Nursing 210 - Test 1

General appearance to look for in a pt #1

General appearance to look for in a pt #1

Apparent state of health

General appearance to look for in a pt #2

LOC

General appearance to look for in a pt #3

Facial Expression

General appearance to look for in a pt #4

Posture, gait, motor activity and speech

General appearance to look for in a pt #5

Odor of body/breath

General appearance to look for in a pt #6

Skin color and obvious lesions

General appearance to look for in a pt #7

Dress, grooming, and personal hygiene

OLD CART

Onset Location Duration Characteristics Associated manifestations Relieving factors Treatment

FIFE

Feelings Ideas Function (what can't you do now that you could before) Expectations

Phases of interview

pre-interview, introduction, working, termination

Pre-interview

Plan: self-reflection, review pt record, set interview goals, review own clinical behavior/appearance

Introduction

put the patient at ease and establish trust (greet pt and est. rapport) est agenda for interview

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)

Termination

summarize important points, discuss plan of care

Techniques of a skilled interview

Active listening, guided questioning, nonverbal communication, empathetic responses, validation, reassurance, summarizing, transitions, empowering the pt

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)

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))

Quantifying Q's

When For how long How many How often Rate (your pain)

Interview basics: open with

What How Tell me about Describe

INTERPRETER

Introduction Note goals Transparency Ethics Respect beliefs Patient focus Retain control Explain Thanks

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)

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

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)

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)

The basics are

Courtesy, connection, comfort, confirmation, empathy, and confidentiality

Types of Questions

Open-ended Direct More focused with more questions leading questions

open-ended Qs

Used to open interview; most useful (what gets you the most info and allows pt to fill in the blanks)

Direct Qs

usually are closed-ended (you need specific answer (short answer--who, what, where, when)

More focused with more questions

permission-giving Qs. the more Qs, the more pieces of the puzzle you get

Leading questions

be careful; pt answers in a way they think you want to hear

Nonverbal communication

Body posture, gestures, facial expressions, eye contact, mirroring, interpersonal distance, active listening

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

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

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

Crying pt

Crying signals strong emotions ranging from sadness to anger offer a tissue, make a supportive remark

Angry or disruptive pt

Accept angry feelings from patient you can validate their feelings without agreeing

Yes/No Qs

Do you Have you/have you ever Are you

Subjective data

obtained prior to physical exam; symptoms; all about what the pt says

Objective data

obtained in physical exam; signs

Common/concerning symptoms of the neck

Swollen lymph nodes or neck lumps (tender) Enlarged thyroid gland (goiter) Hoarseness

Leading causes of TBI

falls, motor vehicle accidents, blows to the head, assaults

Common/concerning symptoms of the head

headache head injury head or neck surgery traumatic brain injury

When a node is detected, note:

size, shape, consistency, delimitation (discrete or matted together), mobility, tenderness

Tender nodes suggest

inflammation

Hard/fixed nodes suggest

malignancy

Keloid

secondary lesion; huge scar that extends beyond border of the initiating injury

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)

Vitiligo

depigmentation of skin (extreme lack of melanin; cow) pale areas are the vitiligo

patient's perspective on the illness

FIFE

Four general goals of examination

Maximize pt's comfort Maintain pt safety Avoid unnecessary changes in position Enhance clinical accuracy and efficiency

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)

Melanoma

black tumor pigment-producing melanocytes lethal--causing 70% of skin cancer deaths

Basal Cell carcinoma

Basal level of epidermis accounts for most skin cancers sun-exposed areas pearly white/translucent grow slow, rarely metastasize

squamous cell carcinoma

Arise in upper layer of epidermis crusty and scaly red, inflamed, ulcerated

Local warmth means

inflammation or cellulitis

Dry skin

Hypothyroidism

Dehydration

Dry mucous membranes, cracked lips, dry skin, and lack of tears

Jaundice suggests

liver disease or excessive hemolysis of RBCs

Cyanosis in congestive heart failure

usually peripheral, reflecting low blood flow; venous obstruction may cause peripheral cyanosis

Central cyanosis

advanced lung disease, congenital heart disease, and hemoglobinopathies

Pallor results from

decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency.

The nursing process steps

Assessment Diagnosis Planning Implementation Evaluation

How one thinks solves problems and makes decisions

developmental level

Environmental influences

favorable conditions to promote health

Spiritual influences

living peacefully, morally, and ethically

Cultural influences

favorable connections to promote health

Social well-being

supportive relationships with family and friends

Emotional health

Positive outlook and emotions channeled in a healthy manner

physical health

How the body works and adapts

Inspection of NEVI (aka moles)

color, shape, size, surface, number, location

Size of mole should be

<6 mm (eraser of #2 pencil)

Normal number of moles

10-40

Location of moles

typically above waist, mostly not on breast, butt, or scalp

cyanosis

lack of o2

pallor

poor circulation

Color of skin

jaundice, pallor, cyanosis, erythema, pale and shiny (i lower extremities; smooth and hairless)

Unusual Moles ABCD

Asymmetrical (lumpy) Borders (irregular) Color (multicolor or black) Diameter (greater than 6mm)

Primary lesion

occurs from some pathological process

Secondary lesion

time; results from later evolution of external trauma to primary lesion

Vascular lesion examples

Petechiae (tiny red dots) Purpura (flood of bruising not associated with trauma) Ecchymosis Spider angioma (vessels) Venous star Telangiectasia

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)

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

Characteristics of lesion to document

size shape color texture elevation or depression pedunculation (skin tag; a piece of skin or a stalk) Exudate

Café-Au-Lait spot

A slightly but uniformly pigmented macule or patch with a somewhat irregular border

Location and distribution

Generalized or localized region of the body patterns discrete or confluent

Configuration (shape)

Annular grouped linear Arciform Diffuse

Palpation of skin

moisture, texture, temp, tenderness, turgor, edema

Other skin variations that don't fall into primary or secondary lesions

callus, cutaneous horn, seborrhea, cutaneous tag

Inspection and palpation of hair

Distribution Texture Quantity (alopecia or hirsutism) parasites

Clubbing of nails

Smokers; associated with chronic cardiovascular or pulmonary disease; hypertrophy of the tissue beced

special histories

Infants/children (still developing; how was pregnancy) Adolescents Pregnant women Older adults (polypharmacy)

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

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)

parts of lymphatic system

lymph nodes lymphatic fluid and lymphocytes thymus spleen tonsils/adenoids peyer patches

Function of lymphatic system

Immunity, phagocytosis, collector of interstitial fluid

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)

Lymph nodes are most accessible

head neck arms axilla inguinal area

Inspection and palpation of lymph nodes

edema, erythema, size, consistency, mobility, discrete or matted, tenderness, warmth

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)

Evaluate that lump!

size, shape, surface, site, symptoms, softness, squeezability, spread, sensation