N225

What are 8 important lifestyle and personal habit questions to ask a patient?

• bathing and shampooing routines

• change products

• wear false nails or wigs

• go to the nail salon or gym

• sun exposure

• assess their skin

• exposure to chemicals or radiation

• diet

When doing a physical examination what should the environment look like?

• use of natural or artifical light that resembles it

• ensure patient is draped

What should be done for a physical examination of skin?

inspect and palpate the patient

What to assess for in a patient’s skin color?

• increased pigmentation

• loss of pigmentation

• redness of skin

• cyanosis

• pallor

• jaundice

How to inspect for moisture on skin?

• carefully inspect skin folds

• inspect/observe the surface

How should the skin normally appear moisture wise?

should be dry to the touch without flaking or cracking

What are abnormal skin moisture findings?

• excessive dryness

• excessive oiliness

• excessive sweating

How to check a patient’s temperature?

• back of hands (dorsum)

What should a nurse take note of with a patient’s temperature?

• Generalize warmth or coolness

• increased temperature with erythema (reddness)

How to test for mobility and turgor of skin?

• lift skin fold of collarbone

Mobility

Ease with which skin lifts

Turgor

Speed with which skin returns into place (elasticistiy)

Edema

extra fluid in intersitial spaces (fluid where it is not supposed to be)

How does edema present itself?

• swelling

• Skin tight and puffy

Pitting Edema

interstitial fluid is mobile

Nonpitting edema

• local infection or trauma

• protein rich fluid is trapped in tissue

What is the measuring scale for edema?

1-4

Purpose of Health History

Establish trust, gather health information, and improve patient well-being.

Goal of Nurse During Interview

Improve the patient's well-being through therapeutic communication and accurate data collection.

Pre-Interview

Acknowledge biases, review patient record, set interview goals, and present a professional appearance.

Introduction Phase

Greet the patient, establish rapport, verify identity, explain purpose, and establish the interview agenda.

Working Phase

Obtain patient information, respond to emotional cues, use OLDCART, clarify symptoms, and negotiate a plan.

Termination Phase

Notify the patient the interview is ending, summarize findings, discuss the plan of care, and answer questions.

OLDCART

Onset, Location, Duration, Characteristics, Associated symptoms, Relieving/Aggravating factors, Treatment.

Onset

When did the symptom begin?

Location

Where is the symptom located? Does it radiate?

Duration

How long does the symptom last?

Characteristics

What does the symptom feel like? How severe is it?

Associated Symptoms

What other symptoms occur with it?

Relieving/Aggravating Factors

What makes the symptom better or worse?

Treatment

What treatments have been tried? Were they effective?

FIFE

Feelings, Ideas, Function, Expectations.

Active Listening

Paying close attention to verbal and nonverbal communication while encouraging the patient to elaborate.

Guided Questioning

Uses open-ended then focused questions while avoiding leading questions.

Open-Ended Question

Allows the patient to answer in their own words.

Leading Question

A question that suggests the desired answer and should be avoided.

Clarification

Asking the patient to explain what they mean.

Reflection

Repeating or restating the patient's words to encourage further discussion.

Validation

Confirming that you understand the patient's message correctly.

Empathy

Understanding and acknowledging the patient's feelings.

Sympathy

Feeling sorry for the patient's situation.

Summarizing

Restating the main points to confirm understanding.

Transition

A statement that smoothly changes the interview topic.

Empowering the Patient

Helping the patient take responsibility for their own healthcare.

Nonverbal Communication

Communication through body language, facial expression, posture, touch, and eye contact.

Subjective Data

Information reported by the patient; symptoms, feelings, beliefs, and history.

Objective Data

Information observed or measured by the nurse through physical examination, vital signs, labs, and diagnostic tests.

Nursing Process

ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation.

Assessment

Collect subjective and objective data about the patient.

Diagnosis

Analyze assessment data to identify nursing problems.

Planning

Set priorities, goals, expected outcomes, and nursing interventions.

Implementation

Carry out nursing interventions and patient education.

Evaluation

Determine if goals were met and modify the care plan as needed.

Comprehensive Health History

Complete health history and head-to-toe assessment for a new patient.

Focused Assessment

Assessment directed toward a specific problem or complaint.

Follow-Up History

Assessment evaluating an existing problem after treatment or intervention.

Emergency History

Rapid assessment focusing only on life-threatening problems.

History of Present Illness (HPI)

Description of the chief complaint using OLDCART.

Review of Systems (ROS)

Head-to-toe review of symptoms by body system.

Health Patterns

Questions about lifestyle, nutrition, sleep, coping, exercise, values, relationships, and self-concept.

Cultural Assessment

Systematic assessment of a patient's cultural beliefs, values, and practices to guide individualized care.

Purpose of Cultural Assessment

Provides the foundation for planning, implementing, and evaluating culturally competent care.

Self-Reflection in Cultural Assessment

Identify personal biases, stereotypes, and prejudices before caring for patients.

Cultural Humility

Self-awareness, respectful communication, and collaborative partnerships.

Communication and Language Assistance

Provide qualified interpreters and communication methods appropriate for the patient's needs.

CAGE Screening Tool

Cut down, Annoyed, Guilty, Eye-opener.

Positive CAGE Screen

Two or more "yes" responses.

Questions After Positive CAGE

Ask about blackouts, seizures, accidents, injuries, job problems, conflicts, and legal issues.

Sensitive Topics

Remain nonjudgmental, explain why information is needed, and ask respectfully.

Neurodiversity

The concept that individuals experience and interact with the world differently.

Examples of Neurodiversity

Autism spectrum disorder, learning differences, Tourette syndrome.

Interviewing Neurodiverse Patients

Check understanding, reduce sensory distractions, avoid metaphors, and use clear language.

Documentation

If it wasn't documented, it wasn't done.

Physical Examination

Purpose is to collect objective data and identify changes in health status.

Inspection

Visual examination using observation.

Palpation

Assessment using touch.

Percussion

Tapping the body to produce sounds that assess underlying structures.

Auscultation

Listening to body sounds using a stethoscope.

Diaphragm of Stethoscope

Used to hear high-pitched sounds.

Bell of Stethoscope

Used to hear low-pitched sounds.

IPPA

Inspection, Palpation, Percussion, Auscultation.

Sequence of Physical Examination

Head-to-toe, right side first, minimize patient repositioning.

General Survey

Initial overall observation of the patient's appearance and condition.

General Appearance

Overall health, age, hygiene, dress, grooming, posture, and gait.

Level of Consciousness

Awake, alert, and oriented to person, place, and time.

Signs of Respiratory Distress

Tripod position, labored breathing, shortness of breath.

Signs of Pain

Grimacing, guarding, crying.

Vital Signs

Blood pressure, pulse, respirations, and temperature.

Acute Pain

Sudden pain related to injury or illness.

Chronic Pain

Pain lasting longer than 3 to 6 months.

Pain Assessment

Use OLDCART and a pain scale.

Visual Analog Scale

A pain rating scale using a continuous line.

Numeric Rating Scale

Pain scale from 0 to 10.

Verbal Rating Scale

Uses descriptive words to rate pain.

Nociceptive Pain

Pain caused by tissue damage.

Neuropathic Pain

Pain caused by injury to the peripheral or central nervous system.

Psychogenic Pain

Pain influenced by psychological factors.

Idiopathic Pain

Pain with no identifiable cause.

Four A's of Pain Management

Analgesia, Activities of Daily Living, Adverse Effects, Aberrant Drug-Related Behaviors.

Analgesia

Degree of pain relief achieved.