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181 Cards in this Set
- Front
- Back
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What physical assessment do you use when touching to feel vibrations and locate body structures?
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Palpation
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An initial change in the skin
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primary lesion
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Assessment =
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Foundation
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All dcisions and actions are based on
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initial and ongoing assessments
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Best equipment for an assessment
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your 2 hands
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assess for a _____________ then you will know how well meds work
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baseline
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What are the 5 steps of the nursing process
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1. Evaluation
2. Intervention 3. Plan 4. Nursing diagnosis 5. Assessment |
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What kind of assessment do you do when it is the patients first visit
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Comprehensive
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Are the subjective and objective assessments....
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consistent
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subjective + objective =
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Data base
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Types of Health assessments: Compete=
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INITIAL, COMPREHENSIVE
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Types of Health assessments: EPISODIC=
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PROBLEM ORIENTED...your cough today
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Types of Health assessments: INTERVAL OR FOLLOWUP=
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CHANGES FROM BASELINE...had surgery, followup
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Types of Health assessments: EMERGENY
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ABC'S...trump everything
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Critical thinking skills
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1. always observing pts
2. do they understand what the doctor said |
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physical findings
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do pt's values reflect what you see
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Introduction to Health assessment: Aspects (5)
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1, Structured interview
2. observation 3. Physical findings 4. lab findings 5. documentation |
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Primary Objective of Structured interview:
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Gather information to determine another's concerns and needs regarding heath care.
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4 COMMUNICATION GOALS
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1. DISCOVER INFO THAT LEADS TO NURSING DIAGNOSIS AND PLAN OF CARE.
2. PROVIDE THE PATIENT WITH INFO REGARDING THE DIAGNOSIS 3. NEGOTIATE WITH THE PATIENT REGARDING HEALTHCARE MANAGEMENT 4. COUNSEL ABOUT DISEASE PREVENTION. |
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Your perspective 4 things
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1. confrontation, 2 interpretation 3. explanation, 4 summary
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interviewing traps (10)
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1. False reassurance
2. giving unwanted advice (well if I had) 3. using authority 4. avoidance language 5. distancing 6. professional jargon 7. leading questions 8. talking too much 9. interrupting 10. asking why |
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Brief statement of why the pt is here should always be
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...in the pts own words
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Begin interview with obtaining identifiers like
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date, time,sex, race, occupation, referral
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COLDSPA: C
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Character or quality
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Character or quality question
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what does it feel like?
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COLDSPA: O
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onset
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Onset question
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When did it start?
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COLDSPA: L
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Location
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Location question
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Where does it hurt?
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COLDSPA: D
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Duration
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Duration question
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How long does it last
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COLDSPA: S
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Severity of symptoms
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Severity of symptoms question
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On a scale of 0-10, 10 being the worst pain, what is it now?
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COLDSPA: P
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Pattern
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Pattern question
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Does it come at certain times, anything make it better?
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COLDSPA: A
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Associated factors/how it affects the client
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Gravida
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# of pregnancies
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Para
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# of births
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4 physical assessment techniques
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1. Inspection (critical observation)
2. Palpation (light/deep) 3. Percussion (types/sounds) 4. Auscultation |
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crepitus
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crackling or popping sounds under skin or in joints
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tympany
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hollow sound
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hyperresonance
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gas sounds
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resonance
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norm, lungs
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dullness
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rib, liver
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flatness
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stool in colon, rib
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Sites of temperature (4)
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oral, axillary, rectal, tympanic
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pulse qualities
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rate, rhythm, quality
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qualities of respiration
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rate, depth, rhythm
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What shouldnt be down within 30 min of exam
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alcohol, tobacco, caffeine, exercise
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Normal oral temp
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(98.6F/ 37C)
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normal Axillary
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97.6F/36.3C
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normal rectal
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99.6/37.7
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Normal Aural
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99.6/37.7C
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Types of pulse rhythm
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Regular, regularly irregular, irregularly irregular
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Bradycardia
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pulse less than 60
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Tachycardia
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pulse greater than 100
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Sinus arrhythmia
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often seen in children, fast then slow
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What conditions would affect a persons heart rate
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temp, anxiety, pain, smoke
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What is the normal respiratory rate
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12-20 breath per minute
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Tachypnea
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greater than 20 breath per min
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Bradypnea
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less than 12 breaths per min
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Systolic pressure
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maximum pressure felt on the artery during left ventricular contraction, or systole
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Diastolic pressure
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the resting pressure the blood exerts btw each contraction
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Pulse pressure
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the difference between the systolic and diastolic and reflects the stroke volume
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What are the 11 functional health patterns
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1. Health perception (health management)
2. Activity (exercise) 3. Nutritional (metabolic) 4. Elimination 5. Sleep (rest) 6. Cognitive (perceptual) 7. Self-perception (self concept) 8. Coping (stress tolerance) 9. Sexuality 10. Role (relationship) 11. Value (beliefs) |
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What do you use if you can't palpate a pulse?
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doppler
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Mean arterial pressure (MAP) -
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pressure forcing blood into the tissues
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What is the first sound heard when obtaining blood pressure
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Korotkoff sound
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Orthostatic vital signs
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Serial measurements of pulse and blood pressure taken n
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WHen are orthostatic vital signs taken (3)
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1. volume depletion is suspected
2. Pt is hypertensive or is taking antihypertensive meds 3. pt reports fainting or syncope |
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Assess orthostatic vital signs in what positions
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Lying, sitting, standing
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Pt is considered orthostatic bp when
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drop of more than 20 mmHg in SBP or pulse increases by greater than 20 bpm
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systolic bp below 80 may be a sign of
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shock
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If the right has ____ degree difference than the left take the right
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10
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Pressures in the beginning of the visit may be higher due to the
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'white coat effect'
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What pressure is considered preHTP
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systolic (120-139) diastolic (80-89)
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'Normal' BP
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systolic <140 and diastolic < 90
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Isolated systolic HTN
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systolic > 140 and diastolic < 90
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Mild HTN
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systolic 140-159 and diastolic 90-99
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Moderate HTN
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systolic 160-179 and diastolic 100-109
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Severe hypertension
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systolic 180-209 and diastolic 110-119
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Crisis Hypertension
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systolic >210 and diastolic > 120
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Documentation of Data from the Assessement....SOAP
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Subjective data
Objective data Assessment (functional health patterns and nursing diagnosis) Plan |
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Central cyanosis
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O2 saturation less than 80%...blue around mouth
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Peripheral cyanosis
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Decreased cardiac output ... nail beds and extremities are blue
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Severe cardio/pulmonary in hands
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clubbing
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Xanthomas
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lipid deposits (yellow deposits around the eyes)
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Normal O2 stats
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96-100%
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Smoker's O2 stats
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92-94%
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Epidermis
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Avascular, synthesizes keratin, contain melanocytes, basement membrane connects it to the dermis
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Dermis -
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very vascular, consists of mostlly collagen (resist tearing), sensory nervs, elastin, erectoris pylorum (hair folicles), autonomic nerves
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subcut layer
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loose connective tissue, insulate, absorb shock, generate heat,increased mobiliity over organs
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Eccrine sweat glands
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regulate body temp by secreting sweat (NaCl soln)
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Apocrine sweat glands
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in axillae, nipples, anogenital, respond to emotions w thick milky fluid, open into hair folicles. No odor
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Body odor results
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bacteria breaking down sweat
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What is the skin system called
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integumentary system
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What is the basal cell layer called
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stratum germinativum
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what is the half moon shaped at bottom of nail?
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Lunula
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Where does the nail grow from?
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Nail matrix
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What are the 9 functions of the skin
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1. Protection
2. Sensory perception 3. temperature control 4. vitamin synthesis 5. excretion 6. regeneration 7. blood pressure regulation 8. communication 9. identifcation |
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What are types of subjective data for the skin (9)
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1. previous history of skin problems
2. changes in color/pigmentation 3. change in mole 4. excessively dry/moist 5. itching 6. bruising 7. rash/lesion 8. medications 9. allergies |
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6 things to note in skin assessment
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1. color changes
2. symmetry 3. distribution 4. thickness, calluses 5. skin lesions 6. vascular changes |
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When looking at skin color....
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1. general pigmentation,
2. note widespread color change, pallor, erythema, cyanosis, jaundice |
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what is erythema
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redness of the skin
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When palpating skin look at (7)
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1. moisture
2. temperature 3. texture 4. thickness 5. turgor 6. edema 7. mobility |
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Moisture
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Perspiration and oiliness
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temperature
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symmetry, coolness/warmth
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texture
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smooth, soft, even, roughness
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thickness
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calluses
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turgor
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resilient when pinched, forearm, sternum
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edema
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Graded on a 4 point scale, note location/amount
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Mobility/turgor
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connective tissue disorders
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What do you inspect for with Lesions (9)
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1. Size
2. Shape 3. Color 4. texture 5. elevation 6. Location/distribution 7. pattern 8. configureation 9. exudates |
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What do you describe with the configuration of lesions?
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annular (rings), grouped, linear, arciform (bowshaped), diffuse
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What do you describe with the exudates of lesions? (4)
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Color, amount, constitency, odor
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Tannish brown color cast to legs
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venuous ulcer
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Reddish color to ulcer
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arterial
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erythema
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redness
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excessive roughness could be (2)
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keritinitis/healing skin
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scant means
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very little
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copious means
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a lot
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purialant
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thick
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describe pseudomonus
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strong smell, green, stringy
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Macule
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circumscribed, flat, non-palpable CHANGES IN COLOR thats <1cm in diameter
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examples of macules
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freckle, flat mole, distinct
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Circumscribed, flat, non-palpable, CHANGES in COLOR > 1 cm in diameter
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patch
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example of patch
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vitiligo, port wine stain, cafe au lait patches
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What is an initial manifestation of the pathological process?
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Primary Skin Lesions
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Palpable, elevated solid mass less than 1 cm
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papule
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Palpable elevated solid mass greater than 1 cm, deep & firm
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Nodule
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example of papule
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wart, elevated mole
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example of nodule
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lipoma, fatty tumor, nevus
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What is a wheal
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irregular, transient area of localized skin edema
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Examples of wheals
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Tb test, hive, insect bite
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What is a plaque
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Elevated firm, palpable solid mass, doesnt go deeper, rought, flat surface > 1cm in diameter
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What is an example of plaque
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Psoriasis, acetinic keratosis, lichan palas, seborrheic dermatitis
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Circumscribed, superficial elevation of skin by fluid...less than 1 cm
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Vesicle
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Example of vesicle
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poison ivy, burn blister, chicken pox, herpes
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Circumscribed, superficial elevation of the skin by fluid....greater than 1 cm
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Bulla
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Example of Bulla
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Contact dermatitis, large burn blisters
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What is a pustule
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Circumscribed, superficial elevations of the skin by purulent, cloudy fluid.... acne, carbuncles
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What are secondary Lesions
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They result from trauma or evolution of primary lesions
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What are 2 types of 2ndary Lesions
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1. Debris on surface...Crust....scab
2. Breaks in Continuity |
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What 5types of breaks in continuity for 2ndary Lesions
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1. Fissure,
2. Ulcer 3. Excoriation 4. Scar 5. Erosion |
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Fissure
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Linear crack in skin....breaks through epidermis to dermis
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Ulcer
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deep skin loss in dermis, bone, fat, pressure ulcer
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Excoriation
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Loss of epidermis, abrasion, scratch
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Scar -
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Healed wound, flat connective tissue
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Erosion
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Wearing away of superficial epidermis, wet, moist, etc
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Eschar tissue
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Black, dead, necrotic tissue
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The only time that you can say NORMAL....
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Bowel sounds
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Name 3 types of vascular lesions
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1. Petechiae
2. Ecchymosis 3. Hematoma |
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What are small, red/purple, non-blanchable spots caused by intravascular defects and infections
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petechiae
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What are bruises that are red/purple, non blanchable ...made by trauma, vasculitis, vascular wall destruction...or medications, poor clotting factors
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Ecchymosis
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Blood clot, swelling under the skin, will elevate the skin, blood leaking under the tissue...often from sheath removal or trauma
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Hematoma
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Red/purple non blanchable intravascular/ infections > 0.5 cm +
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PURPURA
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Normal nail bed angle
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160 degrees
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Look for on nails...(3)
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ridges, grooves, pitting (with psoriasis)
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5 steps of clubbing
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1. Nail bed becomes soft
2. Loss of normal 160 angle 3. Increased convexity of nail fold 4. Thickening of whole end of finger 5. shiny/ nail/skin striated |
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Nail deformity that is red/swollen around nail....tender nail
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Paronychia
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Chronic Paronychia comes from ....and Acute paronychia comes from
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fungal....bacterial (break)
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Thin depressed nails
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Koilonychia...bc congenital/inherited....or iron deficiency/anemia
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Optimal nutritional status reflects...
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balance btw intake and metabolic demands of growth, pregnancy and illness.
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Normal lab for hemoglobin
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14-18 g/dl
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hemoglobin labs increase with .... and decrease with ....
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dehydration....iron deficiency/blood loss/fluid retention
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Hematocrit normal lab
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36-49%
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Hematocrit decreases....
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proportionally with hemoglobin
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Normal cholesterol...
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less than 200
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Normal triglycerides
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less than 200
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Normal Albumin lab....usually for....
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3.5-5 g/dl...looks at weeks past
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decreased albumin means
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protein calorie malnutrition or overhydration, decreased liver function
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Prealbumin normal lab
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15-25 mg/dl
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Whats another name for History of Present illness
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Symptom analysis
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What is EOM
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Extra Ocular muscles
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Adventitious sound heard predominantly on inspiration
in lung bases |
What are crackles or rales
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Adventitious sound mostly heard on expiration in upper
airways |
What are rhonchi
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Normal breath sound heard over most of the
lung field: inspiration > expiration |
What is a vesicular sound
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Level of diaphragm posteriorly with relaxed
breathing and on deep inspiration |
T10 and T12
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What would be an expected finding when performing an eye positions test on a patient who
has an inner ear infection? |
Nystagmus
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What are anthropometric measures?
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Weight, height, BMI
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Sebaceous glands
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secrete sebum, a lipid substance that keeps the skin from
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