exam one 319 (all chapters)

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

objective data

what you as the health professional observe by inspecting, percussing, palpating and auscultating during physcial exam; signs

what are the five steps of the nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

outcomes must be

*measurable

*include time frame

*be realistic and reasonable

*be individualized

requirements for inspection

Good lighting

Adequate exposure

Occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal specula

what is the first step of assessment

inspection

What does palpation tell us

assess:

temperature, texture, and mositure

organ location & size

swelling, vibration, pulsation

presenence of lumps or masses

What are finger tips used to asses during palpation

skin texture

swelling

pulsations

presence of lumps

What are finger and thump used to asses during palpation

detection of position, shape and consistency of organ or mass

What are dorsa of hands and fingers used to assess during palpation

temperature

What are base of fingers or the ulnar surface of the hand used to assess during palpation

vibrations

what is percussion

tapping the person's skin with short, sharp strokes to assess underlying structures

depict that an area is dense or air-filled

add in percussion noise

on ipad

What is auscultation?

listening through a stethoscope

What is a nosocomial infection?

an infection acquired in a hospital

what is obtained through inspection

physical appearance

body structure

mobility

behavior

what does waist circumference tell us

assesses body fat distribution as an indicator of health risk

what is unhealthy waist circumference

males: >40 inches

females: >35 inches

what is gait

uses a wider base to compensate for diminished balance

how is temperature regulated

by the hypothalamus

what is the average oral temperature

36.5-37 celsius

97.7- 98.6 Fahrenheit

what temp is the most accurate

rectal temp, .7-1 Fahrenheit/ .5 celsius higher then oral readings

what is normal pulse characteritics

2+ is a normal strength/force

What is orthostatic hypotension?

A drop in blood pressure due to a sudden change of posture by >20mm Hg of systolic and/or increase in pulse >20bpm

What is the purpose of a patient interview

chance to gain understanding of clients beliefs, concerns, and perception of their health state

compile subjective data

how do you ask for a direct/open ended question

asking for narrative information

how do you ask a closed question

ask specific info leading to a forced choice

like yes.no

how should ask questions during the patient interview

- only one direct question at a time

- ask open questions first

what is a complete health history

A comprehensive record of past and current health states

physical exam

full health history

what is a focused/ problem centered health history

targeted in scope

used in all settings

limited, short-term problems

Emergency Health History

Focuses on gathering information so that the interventions can resolve the immediate problem stability

for life-threatening problems

what is a chief complaint

A brief, spontaneous statement in the client's own words of why they are seeking care

should be in quotes

what is history of present illness or HPI

depends on well or ill client

follows chronological order of onset of illness to present

follow OLDCARTS mnemonic to assess

What is OLDCARTS?

O - origin

L - location

D - duration

C - character

A - alleviating/ aggravating factors

R - radiating

T - timing

S - severity

What is the PQRST pain assessment?

1. Provocation

2. Quality/Quantity

3. Region/Radiation

4. Severity (pain scale)

5. Timing (when did it begin)

what should be aksed when obtaining a past health history

allergies--> what are the reactions

chronic illnesses---> treatments

any recent hospitalizations or surgery-> date of when it was

immunizations

accidents or injuries

last examination date

What needs to be covered in medication reconciliation

prescriptions

OTC meds

herbal medications

what needs to be asked about each medication during client interview

generic name

trade name

dose

route

frequency

duration

purpose

what is ROS or review of systems

evaluates the past and present health state of each body system

health promotion

what is SDOH (social determinants of health)?

conditions in the envionment where people are born, live, learn, work, play, worship, and age affect health, functioning and quality of life

contributes to health disparties and inequities

pain is what kind of date

unpleasant sensory and emotional experience is subjective data

what is nociceptor pain

occurs in functioning and intact nerve fibers

triggered by outside events

result of actual or potential tissue damage

what is neuropathic pain

caused by lesions or disease in nerve fibers

an abnormal process of pain messaging

difficult to assess and treat

associated conditions are: diabetes, HIV/AIDS/, chemo, sciatica

what is visceral pain

Originating from interior organs

Aching, Poorly localized, Often accompanied by autonomic responses (vomiting, nausea, pallor, diaphoresis)

What is somatic pain?

originating from muscle, bone, joints, tendons, or blood vessels

deep somatic: aching or throbbing

superficial: sharp, or burning

refferred pain

pain that is felt at a particular site but originates from another location

What is acute pain?

protective, temporary, usually self-limiting, and resolves with tissue healing

What is chronic pain?

Pain continues for 6 months or longer

does not stop when injury heals

outlasts its protective purpose

How often should you evaluate/document pain after treating it

after 30-60 mins

what cervical vertabra is palpable when the head is flexed

C7

Which cranial nerve is responsible for forming facial expressions

cranial nerve VII (7)

which cranial nerve is responsible for facial sensations

Cranial nerve V (5)

What are the 3 salivary glands and where are they located?

parotid glands: in the cheeks over the mandible, below the ear

submandibular: beneath Mandible at angle of the jaw

sublingual: at the floor of mouth

what are the two major neck muscles

sternomastoid ---> head rotation & felxion

trapezius----> shoulder and head movement

Which cranial nerve is responsible for moving the neck and muscle strength, shruging the shoulder

cranial nerve XI (11)

what is the landmark used to find the thyroid

cricoid cartilage

where are the greatest supply of lymp nodes

in the head and neck (60-70 nodes)

where do all head and neck nodes drain to

into the deep cervical chain

what class of drugs can cause tics

anti-psychotic drugs

acromegaly

enlargement of the extremities/ cparse face

exophthalmos

abnormal protrusion of the eyeball, caused by hyperthyroidism

tense rigid muscles, flat affect

caused by parkinsons or dementia

marked asymmetry

caused by stroke or bells palsy

what cranial nerve is affected by bells palsy

CN VII (facial)

What causes Parkinson's disease?

deficiency of dopamine

what cranial nerve is responsible for smell

cranial nerve I (olfactory)

what are turbinates

Layers of bone within the nasal cavity (Superior, midline, and inferior)

they warm, humidify and filter inhaled air

what does stiff coarse nasal hairs lead to

decreased olfactory nerve fibers which then causes decreased smell

what questions should ask regarding nasal discharge

consistency, color, amount

what is a nasal polyps

smooth pale grey nodules which are overgrowth of mucosa are most commonly caused by chronic allergic rhinitis

what is the tonsil grading system

1+ = visible

2+ = halfway between tonsillar pillars and uvula

3+ = touching uvula

4+= touching each other

0= not visible or surgically removed

normal is 1+ or 2+

what is the medical term for runny nose

rhinitis

what is the medical term for nose bleed

epistaxis

what virus causes cold sores

herpes simplex virus type 1

medical term for canker sore

aphthous ulcer

mental status

a person's emotional and cognitive functioning

what are the main components of mental satus assessment (ABCT)

appearance

behavior

cognition

thought process

what does the finger tips assess during palpation

skin texture

swelling

pulsation

presence of lumps

what does the fingers and thumb assess during palpation

detection of position, shape, and consistency of organ or mass

what does the dorasa of the hand assess during palpation

temperature of the skin

what does the ulnar surface of the hand assess during palpation

vibrations

percussion sounds: Resonant

normal lung tissue

clear, hollo

percussion sounds: hyperresonant

normal over the child's lung

Abnormal in the adult --> can indicate emphysema

booming sound

Percussion sounds: Tympany

normal stomach and intestine (over air-filled viscus)

sounds like a drum

percussion sounds: Dull

heard over dense organs like the liver or spleen

muffled thud sound

percussion sounds: Flat

No air is present, over thigh muscles, or bone or tumor

dead stop of sound, dullness

how many lympnodes are we assessing in the head and neck

9

hat are assessing during palpation of lymp nodes

size, warmth, mobility, and tenderness

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