Core exam 1

health history provides what kind of data?

subjective.

physical assessment provides what kind of data?

objective.

chief concern

a brief statement in the pt’s own words for the reason of seeking care

subjective data

what the patient may tell us

objective data

what we can see, measure, or detect

what are the 2 different sources of data?

primary and secondary

who is a primary source?

the patient

who/what is a secondary source

family members, pts chart, previous nurses, labs, and literature

what are the different types of assessments?

initial (base-line), problem-focused (system specific), emergency assessment, and ongoing reasessment

what type of assessment is performed within a certain time frame right after admission and is used to establish a baseline for problem identification, refrence, and future comparison?

initial (baseline) assessment

what type of assessment is an ongoing process integrated with nursing care and is used to determine the status of a specific problem identified in the earlier assessment

problem-focused (system specific) assessment

what type of assessment occurs during physiologic or psychological crisis and is used to identify life threatening problems or identify new or overlooked critical problems (ex. asthma attack, cardiac arrest, stroke symptoms, etc)

emergency assessment

what type of assessment occurs minutes to months after initial assessment and is used to compare the pts current status to baseline data previously obtained?

ongoing reassessment

what type of questions are used in the nursing practice?

open ended and close ended questions

considering hearing situations, framing questions in a more understandable way, considering shorter memory, making sure support or assistance is accessible, and considering mobility is all guidelines for who?

older adults

observation includes:

hearing, vision, smell, and touch

interviewing includes:

asking for symptoms, pain, education, support, and therapy

what is the sequence of examination?

1. inspect

2. palpate'

3. percuss

4. auscultate

what is the sequence of examination exeption for the abdomen?

1. inspect

2. auscultate

3. percuss

4. palpate

reflects the balance between heat the body produces and heat lost from the body to the environment

tempurature

the measurement of heart rate and rhythm. corresponds to the bounding of blood flowing through various points in the circulatory system

pulse

reflects the force the blood exerts against the walls of the arteries during cardiac muscle contraction and relaxation

blood pressure

core temperature measurement sites

rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus, and urinary bladder

surface temperature measurement sites

skin, mouth, and axillae

expected oral temperature range

36-38 degrees celsius and 96.8-100.4 degrees fahrenheit

expected rectal tempurature

0.5 degrees celsius or 0.9 degrees fahrenheit higher than oral and tympanic temperatures

expected axillary temperature

0.5 celsius or 0.9 fahrenheit lower than oral and tympanic temperatures

expected temporal temperature

1 fahrenheit higher than oral and 2 fahrenheit higher than axillary

expected resting pulse range for adults

60-100 beats per minute

0 pulse strength

absent

1+ pulse strength

diminished and weaker than expected

2+ pulse strength

brisk and expected

3+ pulse strength

increased and strong

4+ pulse strength

full volume and bounding

expected pulse range for one week old infants

90-160 beats per minute

what are the 9 different pulse points?

1. temporal

2. carotid

3. brachial

4. radial

5. femoral

6. popliteal

7. posterior

8. tibial

9. pedal

where is the apical pulse?

5th intercostal space on the left side

normal blood pressure

less than 120/80

elevated blood pressure

120 to 129 over less than 80

what does the general survey include?

facial expression, physical appearance/skin color/personal hygiene, and nutrional status

what does the neurological survey include?

speech (clear and coherent), communication, hearing, LOC, orientation, and GCS (eye opening, verbal response, and motor response)

what is a priority action to prevent falls?

providing a fall assessment

checking for fall risk ID, monitoring the patient’s gait, balance, and LOC, watching for meds that cause dizziness or confusion, clearing the floor, and providing exit safety measures is part of what

fall prevention

what are the 2 different types of restraints?

physical and chemical

what are some examples of physical restraints?

ties, vests, and mitts

what is an example of chemical restraints?

sedative medication

confining a patient to a room involuntarily (locking the door from the outside)

seclusion

how often do you provide a skin assessment to a restrained patient?

Q2

what is code red in the hospital?

fire

what does RACE stand for?

rescue, alarm, contain, and extinguish

what does PASS stand for?

Pull, aim, squeeze, and sweep

what are the symptoms of carbon monoxide poisoning?

nausea, vomiting, headache, weakness, and unconsciousness

what are the requirements for a pain assessment?

PQRST

what does PQRST stand for?

P: provocation/palliation (anything that makes it better or worse)

Q: quality (dull or sharp?)

R: region and radiation (where is it and does it spread?)

S: severity (0-10)

T: time (when has it started? does it come and go?)

what are the 4 types of pain?

acute pain, chronic pain, nociceptive pain, and neuropathic pain

what type of pain is protective, temporary, has direct cause, and can lead to chronic pain if unrelieved?

acute pain

what kind of pain is not protective, ongoing or recurs frequently, and lasts longer than 6 months

chronic pain

what type of pain arises from damaged or inflamed tissue, usually a throbbing, aching, adn localized pain?

nociceptive

what are the 3 types of nociceptive pain?

somatic, visceral, and cutaneous

nociceptive pain in the bones, joints, muscles, skin, or connective tissues

somatic

a nociceptive pain in internal organs (the stomach or intestines) that causes referred pain to other body locations seperate from the stimulus

visceral

a nociceptive pain in the skin or subcutaneous tissue

cutaneous

pain that arises from abnormal or damaged pain nerves. it includes phantom pain, pain below the level of a spinal injury, and diabetic neuropathy

neuropathic pain

treatment approaches used in addition to or to enhance conventional medical care

complementary therapy

treatment approaches that become the primary treatment and replace allopathic medical care

alternative therapy