Nursing assessment lecture exam 1

ecchymosis

bruises

Malnutrition skin/hair/nail findings

dry/brittle hair, hair loss, thin/fragile skin, poor wound healing, brittle ridged nails, edema

What is the prioritization framework to decide who to see first when clients need attention

ABCDE method - airway, breathing, circulation, disability, exposure

Cancerous lesion risk factors

Excessive sun/UV exposure, fair skin, family history, history of sunburns, immunosuppression, older age

Skin changes in older adults

Thinner/drier/less elastic skin, reduced subcutaneous fat, slower wound healing, decreased sweat/oil gland activity, reduced turgor, thicker/brittle nails, thinning/graying hair

normal range for body temperature

36-38 or 96.8-100.4

Bradypnea

less than 12 breaths per min

tachypnea

more than 20 breaths per min

visceral pain

deep pain

somatic pain

bone muscles or ligaments → throbbing feeling

chronic pain

lasts more than 6 months

referred pain

felt elsewhere from where pain originates

2 meds that effect breathing

narcotics and sedatives

expected blood pressure

120/80

hypotension

less than 90/60

hypertension stage 1

130-139/80-89

hypertension stage 2

greater than 140/90

hypertensive crisis

180/110

pallor

pale skin

expected variations for skin tone

hyperpigmentation (birthmarks, sun spots) and hypopigmentation (scars, stretch marks)

Where can you measure blood pressure

upper arm, forearm, wrist, calf, thigh

AOx4

alert and orientated —> person place time situation

stupor

unconsciousness but responds to pain (rub sternum)

obtundation

difficult to arouse

erythema

inflammation and redness

crepitus

cracking sounds when bones rub together

spasticity

increase muscle tone

fasciculation

rapid twitching

myoclonus

jerking

factors that effect temperature

age, hormones, stress, diurnal rhythms

expected heart rate

60-100

pulse measurement scale

0= absent

+1 = weak, thready

+2 = normal, brisk

+3 = increased, strong

+4 = bounding, full volume

expected pulse oximetry %

95-100% (unexpected <90)

PLEASE acronym for health history

p- past medical history

l - last oral intake

e- events leading to illness or injury

a- allergies AND type of reaction

s- symptoms or chief complaint

e- each medication and supplement

ISBARR - method of shift report or communication with providers

identify, situation, background, assessment, recommendations, read back

is pain scale objective or subjective

objective

difference btw comprehensive or focused health assessment

comprehensive - head to toe

focused - cheif complaint (hospital setting)

what is collected in a general data collection

biographical data, source of health history, reason for seeking care, current health status, past health history, family health history, personal/social history, review of systems

history of present illness - acronym

OLD CARTS

onset, location, duration, characteristics, aggravating factors, related symptoms, treatment, severity

OPQRST - O

Onset: when did the symptom start, and was it sudden or gradual?

OPQRST - P

pattern/precipitating factors: what makes the symptom better or worse?

OPQRST - Q

Quality: how does the symptom feel (sharp, dull, burning, aching)?

OPQRST - R

Radiation: where is the symptom located, and does it spread?

OPQRST - S

Severity: how bad is it, rated 0-10?

OPQRST - T

Timing and treatment: is it constant or intermittent, and how long does it last?

Subjective data

Information the patient reports (symptoms, feelings, history) - e.g., "I feel nauseous"

Objective data

Information the nurse observes or measures (signs) - e.g., vital signs, exam findings, lab values

Pack-year formula

Packs smoked per day x number of years smoked

General survey components

Appearance (General impression), Behavior (fidgety, anxious, sweating, angry), Indicators of abuse/neglect/human trafficking, Body structure (thin, obese), Mobility (gait, balance, fluidity),

Height/weight/BMI, Vital signs, Pain

Cultural considerations in general survey

Eye contact norms, personal space, modesty/gender preferences, health beliefs/folk remedies, language/interpreter needs, family involvement in decisions

Blood pressure - proper technique

Patient seated with arm at heart level, feet flat, back supported; no caffeine/smoking 30 min prior; correct cuff size; cuff 1 inch above antecubital space

Cuff too small effect

Falsely elevated (high) blood pressure reading

Cuff too large effect

Falsely low blood pressure reading

Orthostatic hypotension

systolic drops 20 or diastolic drops 10

(decrease in blood pressure that occurs when getting up) (1-3 min intervals)

Orthostatic hypotension symptoms

Dizziness, lightheadedness, blurred vision, syncope, weakness upon standing

Apical pulse location

5th intercostal space, midclavicular line

Apical pulse counting time

60 seconds

Oral temperature procedure

Wait 15-30 minutes after eating/drinking/smoking; place probe in posterior sublingual pocket; patient keeps mouth closed

Normal radial pulse

60-100 bpm, regular rhythm, strong and equal bilaterally

Abnormal radial pulse findings

Tachycardia, bradycardia, irregular rhythm, weak/thready pulse (poor perfusion), or bounding pulse (fluid overload)

bradycardia

less than 60 bpm

tachycardia

greater than 100 bpm

Stethoscope diaphragm

larger side: best for high-pitched sounds like breath sounds, normal heart sounds, and bowel sounds

Stethoscope bell

smaller side: best for low-pitched sounds like some heart murmurs and vascular sounds

Normal respiratory rate (adult)

12-20 breaths per minute, regular rhythm

Physical exam sequence (general)

IPPA -Inspection, Palpation, Percussion, Auscultation

Physical exam sequence (abdomen)

Inspection, Auscultation, Percussion, Palpation - auscultation moved up to avoid altering bowel sounds

Inspection (purpose)

Visual observation to identify visible abnormalities, color, and symmetry

Palpation (purpose)

Uses touch to assess texture, temperature, tenderness, masses, and pulses

Percussion (purpose)

Tapping to determine density of underlying tissue (dull vs. resonant vs. tympanic)

Auscultation (purpose)

Listening with a stethoscope to evaluate sounds produced by organs (heart, lungs, bowel)

unexpected level of consciousness progression

confusion → lethargy → obtunndation → stupor —> comatose

Normal nail base angle

Approximately 160 degrees

Nail clubbing

Nail base angle >180 degrees, flattened/bulging nail, spongy nail bed- associated with chronic hypoxia

Normal capillary refill

Color returns within 2 seconds after pressure is released

Skin turgor test

Gently pinch skin (sternum or forearm), release, and observe how quickly it returns to place

Abnormal skin turgor ("tenting")

Skin remains raised and slow to return - sign of dehydration (less reliable in older adults)

Cyanosis

Bluish discoloration of skin/mucous membranes due to inadequate oxygenation

Cancerous lesion risk factors

Excessive sun/UV exposure, fair skin, family history, history of sunburns, immunosuppression, older age

ABCDE - A

Asymmetry

ABCDE - B

Border irregularity

ABCDE - C

Color variation

ABCDE - D

Diameter greater than 6mm

ABCDE - E

Evolving - changing in size, shape, or color

Pressure ulcer risk factors acronym

AVOIDS PRESS

aging skin, vascular disorders, obesity, immobility, diabetes, skin friction, poor nutrition, reduced RBC, edema, sensory deficits, sedation

Pressure ulcer prevention

Reposition every 2 hours, use pressure-relieving surfaces, keep skin clean/dry, ensure adequate nutrition/hydration, minimize friction/shear

Pressure ulcer Stage 1

Intact skin with non-blanchable redness, swollen tissue, darker skin

Pressure ulcer Stage 2

Skin is NOT intact, Partial-thickness skin loss, no fatty tissue visible, may resemble a blister

Pressure ulcer Stage 3

Full-thickness SKIN loss; subcutaneous fat may be visible, damage to or necrosis of SUBQ tissue, no bone/tendon/muscle exposed

Pressure ulcer Stage 4

Full-thickness TISSUE loss with exposed bone, tendon, or muscle

Unstageable pressure ulcer

Wound base covered by slough/eschar so true depth cannot be determined

Deep tissue injury (DTI)

Skin is intact, tissue beneath surface is damaged, appears purple or dark red

5 rights of delegation

task, circumstance, person, direction, supervision

nursing process

assessment, analysis, planning, implementation, evaluation

ethical principals

nonmaleficence, beneficence, autonomy, justice, confidentiality