exam 1

location, character/quality, quantity/severity, timing, setting, aggravating/relieving factors, associated factors, and patient’s perception

what are the eight critical characteristics?

greeting, name, self-introduction, purpose of interview/why you’re there, timeframe, expectations, and confidentiality

What should be included in your introduction of a patient interview?

biographic data, reason for seeking care, present health/history of present illness (HPI), past history, medication reconciliation, family history, review of systems, functional assessment/activity of daily living (ADLs)

what is the health history sequence?

name, age, DOB, birthplace, address, phone number, gender, martial status, race, ethnicity, language, occupation, and record the source of information

what is included in the biographic data?

is the primary reason that patient is seeking care, documented in their exact words with a timeframe

ex: “I’ve had a burning stomach pain for three days”

what is a chief complaint (cc) and an example of one?

childhood illnesses, accidents/injuries, serious/chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last exam date, and allergies

what are some questions to ask when gathering past medical information?

pain rating, feelings/symptoms, and patient concerns

what are 3 examples of subjective data?

vital signs, physical examination findings, and lab results

what are 3 examples of objective data?

location, quality, severity, timing, setting, aggravating/relieving factors, associated factors, and patient’s perception

what are critical characteristics to ask a patient about their chief concern?

present health focuses on current health status or detailed specifies of immediate chief complaint

past history covers prior medical events, including past surgeries, hospitalizations, childhood illnesses, immunizations, and allergies

what is the difference between present health and past history?

chief concern is asked as an open-ended question (what brings you in today?)

past history focus on categories (any past surgeries, chronic conditions, or allergies?)

ROS asks head-to-toe direct questions (any chest pain, cough, or joint stiffness?)

what is the best way to ask a patient about their chief concern? their past medical history? their other body systems?

biographic data: identify who the patient is

reason for seeking care: chief complaint

HPI: PQRSTU

past health: summarize prior medical background

family history: tracks genetic risks and heath trends

ROS: evaluates subjective, head-to-toe body systems to cartch unmentioned symptoms

ADLs: measures lifestyle, self-care ability

perception of health: captures the patient’s personal perspective on their overall health

what are the differences between the different parts of a health history?

facilitation, clarification, reflection, explanation, empathy, and confrontation

what are the different therapeutic communications?

facilitation

encourages patient to say more

clarification

asking for confirmation

reflection

echoes to helpe express meaning

explanation

informing person by sharing factual and objective information

empathy

names a feeling and allows its expression

confrontation

clarifying inconsistent information

complete database describes current and past health state and forms baseline to measure all future changes

Focused/problem-centered database collect “mini” database, smaller scope and more focused than complete database.

They are important because it ensures nurses choose the right depth of assessment to deliver good care

how would explain a focused database compared to a complete? why might this be important to understand the differences when it comes to health assessment?

emergency database is a rapid collection of data often complied concurrently with lifesaving measures

includes ABCs, level of consciousness, and immediate physical findings

what might an emergent database include?

assessment: collect, organize, validate, and document data

diagnosis: identify health problems, risk and strengths

planning: prioritize problems/diagnoses, formulate goals, and write nursing orders

implementation: reassess the client, determine the nurse’s needed for assistance

evaluation: collect data related to outcomes, compare data with outcomes

what are parts of the nursing process

subjective data is how the patient is feeling, what the patient states

objective data what we observe, test results, and vital signs

what are the differences between subjective and objective data?

open-ended questions that prompt a narrative response in the patient’s own words

closed-ended question is a direct question that asks for specific facts or a simple “yes” or “no” answer

what is the difference between an open-ended question and a close-ended question?

facilitation encourages patients to say more

clarification asks for confirmation

explain the difference between facilitation and clarification?

empathy is when you develop an understanding and sensitivity for others feeling’s

this is important b/c it promotes open communication, and helps nurses deliver compassion, and patient-centered care.

what is empathy? why is it important in nursing?

For example patient “I’ve been feeling really overwhelmed in the mornings” nurse “go on, I’m listening (or nodding and saying “tell me more”)

what is an example of facilitation in a conversation with a patient?

having your full attention to the patient by leaning forward and nodding while saying, “Mm’hmm, go on” to encourage that patient to keep sharing details without interrupting their flow

why is health assessment an important link in the nursing process?

during an emergency assessment to quickly gather specific, life-saving information, such as asking a patient experiencing chest pain

what is an example of when you would use a close-ended statement or question?

erythema

red colored skin

pallor

pale colored skin

jaundice

yellow colored skin

cyanosis

blue colored skin

diaphoresis

thyrotoxicosis and stimulation of nervous system with anxiety or pain

edema

is fluid accumulating in the intracellular spaces and not normally present

skin tugor

pinched skin recedes slowly or “tents” and stands by itself (less elasticity)

capillary refill

depress the nail edge to blanch and then release, noting the return of color

begins the moment you first lay eyes on the patient before you even start the formal physical examination/health history interview

when does the general survey begin?

inspection

what part of assessment is the general survey (inspection, percussion, palpation, or auscultation)?

physical growth

what is the best index of a child’s growth?

new born: 32-38 cm average of 34 cm about 2 cm larger than chest circumference

6 months-

what should you know about an infant’s head circumference at age 1 month? What about 6 months? 1 year/12 months?

stature, nutrition, symmetry, posture/position, and contour

what are 3 body structure findings in a general survey?

facial expression, mood and affect, speech, speech pattern, dress, and personal hygiene

what are 3 behavior findings in a general survey?

BMI stands for body mass index

overweight: 25.0-39.9 and obese: greater than 40.0

BMI= weight in kg/(height in meters) ^2 or BMI: weight in lbs x 73/(height in inches)^2

how would a nurse calculate a patients BMI? what does DMI stand for? what is considered overweight and obese?

adults: standing scale, morning time, light clothing, no shoes, and empty bladder

infants: calibrated platform scale, completely naked/clean diaper, hand hovering for safety

children: standing scale, light clothing, and no shoes

what is considered best technique for weighing adult patients? Infants? Children?

dizziness

a range of sensation associated with impaired spatial perception, balance, or lightheadedness

vertigo

specific type of dizziness characterized by a false sensation of self-motion/environmental movement

Imbalance or lack of proportion between the features on the left and right sides of the face.

What is facial asymmetry?

Enlarged tonsils are graded on a 1+ to 4+ scale based on their size and how much space they occupy in the oropharyngeal airway between the anterior tonsillar pillars and the uvula: 1- visible 2-  halfway between tonsillar pillars and uvula 3- touching uvula 4-touching one another

How do you grade enlarged tonsils?

Have patient depress tongue with tongue blade. Check for color, exudate, or lesions. Test cranial nerve 12 (hypoglossal) ask a person to stick out tongue, should protrude in midline. Note any breath odor, halitosis (poor oral hygiene, consumption of alcohol, smoking/dental infection)

How do you assess the palate and uvula?

protect, prevent penetration, perception, fluid balance, temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D

what is the function of the skin?

ecchymosis

a purplish patch resulting from extravasation of blood into the skin, more than. 3mm in diameter

macule

solely a color change, flat and circumscribed, less than 1 cm

papule

felt and caused by superficial thickening of the epidermis

linear

scratch, streak, line, or stripe vesicle: elevated cavity containing fluid up to 1 cm (blister)

nodule

solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule

pustule

pus in cavity that is circumscribed and elevated

fissure

linear crack with abrupt edges extending into dermis

ulcer

deeper depression extending into dermis with irregular shape, may bleed, leaves scar

Cardiovascular:

1. cyanosis: poor tissue perfusion or severe deoxygenation

2. pallor: decreased cardiac output, peripheral vasoconstriction

Abdominal:

1. jaundice: indicating hepatic dysfunction

2. spider angiomas: chronic liver disease/cirrhosis

Pulmonary:

1. cyanosis: impaired gas exchange, hypoxemia

2. clubbing of fingers: chronic hypoxemia, COPD, pulmonary fibrosis, and lung cancer

What skin findings tell you something about the cardiovascular system?  Abdominal system? Pulmonary system?

Cyanosis, rapidly spreading erythema with skin sloughing, and unstageable pressure injuries (stages 3 & 4)

Name 3 findings of the integumentary system that would be a priority finding?

Braden Scale: Sensory perception, moisture, activity, mobility, nutrition, friction and shear (scoring less than 9)

Describe patients, diagnoses, history, and other considerations that might place someone at risk for a pressure injury?

Infants: sweat and sebaceous glands are less active and so skin’s hydrolipid film is relatively weak, barrier function is impaired and is less resistant, sensitive to chemical, physical, and microbial influences, prone to drying out, and more sensitive to UV

Older adults: epidermis thins and flattens, less elasticity, loss of collagen, slow wound healing, decrease in sweat and sebaceous glands (dryness, deep wrinkles), melanocytes decrease and rate of hair growth decreases, and nails grow slower and become more thicken

What lifespan changes in the skin can affect their overall health?

Normal:

1. Temp 37 degrees Celsius/98.6 degrees Fahrenheit

2. Pulse: 50-95 beats with 2+ force, and regular rhythm

3. Respirations: 16-25 breaths and non-labored

4. BP: less than120/less than 80

5. O2: 97-99%

Irregular:

1. Temp: above 37.8 degrees Celsius or below 36 degrees Celsius

2. Pulse: less than 50 beats or more than 95 beats, 3+, 1+, or 0 force, and irregular rhythm

3. Respirations: 8-12 or more than 25 breaths, labored

4. BP: greater or below 120/ greater or below 80

5. O2: less than 97%

What vital sign findings are normal? What vital sign findings would make you concerned?

Have patient rest supine for at least 3 minutes, take baseline readings of pulse and BP, and then repeat with person sitting and then standing. Abnormal finding: orthostatic hypotension: drop in systolic pressure of greater than 20mmHg or diastolic pressure greater than 10mmHg after changing into a standing position.

How would you check orthostatic blood pressures?  What would be considered an abnormal finding?

Recheck BP after 1-2 minutes, ensure cuff is appropriate size and positioned correctly over brachial artery, measure on opposite arm, or ask for another nurse to double check reading

What should you do if you are not sure if the blood pressure reading is correct?

Count heart rate for the full 60 seconds and count total bpm, evaluate the patient for signs of distress, chest pain, shortness of breath, dizziness, verify medical history, and document of irregularity in patient’s chart

What would you do if you noticed a patient’s heart rate was irregular and it seemed like a new finding?

1. BP 200-/85: recheck manually with proper cuff size. Assess for target organ damage (headache, chest pain, vision changes). Elevate head of bed and notify provider immediately.

2. Temp 104.5: apply non-invasive cooling agent without inducing shivering and notify provider.

3. HR 45: check for symptoms and review baseline. If asymptomatic and stable, document as a normal physiological variant. If not asymptomatic assess for lightheadedness, or chest pain. Obtain 60-second pulse, review medications, and notify provider.

4. SPO2 90%: check respiratory effort and verify probe placement (not on nail polish, pt doesn’t smoke) and position comfortably, apply supplemental oxygen per protocol.

5. RR 32: elevated head of bed, assess lung sounds and oxygen saturation, coach deep breathing, and notify provider.

Consider next nursing steps if a patient’s BP is 200/85?  Or what about a Temp of 104.5? Or a Heart Rate of 45 of a marathon runner?  Heart rate of 45 of an 89-year-old female?  O2 sat of a 2-year-old child at 90%? Make up your own vital signs and consider next steps…..

Irregular heart rate: <50 bpm= bradycardia

Sinus arrhythmia is when the heart rate varies with respiratory cycle (speeding up with inspiration, slowing down to normal with expiration)

What is an irregular heart rate?  Is this something concerning? What is sinus arrhythmia?

Yes if after exercising or doing something with cardio.

Could someone have a 3+ pulse bilaterally that was considered normal?

Blood pressure measures how fast the heart contracts and rests.

Systolic is when the heart contracts.

Diastolic is when the heart rests.

Pulse pressure is the difference between systolic and diastolic.

Factors affecting BP: age, sex, weight, exercise, etc.

Mean arterial pressure (MAP) is the average blood pressure in a person’s arteries during a single cardiac cycle.

Pretend to describe to your patient what a blood pressure is?  What is the systolic? What is the diastolic?  What is the MAP?  What is pulse pressure?  What are 3 things that can affect someone’s blood pressure?

1. Faulty arm position (above or below level of heart)

2. taking blood pressure when person is anxious/angry

3. cuff wrap is too loose/uneven/bladder balloon out of wrap

What are 3 common errors in taking a blood pressure measurement?

Ages over the age of 3 years old.

Verify cuff size, calm child, try different areas arms or thighs, or use manual papulation/auscultation

At what age is most common to take regular blood pressures?  What if you are having a difficult time obtaining a blood pressure on a 2-year-old?