adult pulse range

60-100 bpm

Newborn Respiratory rate

30-60 breaths pm

Infant respiratory rate

25-30 breaths per min

1-3 years respiratory rate

25-30 breaths per min

3-12 years respiratory rate

20-25 breaths per min

12-20 years respiratory rate

16-20 breaths per min

Adult respiratory rate

12-20 breaths per min

older adult respiratory rate

12-20 breaths per minute

expected O2 saturation across lifespan

95-100%