NURS 3108 - Exam #1

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Health assessment information (database)

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Health

240 Terms

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Health assessment information (database)

•History (Subjective Data-70%) • Physical Examination (Objective Data-20%) • Laboratory/Imaging Studies (Objective data-10%)

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subjective

symptom: what the patient feels/ communicates

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objective

Sign: clinical findings collected during physical examination

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Clinical manifestations

signs/ symptoms collected

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Three levels of health promotion

  1. Primary= promotion of healthy lifestyle

  2. Secondary= screening efforts to detect disease

  3. Tertiary= minimizing disability from illness/ injury to allow for most productive life within limitations

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Purpose of health history

subjective: picture into past and present

  1. comprehensive

  2. problem based

  3. follow- up

  4. screening

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Therapeutic communication

most important skill: is communication. -active listening -clarifying

  • reflecting

  • open-ended questions

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Non-therapeutic communication

  • using medical terminology w no explanation

  • interrupting

  • disagreeing

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Health illiteracy

patient does not understand, so help them understand with handouts, video, etc. Help patient understand

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Professional nursing behavior

calm, organized, competent, professional

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Health history: biographic information

name, age, gender, occupation

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CC (Chief Complaint)

presenting problem; why seeking care

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HPI (History of Present Illness)

History of present illness - brief history of as to what is wrong with the patient at the present time. chronological record onset- current

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HPI: presenting symptoms

-Start with "presenting" symptoms

  • Description of symptoms in patient's own words ->last time felt well, overall health before, previous episodes of similarity

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LOCSTAAM

Location, Onset, Character, Severity, Timing, Associated factors, Aggravating/Alleviating factors, Meaning to the patient

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OLDCARTS

Onset, Location, Duration, Character, Aggravating/ relieving factors, Related symptoms, Treatment, Severity

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Location

-Point to spot where it hurts or describe

  • Is it localized or generalized?

  • Does it radiate (or move toward or away from)?

  • Ex. stomachache: patient c/o pain in the RUQ that radiates towards the umbilicus

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Onset

-When did symptoms first start? -Precipiatating factors? -Setting in which symptom occured? -What were you doing at the onset of symptoms? -Where were you during the onset of symptoms? -Patient c/o pain in the RUQ that radiates toward the umbilicus x 2 weeks. Pain occurs after eating fatty foods

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Character

-What the patient feels or symptoms look like -Describe sensation or appearance to the best of the patients ability -Patient c/o stabbing pain in the RUQ thay radiates toward the umbilicus x 2 weeks. Pain occurs after eating fatty food Specific descriptive terms such as... burning, sharp/dull, aching, gnawing, throbbing, shooting, stabbing, crushing, cramping

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Severity

-Size, extent, number amount -Measure if possible -Grade on scale 1-10 (for A&O pts) -Better, worse, same? -How limiting are symptoms? -Patient c/o stabbing pain in the RUQ that radiates toward the umbilicus x 2 weeks. Pain= 5/10, occurs after eating fatty foods. No changes in level of pain since onset. For PEDS use: FACES

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Timing

  • Chronological (when started?)

  • Duration (how long have you had them & how long do they last?)

  • Frequency (constant, intermittent?)

  • Pattern (# times per day, week, month, after meals, at bedtime, etc)

  • Patient c/o stabbing pain in the RUQ that radiates toward the umbilicus x 2 weeks. Pain= 5/10, occurs 1-2 times per day after eating fatty foods and lasts 1 hour. No changes in level of pain since onset.

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Aggravating and Alleviating symptoms

-What makes the symptoms worse or better? -What aggravates them- weather, activity, food, medication, standing, bending over, fatigue, time of day, season, etc -What relieves symptoms? (rest, medication, ice, etc) What have you tried to do or take to relieve symptoms

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Meaning of symptoms to patient

What are you most worries about Did the pain wake you up from sleep How does it affect daily activities How they have been coping

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past medical history

Childhood Illnesses, adult illnesses, Accidents or Injuries, hospitalization, immunization, health examination, screening tests

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Family history

genogram, age currently, each persons state of health

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Screening tools

  • substance abuse screening (CAGE, TACE, CRAFFT)

  • domestic violence screening

  • eating disorder screening

  • adolescent screening for general issues HEADSS

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CAGE

cut down, annoyed, guilty, eye opener

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TACE

Take you to get high (how many drinks), Annoyance (who criticizes your drinking), Cut down on your drinking (should you cut down on your drinking?), Eye-opener (have you ever had an eye-opener drink to wake you up in the AM)

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CRAFFT

screening tool for substance abuse in adolescents Car, Relax, Alone, Forget, Friends, Trouble

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HITS (DV)

Hurt you physically, Insult or talk down to you, Threaten you with physical harm, Scream or curse at you

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HEADSS

Adolescent screening for general issues HEADSS(home life, education, substance use, emotional, sexuality)

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Present health status

current health condition, current medication, allergies

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General survey

  • 1 step of assessment

  • observation/ inspection

  • baseline of info

  • every day use

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SENSES to observe

only senses: visual- see/ look auditory- hear/ listen olfactory- smell tactile- tocuh/ feel

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Assessment done head to toe? Why do we do this?

cephalocaudal; clean to dirty

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key concept is to assess for:

symmetry

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Initial observation

mental status? Where did you find pt? General appearance? Overall development and nutrition Noticeable odor dress/ grooming hygiene appropriate

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first impression

speech Facial expressions & affect Behavior Breathing Age Response to questions Tremors/tics Eye contact skin color family posture

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assessment techniques

  1. Inspection

  2. Palpation

  3. Percussion

  4. Auscultation

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inspection 1

what do you see

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palpation 2

hands to detect tenderness/ painful areas

  • temp

  • texture

  • moisture

  • masses

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Light palpation

one hand 1/2 in deep (1 cm) RN's use

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deep palpation

two hands 1 1/2 in (4 cm)

  • organ size

  • advanced practice

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bimanual palpation

two hands to assess the kidneys and uterus

  • advanced practice

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percussion 3

striking, tapping of body to produce sound/ vibration

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Palpating technique

-finger pads are most sensitive part of the body

  • dorsal to assess temp

  • warm hands, short nails

  • tell pt

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direct percussion

involves striking a finger or hand directly against the patient's body

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indirect percussion

tapping a finger on another finger help against chest wall/ abdomen

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Auscultation 4

listening with stethoscope-- amplifies sound in body cavities/ blocks room sounds

  • must have diaphragm and bell

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Diaphragm

high-pitched sounds like breath, bowel, and normal heart sounds

  • hold firmly on skin

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Bell

best for low pitched sounds like extra heart sounds, murmurs

  • lightly against skin

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Culturally competent care

delivered when nurses value health or illness through patient's eyes

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Diverse cultural example

Native Indians emphasize spirituality

  • nurse touching someone has spiritual power

  • honor includes components of appreciation and respect

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"Melting pot"

U.S. has many cultures and religions

  • 20% speak other language than english at home

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Diversity can create challenges when caring for a patient but

do not force compliance but work with beliefs and value systems

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cultural competence

Learning process:

  • self-awareness

  • reflective practice

  • knowledge or core cultural issues

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cultural competence

  • recognizing ones own culture, values, biases, and using patient-centered communication skills

  • required acceptance

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Cultural competence requires healthcare providers to be sensitive towards__________

Patients Heritage, sexual orientation, socioeconomic situation, ethnicity, cultural background

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You are not responsible for knowing _a, practices, and values of all groups. You ARE responsible for asking about b

a) health beliefs b) beliefs

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Culture

All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview.

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Ethnicity

Social group within a cultural and social system that share common cultural and social heritage including: Ex. language, history, religion, symbols, folklore

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Race

is genetic in origin and includes physical characteristics Ex. skin color, bone structure, eye color, hair color

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religion

An organized system of beliefs, rituals, and practices with individual participants

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spirituality

broader concept: Prayer Meditation Listening to music Intentional appreciation of beauty Being present in the world with others

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Impact of culture

influences way patients seek medical care and clinicians provide care

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1 become culturally competent

respect pt by assessing individuals

  • beliefs, values, preferences, needs

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2 do not stereotype

recognize uniqueness

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  1. Develop a Template for Assessment

Direct the assessment of patient's health beliefs and practices that reflect his/her cultural heritage.

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Personal and psychosocial open ended questions

allow for the patient to give own response and elaborate

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open ended question examples

  1. roles in family

  2. special dietary practices

  3. note patients surroundings

  1. who makes decisions in your family

  2. are there any foods forbidden by your culture

  3. any religious symbols

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VS: Temperature

-regulated by hypothalamus body generates heat by shivering and vasoconstriction & cools by vasodilation

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vasoconstriction

Reduces blood flow and heat transfer by decreasing the diameter of superficial blood vessels.

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vasodilation

increase heat loss through skin; evaporation of perspiration. Widening of blood vessels

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pyrexia

fever response

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Temperature range

97.2 F- 99.9 F (36.2 C-37.7 C) fever is T>100.4 (38 C) oral, rectal, axillary, tympanic, forehead

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VS: Pulse

heart rate. ventricular heart contraction pushes a pressure wave of blood throughout arterial system

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Pulse range

60-100 bpm carotid, brachial, radial, femoral, popliteal, dorsalis

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VS: Respiratory rate

inspiration: diaphagram moves downward, external intercostal muscles increase expiration: internal intercostal muscles decrease diameter

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Respiratory rate range

12-20 breaths/ min

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tachypnea

faster than normal respiratory rate

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bradypnea

slower than normal respiratory rate

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VS: blood pressure

force of the blood against the wall of an artery as the ventricles contract and relax

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blood pressure range

120/80 (systolic: 120-139) (diastolic: 60-89)

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VS: Pain

common, uncomfortable sensation and emotional experience associated with actual or potential tissue damage

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Acute pain

is sudden, of short duration, and usually associated with surgery, injury, or acute illnes

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Chronic pain

is persistent, lasting weeks, or months, or longer; usually sustained by a pathophysiologic process

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Neuropathic pain

pain is long-term, associated with damage or dysfunction of the CNS or PNS.

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Pain in infants/ children

-Increased pulse and respiratory rate -Lower blood pressure than adults -Behavioral cues -Less able to modify pain impulses -Easily distracted but still have pain -Different pain scales

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pain in older adults

-No diminished perception of pain -Decreased pain threshold -Pain from chronic conditions

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Pain is subjective or objective?

subjective!

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Pain scales

OLDCARTS or LOCSTAAM

  • numeric: 0-10 -descriptive: none-worst -visual: point to an area on scale

  • children, Under sedation: wong/baker FACES -infants: observe the behavior

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To assess pain you inspect:

body movements, facial expressions, vocal, vitals, pupils, attention span, palpate skin

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Pain control measures

Distraction, relaxation, ice, heat, massage, transcutaneous electrical nerve stimulation (TENs), acupuncture

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Alert and orientated x 4 (A&Ox4)

-most important indication of neurological status -test in order: time, place, situation, and person -pt becoming disorientated will lose in that order

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A&O X4 steps

  1. Time

  2. Place

  3. Situation

  4. Person

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Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints (higher the better -- best 15)

<p>a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints (higher the better -- best 15)</p>
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cerebral functioning

  1. judgement

  2. abstract thinking and reasoning

  3. memory

  4. communication skills

  5. calculation

  6. Vs

  7. Eyes

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Nutrition: Subjective Assessment

Questions explore dietary intake and perceived nutrition-related problems

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Tools for nutrition assessment

•24-hour Dietary Recall •Typical Day •Use of food diary •Food frequency questionnaire •Comprehensive diet history (more often done by nutritionist) •Use of tools: 'My Plate' •Assessment of diet in terms of variety of foods, serving sizes, disease specific, etc.

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Nutrition: Physical Assessment (Objective)

•Height & Weight (BMI) •Waist Circumference •General appearance & orientation •Skin (hydration, vitamins) •Hair & nails (protein, iron) •Eyes (vitamin deficiencies [A]) •Oral Cavity (ability to eat, vitamin deficiency [B]) •Extremities (size, shape, movement, strength)

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