Nursing Lecture Review Flashcards

Flashcards covering key vocabulary terms from Weeks 1-3 of lecture notes.

Health Assessment

Collection of information, clinical judgement, and evaluation of obtained data to deliver plan of care via SUBJECTIVE and OBJECTIVE data.

Comprehensive assessment

full head-to-toe exam, includes questions

-only RNs can perform

Focused assessment

focused on a body system or body part

Subjective Assessment

Reviews the chief complaint (reason for seeking care)

Previous/chronic health conditions to help current assessment

Health History

structured conversation to allow nurse to gather pertinent details about background and current medical status of client (DOB -> reason for seeking care)

Past Medical History (PMH)

ENTIRE medical history

Review of Systems (ROS)

SUBJECTIVE review of body systems in head-to-toe manner to assess OVERALL HEALTH

Functional Assessment

Determines client’s ability to take care for themselves when they are not experiencing illness

General Survey

Initial impression of client’s general health; Quick, overall (objective) observation of client and notes any issues that require more focused assessment

Therapeutic Communication

Verbal and nonverbal communication to establish trust and build rapport with a patient.

Level of Consciousness (LOC)

how alert and oriented is the client to person, place, time and situation?

Delirium

Acute confusion that comes and goes (intermittent)

Dementia

Chronic, progressive confusion

Lethargic

Not fully awake, drifts off to sleep with lack of interaction/stimulation, but easily awakened with name or verbal stimulation

Obtunded

Asleep and needs LOUD STIMULUS or physical stimulation. Confused with one-word sentences when awake, falls back asleep without constant stimulation

Stupor

Unconscious but responsive to PHYSICAL STIMULI or PAIN with movement or INCOHERENT VOCALIZATIONS (strong stimuli)

Comatose

Completely unconscious and no response to physical or painful stimuli

Pulse

reflects circulatory/cardiac status (contraction of heart and blood flow through peripheral arterial system)

Respirations

Exchange of O2 and CO2 during ventilation, diffusion, and perfusion

Blood Pressure

Force of pulsing blood on walls of artery, indicates cardiovascular health

Pulse Oximetry

Detects amount of oxygen bound to Hb, estimates arterial oxygen status, indicates respiratory status

Pain

SUBJECTIVE based on client’s perception of pain, physical or emotionally cognitive

Visceral Pain

Larger internal organs, travels along ANS “Deep cramping, squeezing, dull” Sweating, nausea, vomiting

Somatic Pain

Musculoskeletal system Deep somatic pain in bones, tendons, ligaments, and blood vessels “Throbbing, deep, achy” Sweating, nausea, and tachycardia

Referred Pain

Felt in one area but originates from another

Acute Pain

Transient pain from injury/illness; Short duration (less than 6 months)

Chronic Pain

Persistent that lasts more than 6 months, recurring, and may be severe

Skin

the LARGEST ORGAN (epidermis, dermis, subcutaneous tissue (fat), muscle)

Inspection (Skin Assessment)

eyes

Palpation (Skin Assessment)

Hands

Cyanosis

blue-ish due to lack of O2 in lips, nail, mucosa membrane

Ecchymosis

bruises from bleeding; color depends on stage of healing

Erythema

inflammation; flushed/intense red or purple (darker skin tones)

Jaundice

yellow-ish due to increase bilirubin (body unable to break down)

Pallor

pale/light color from anemia (lack of O2 in RBC) or circulatory issue

Skin Lesion

anything abnormal

Petechiae

Small pinpoint (1-3mm) red-ish purple spots

Infection, trauma -> ruptured capillaries

Ecchymosis

Collection of blood in dermis (>3mm)

Red/purple-ish -> blue or yellow during healing (trauma)

Purpura

Collection of petechiae and ecchymosis covering an area; Infection, bleeding disorder

Macule

<1cm (freckle, mole, measles, scarlet)

Patch

1cm (birthmark, vitiligo, hormone changes)

Papule

<1cm (warts, elevated mole, skin tags)

Plaque

1cm (psoriasis, eczema)

Wheal

Irregular area of edema (insect bites, allergies, hives)

Nodule

<2cm from deeper in dermis (melanoma, hemangioma)

Tumor

2cm from deeper in dermis (lipoma, neoplasm)

Vesicle

<1cm superficial with serous fluid (varicella, shingles, acute eczema)

Bulla

1cm superficial with serous fluid (blister, medication reaction)

Pustule

<1cm superficial with purulent fluid (acne, herpes, simplex)

Cyst

Encapsulated, from dermis or subq, filled with liquid or semi solid (cystic acne, sebaceous cyst)

Lichenification

Thickened and elevated skin from chronic scratching (psoriasis, eczema, chronic skin inflammation)

Crust

Thick, dried fluid when pustules/vesicles break open and dry up (scab, eczema, diaper dermatitis)

Scale

Excessive shedding of keratin cells, dry/greasy flakes that are white or silvery (psorasis, eczema)

Fissure

Straight line crack with absrupt edges that goes into dermis (cheilosis)

Erosion

Shallow depression in epidermis, moist without bleeding (Varicella, Herpes, Simplex)

Ulcer

Deeper depression involving loss of epidermis and dermis. May bleed

Excoriation

Loss of epidermis in linear crusted areas (abrasions, scratches)

Turgor

pinch clavicle or hand and watch for skin recoil

Edema

accumulation of excess fluid in interstitial spaces between tissues

ABCDE Rule

Asymmetry

Border

Color variation

Diameter (greater than 6mm) - #2 eraser

Evolution: rapidly in a month or two

Risk factors for Pressure Injuries (Ulcer)

-Immobility

-Aging (skin thinning)

-Malnutrition

-Moisture

-Friction Injury

Interventions for Pressure Injuries (Ulcer)

-Repositioning every 2 hours

-Pressure-relieving mattress (air)

Pressure Injuries (Ulcer) Stages

1. Red, non-blanching (do not massage), different texture and temperature (firm/soft or warm/cool)

2. Partial dermis loss, shiny/dry with pink wound bed, intact or ruptured blister

3. Full thickness skin loss with damage or necrosis to subq tissue; fat visible, dead tissue

4. Full thickness skin loss with exposed bones, tendons, or muscle; tissue in wound bed

Pressure Injuries (Ulcer)

caused by impaired circulation to underlying tissue that is squeezed tightly over a solid surface such as a bone prominence

Describe OLDCARTS

Onset

Location

Duration

Characteristic

Associating/Aggravating/Alleviating

Radiation

Timing

Severity/Symptoms

Describe COLDSPA

Characteristic

Onset

Location

Duration

Severity/Symptoms

Pattern

Aggravating/Alleviating/Associating

Skin: Temperature Expected findings

Warm to touch and consistent bilaterally

-If environment is cold, hands and feet is less warm than torso

Skin: Temperature Unexpected findings

Hyperthermia (fever/infection

-Localized (inflammation in joint, trauma to bones/muscles, infection, sunburn)

Hypothermia (poor perfusion - cardiac arrest or shock)

-Localized (Peripheral vascular disease, impaired circulation/blood flow)

How to assess turgor?

Palpate/pinch clavicle or hand and watch for skin recoil to assess elasticity and hydration

Expected vs Unexpected Turgor

Expected: Rapid recoil (brisk bilaterally) - common in older

Unexpected: Tenting (No recoil - dehydration or severe weight loss

Generalized vs Localized Edema

Generalized: Heart or kidney failure

Localized: Infection or trauma

Non-pitting vs Pitting Edema

Non-pitting: fluid retention without indentation (good)

Pitting: leaves finger impression when pressed for 3-4 seconds

Pitting Grades for Edema

Grade 1: 2mm (immediately rebound)

Grade 2: 3-4mm (few seconds)

Grade 3: 5-6mm (10-12 seconds)

Grade 4: 8mm (20 seconds)

How to assess nails?

Pinch/squeeze nail to determine how many seconds of blanching

Expected vs Unexpected findings of Nails

Expected: Smooth, translucent, flat

Unexpected:

-Clubbing (spongy, downward curve, signs of chronic hypoxia)

-Cyanosis, pallor, streaks (melanoma), jagged edges

-Pits, grooves (Raynaud’s)

Health Promotion

-Warm bath water (100-105) for good skin circulation

-Use alcohol free products (excessive dryness)

-Keep abrasions/cuts clean and moisture (use bandaid)

-Skin cancer prevention: SPF 30+, 15 minutes beforehand

-Erythema: wash bacteria; OTC spray, lotion or ointment

-Monthly self-skin exam

Verbal Communication

Words and tone

Active listening, empathy, respectful, acceptance

Nonverbal Communication

Body language

Eye contact, gesture, posture, touch, proximity, and orientation

General Survey Checklist

1. Physical Appearance

2. Body Structure

3. Mobility

4. Behavior

5. Vital Signs

Physical Appearance Observations

-Age (appear stated age)

-Sex (development appropriate for age and sex)

-LOC (alert and orientation)
-Skin Color (even and consistent)

-Facial features (symmetry)

-Overall appearance

Body Structure Observations

-Stature (height consistent with age)

-Nutrition (weight consistent with age)

-Symmetry (bilateral and proportion)

-Posture (upright/erect)

-Position

-Obvious physical deformities

Mobility Observations

Gat: smooth and even ambulation without assistance, symmetrical and opposing arm swing

ROM: Deliberate, accurate, smooth, coordinated movements

Behavior Observations

-Facial expression

-Mood/Affect

-Speech

-Speech pattern

-Dress

-Personal hygiene

Vital Signs Observations

-Temperature

-Pulse

-Respirations

-Blood Pressure

-Pulse Ox

-Pain

Common/average of Vital Signs

1. Temperature

2. Pulse

3. Respirations

4. Blood Pressure

5. Pulse Ox

1. Temperature - 36-38C or 96.8-100.4F (37C or 98.6F)

2. Pulse - 60-100bpm (adults), 50-90bpm (adolescents)

3. Respirations - 12-20 bpm

4. Blood Pressure - <120/80mmHg

5. Pulse Ox - 95-99% RA

What is special to note about temperature?

Rectal/Temporal 1F higher than oral

Axillary lower 1F lower than oral

-Tympanic = oral

What causes temperature to change?

Illness and environment

What does the pulse reflect?

Circulatory/cardiac status (contraction of heart and blood flow)

Pulse points

Temporal

Carotid

Apical

Brachial

Radial

Ulnar

Femoral

Popliteal

Posterior tibilais

Dorsalis Pedis

Which are the most common?

Which do we assess if patient is unstable/poor cardiac output?

Most common: RADIAL and PEDAL

Unstable/Poor CO: APICAL and CAROTID

What do we notice about pulse quality?

-Pulse rate

-Rhythm (regularity)

-Force (strength of heart to pump volume)

“___ pulses are +2 and equal bilaterally)

Pulse force measurements

0 = absent

+1 = weak, thready, diminished pulse

+2 = baseline, brisk (normal range)

+3 = full, bounding

some agencies use 4

What does BP indicate?

Cardiovascular health

What is BP affected by?

-Smoking

-Sex (puberty in males or females past menopause)

-Ethnicity (Black)

-Day - decrease in late afternoon

-Obesity

Medication - BP

Cardiac/Antihypertensive: Lower BP

Vasoconstrictors/Amphetamines: Increase BP

Opioids: HYPOTENSION

Where can you take pulse ox?

Fingers, toes, ears

What is pulse ox affected by?

-Respiratory disease

-Carbon monoxide poisoning

-Jaundice

-Painted/thickened nails

-Recent injection of dyes in circulatory system

-Client movement during testing

-Impaired circulation due to peripheral vascular disease

-Hypothermia

-Vasoconstriction

-Hypotension

-Peripheral edema

Chronic pain

1. Malignant

2. Nonmalignant

1. Malignant

Cancer related, tissue death, organ distention from growing tumor

2. Nonmalignant

Due to musculoskeletal conditions and nerve disorders