Nursing 210 - Test 1

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General appearance to look for in a pt \#1
Apparent state of health
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General appearance to look for in a pt \#2
LOC
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General appearance to look for in a pt \#3
Facial Expression
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General appearance to look for in a pt \#4
Posture, gait, motor activity and speech
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General appearance to look for in a pt \#5
Odor of body/breath
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General appearance to look for in a pt \#6
Skin color and obvious lesions
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General appearance to look for in a pt \#7
Dress, grooming, and personal hygiene
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OLD CART
Onset
Location
Duration
Characteristics
Associated manifestations
Relieving factors
Treatment
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FIFE
Feelings
Ideas
Function (what can't you do now that you could before)
Expectations
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Phases of interview
pre-interview, introduction, working, termination
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Pre-interview
Plan: self-reflection, review pt record, set interview goals, review own clinical behavior/appearance
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Introduction
put the patient at ease and establish trust (greet pt and est. rapport) est agenda for interview
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Working
obtain pt info (invite pt story--ID/respond to emotional cues)(expand/clarify pt story)(generate and test diagnostic hypotheses)(Negotiate a plan further eval, treatment, education and self-management support and prevention)
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Termination
summarize important points, discuss plan of care
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Techniques of a skilled interview
Active listening, guided questioning, nonverbal communication, empathetic responses, validation, reassurance, summarizing, transitions, empowering the pt
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Guided questioning
Helps to continue the patient's story
-moving from open-ended to focused questions
-using questions that elicit a graded response
-asking a series of questions, ONE at a time
-clarifying what the patient means
-encouraging with continuers
-using echoing
-avoid leading questions (has your pain been improving? You don't have any blood in your stool, do you?)
(General--\>specific)
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The silent pt
Reasons: to collect thoughts, remember details, or decide whether you could be trusted with info. (appear attentive--watch for nonverbal cues, encourage to continue when appropriate, silence may be apart of culture, maybe you're asking too many short-answer questions in rapid succession, did you offend patient, did you fail to recognize an overwhelming symptom (pain, nausea, dyspnea))
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Quantifying Q's
When
For how long
How many
How often
Rate (your pain)
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Interview basics: open with
What
How
Tell me about
Describe
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INTERPRETER
Introduction
Note goals
Transparency
Ethics
Respect beliefs
Patient focus
Retain control
Explain
Thanks
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Advance Directive
A person makes provision for health care decisions in event that pt becomes unable to make those decisions (this includes CPR, artificial feeding/hydration, and antibiotics)
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Dying pt
Rarely want to talk about their illnesses
Give them opportunities to talk/listen
Smile, touch, inquiring about a family member, comment on days events, gentle humor
avoid false reassurance
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Confusing pt
Focus on meaning or function of symptom, emphasizing on pt's perspective
Psychological disorder may be present (delirium in acutely ill or intoxicated pt)
If Psychiatric or neuro disorder suspected, shift to mental status exam (LOC, orientation, memory, capacity to understand)
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purpose of interview
Developing a therapeutic relationship
providing a picture of client as a whole person (the history)
Assists in assessing and dx needs (should help to focus the physical exam, 80% of dx are based on interview and health history)
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The basics are
Courtesy, connection, comfort, confirmation, empathy, and confidentiality
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Types of Questions
Open-ended
Direct
More focused with more questions
leading questions
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open-ended Qs
Used to open interview; most useful (what gets you the most info and allows pt to fill in the blanks)
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Direct Qs
usually are closed-ended (you need specific answer (short answer--who, what, where, when)
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More focused with more questions
permission-giving Qs. the more Qs, the more pieces of the puzzle you get
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Leading questions
be careful; pt answers in a way they think you want to hear
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Nonverbal communication
Body posture, gestures, facial expressions, eye contact, mirroring, interpersonal distance, active listening
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Common errors in communicating
Giving advice, changing the subject, social vs therapeutic response, false reassurance, jumping to conclusions, biased questions, ignoring spiritual needs, being judgmental
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pt with altered capacity
Determine whether pt has decision-making capacity
for pts with capacity: obtain consent before talking about their health with others, a spouse may report significant family strains, depression, drinking habits etc. that patient denied. (divide the interview, one with each person)
pt with impaired capacity: find surrogate informant/decision maker. assess quality of relationship with patient and est. how they know patient
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Talkative pt
give pt free reign for 5-10 min
focus on what seems most important to pt
show interest--ask Qs
Don't show impatience if time runs out explain need for second meeting
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Crying pt
Crying signals strong emotions ranging from sadness to anger
offer a tissue, make a supportive remark
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Angry or disruptive pt
Accept angry feelings from patient
you can validate their feelings without agreeing
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Yes/No Qs
Do you
Have you/have you ever
Are you
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Subjective data
obtained prior to physical exam; symptoms; all about what the pt says
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Objective data
obtained in physical exam; signs
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Common/concerning symptoms of the neck
Swollen lymph nodes or neck lumps (tender)
Enlarged thyroid gland (goiter)
Hoarseness
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Leading causes of TBI
falls, motor vehicle accidents, blows to the head, assaults
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Common/concerning symptoms of the head
headache
head injury
head or neck surgery
traumatic brain injury
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When a node is detected, note:
size, shape, consistency, delimitation (discrete or matted together), mobility, tenderness
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Tender nodes suggest
inflammation
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Hard/fixed nodes suggest
malignancy
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Keloid
secondary lesion; huge scar that extends beyond border of the initiating injury
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Lichenification
secondary lesion; Visible and palpable thickening of the epidermis (Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss)
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Vitiligo
depigmentation of skin (extreme lack of melanin; cow)
pale areas are the vitiligo
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patient's perspective on the illness
FIFE
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Four general goals of examination
Maximize pt's comfort
Maintain pt safety
Avoid unnecessary changes in position
Enhance clinical accuracy and efficiency
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Tangential Lighting
optimal for inspecting structures such a the jugular venous pulse, thyroid gland, and the apical impulse of the heart (pulse over the apex of the heart)
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Melanoma
black tumor
pigment-producing melanocytes
lethal--causing 70% of skin cancer deaths
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Basal Cell carcinoma
Basal level of epidermis
accounts for most skin cancers
sun-exposed areas
pearly white/translucent
grow slow, rarely metastasize
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squamous cell carcinoma
Arise in upper layer of epidermis
crusty and scaly
red, inflamed, ulcerated
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Local warmth means
inflammation or cellulitis
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Dry skin
Hypothyroidism
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Dehydration
Dry mucous membranes, cracked lips, dry skin, and lack of tears
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Jaundice suggests
liver disease or
excessive hemolysis of RBCs
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Cyanosis in congestive heart failure
usually peripheral, reflecting low blood flow; venous obstruction may cause peripheral cyanosis
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Central cyanosis
advanced lung disease, congenital heart disease, and hemoglobinopathies
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Pallor results from
decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency.
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The nursing process steps
Assessment
Diagnosis
Planning
Implementation
Evaluation
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How one thinks solves problems and makes decisions
developmental level
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Environmental influences
favorable conditions to promote health
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Spiritual influences
living peacefully, morally, and ethically
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Cultural influences
favorable connections to promote health
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Social well-being
supportive relationships with family and friends
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Emotional health
Positive outlook and emotions channeled in a healthy manner
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physical health
How the body works and adapts
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Inspection of NEVI (aka moles)
color, shape, size, surface, number, location
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Size of mole should be
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Normal number of moles
10-40
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Location of moles
typically above waist, mostly not on breast, butt, or scalp
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cyanosis
lack of o2
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pallor
poor circulation
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Color of skin
jaundice, pallor, cyanosis, erythema, pale and shiny (i lower extremities; smooth and hairless)
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Unusual Moles ABCD
Asymmetrical (lumpy)
Borders (irregular)
Color (multicolor or black)
Diameter (greater than 6mm)
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Primary lesion
occurs from some pathological process
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Secondary lesion
time; results from later evolution of external trauma to primary lesion
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Vascular lesion examples
Petechiae (tiny red dots)
Purpura (flood of bruising not associated with trauma)
Ecchymosis
Spider angioma (vessels)
Venous star
Telangiectasia
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Primary Lesion examples
macule (freckle)
Papule (not flat; raised)
patch
plaque
wheal
nodule
tumor
vesicle (small clear fluid-filled lesion)
Bulla (blister, can be filled like vesicle)
Pustula (zit; raised, small, filled with pus)
cyst (nodule filled with liquid or semisolid)
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Secondary Lesions examples
scale
lichenification
keloid
scar
excoriation (scratched wound)
fissure
erosion
ulcer (compression of skin--\>hypoxia of skin tissue death--\>stage 1 ulcer)
crust (dried residue of skin exudate)
atrophy
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Characteristics of lesion to document
size
shape
color
texture
elevation or depression
pedunculation (skin tag; a piece of skin or a stalk)
Exudate
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Café-Au-Lait spot
A slightly but uniformly pigmented macule or patch with a somewhat irregular border
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Location and distribution
Generalized or localized
region of the body
patterns
discrete or confluent
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Configuration (shape)
Annular
grouped
linear
Arciform
Diffuse
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Palpation of skin
moisture, texture, temp, tenderness, turgor, edema
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Other skin variations that don't fall into primary or secondary lesions
callus, cutaneous horn, seborrhea, cutaneous tag
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Inspection and palpation of hair
Distribution
Texture
Quantity (alopecia or hirsutism)
parasites
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Clubbing of nails
Smokers; associated with chronic cardiovascular or pulmonary disease; hypertrophy of the tissue beced
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special histories
Infants/children (still developing; how was pregnancy)
Adolescents
Pregnant women
Older adults (polypharmacy)
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Immunocompetent
means immune system works; Tissue rejection: if immune system isn't shut down on purpose, the organ will be rejected
We shut it down with steroids; steroids come out of the adrenals and during stress response it suppresses immune system
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immunoincompetent
Immune system gets confused (gets dementia goes after body it should be protecting)
Allergic (overdrive immune system--monster response)
Immunodeficient (HIV/AIDS)
Autoimmune (Arthritis, Hashimotos)
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parts of lymphatic system
lymph nodes
lymphatic fluid and lymphocytes
thymus
spleen
tonsils/adenoids
peyer patches
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Function of lymphatic system
Immunity, phagocytosis, collector of interstitial fluid
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Where do you find lymphatic system
anywhere there are blood vessels except placenta and brain
Placenta: it'd attack the tissue of the baby
Brain: it'd swell and your skulls a closed cavity so somethings gotta go--the foreman magnum. the first thing to go would be the brainstem--you would die
(WHEN LYMPHATIC TISSUE is doing it's job, they swell)
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Lymph nodes are most accessible
head
neck
arms
axilla
inguinal area
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Inspection and palpation of lymph nodes
edema, erythema, size, consistency, mobility, discrete or matted, tenderness, warmth
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Nodes
Ask if the pt knows of any lumps or bumps on their body
most often evaluated region by region during head to toe assessment (Femoral pulse, feel for swollen lymph nodes)
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Evaluate that lump!
size, shape, surface, site, symptoms, softness, squeezability, spread, sensation