Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
514 Cards in this Set
- Front
- Back
|
Health histories can be fulfilled from information found in: |
Interviews with the patient, medical/dental/surgical records etc, physical assessments |
|
|
If a patient has a BMI index of 35, weighs 155kg and has a poor diet/exercise regeime, would you be concerned/what assessment(s) would you undertake? |
Hell yeah you would
a nutritional assessment metabolic assessment cardiovascular assessment |
|
|
What assessment would you do on a patient with O2 saturation of 94%, RR of 22 and an audible wheeze? |
Respiratory assessment. |
|
|
What assessment would you undertake on a patient with a heartrate of 94 and BP of 164/90? |
Cardiovascular assessment
|
|
|
What assessment would you undertake on a patient with a significant weight loss in the last few weeks? |
Nutritional/Metabolic Assessment |
|
|
What assessment would you undertrake on a patient with tingling sensation in their fingers and poor capilary return? |
Cardiovascular assessment
|
|
|
What assessment would you undertake on a patient with unconsciousness due to head trauma? |
Neurological assessment |
|
|
What factors can inhibit the data collection? |
Language barriers lack of rapport with patient poor phrasing of questions interruption education level disabilities generalisation |
|
|
What is a health assessment?
|
A health assessment is a tool used to gather information specific to a system or part of the patient to then make a diagnosis or care plan. |
|
|
What is a health history?
|
A health history is a holistic overview of the patient's health status from information collected about the demographics, previous medical histories and the patient themself.
|
|
|
What is critical thikning?
|
A process of using objective information to analyse and evaluate an issue or topic to come to a conclusion about it/take a course of action. |
|
|
What is EBP?
|
Evidence based practice regards the practical use of the most current and reliable data and information gathered on a topic or subject and evaluation of the practice applied. |
|
|
What is IBL? |
Inquiry based learning is a form of learning where the participant actively seeks out any information gaps that they may have in an attempt to bridge this gap. "Learning how to learn" |
|
|
What is the clinical decision making?
|
It regards decisions about : care plans, treatments, diagnosis and assessments in relation to patients. |
|
|
What is the difference between subjective and objective data?
|
Objective data is measurable (signs), subjective is data from someone's point of view (symptoms) |
|
|
What is the nursing process?
|
A cyclical process of :
assessment diagnosis care planing treament/implementation evaluation. |
|
|
What is the purpose of IBL? |
The purpose of IBL is to allow for autonomy in learning, taking learning from a passive process into an active one which involces the participant.
This has been shown to improve fact/memory retention as the participant is making sure they understand the concepts and facts before moving on as well as helping themselves to understand it. |
|
|
What tool would you use on a patient who is developing pressure wounds?
|
Pressure wound chart/musculoskeletal assessment |
|
|
What is IPPA? |
Inspection Palpation Percussion Auscultation
ORDER OF NURSING ASSESSMENT! |
|
|
What is Inspection?
|
During this portion of the examination, the physician inspects or looks at different parts of the patient's body for cues that may help them with a diagnosis
Eg/ Yellow skin may = jaundice |
|
|
What is Palpation?
|
"Hands-on examination/Touching"During palpation, the physician uses his or hands to examine the patient with touch.
Eg/ Cold hands = Poor peripheral perfusion. |
|
|
What is Percussion?
|
"Tapping"During percussion, the examiner taps a finger on a hand onto the patient.
Hollow and solid areas generate different vibrations
Eg/ used to diagnose fluid in the abdominal and chest cavities or make one suspect the presence of pneumonia - doesn't sound hollow like those 'airy' areas should |
|
|
What is Auscultation?
|
"Listening" (with a stethoscope)During auscultation, the physician listens to the patient's heart beat, lungs, gut and blood vessels.
Eg/ Abnormal heart sounds are a clue to heart disease |
|
|
What are some things looked for in Inspection?
|
Symmetry Discomfort Range of Motion Pallor Sweating/Diaphoresis Pupil Size Possible Aggression/Abnormal behaviour Requires good lighting! |
|
|
What are some things felt for in Palpation?
|
All these are normally fingertip : - masses (can be also by pinching) - Texture - Moisture - Organ location and size - Swelling - Rigidity/spasticity - Crepitation (bone on bone grinding) - Lump/s or mass presence (eg/ breast exam) - Tenderness or pain of patient when touched (including guarding)
Vibrations/Pulsations - use base of finger (knuckle joint)
Temperature - use back of hand |
|
|
What is the Clinical Reasoning Cycle?
|
|
|
|
What are the stages of the Clinical Reasoning Cycle? What is the order?
|
Is cyclic! but there is an order! Always improving patient care!
Consider Patient Care Collect Cues/Information Process Information Identify problems/Issues Establish Goals Take Action Evaluate Outcomes Reflect on processes and new learning |
|
|
What is Gordon’s Functional Assessment?
|
A guide for establishing a comprehensive nursing assessment base. Has 11 categories: Health Perception and Health Management. Nutrition and Metabolism Elimination Activity and Exercise Cognition and Perception Sleep and Rest Self-Perception and Self-Concept Roles and Relationships Sexuality and Reproduction Coping and Stress Tolerance Values and Belief |
|
|
What does Gordon's assess inHealth Perception and Health Management? |
Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health.
Habits that may be detrimental to health are also evaluated eg/ smoking.
Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home. |
|
|
What does Gordon's assess in Nutrition and Metabolism? |
Assessment is focused on the pattern of food and fluid consumption relative to metabolic need.
Adequacy of local nutrient supplies is evaluated.
Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system. |
|
|
What does Gordon's assess in Elimination? |
Data collection is focused on excretory patterns (bowel, bladder, skin).
Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified. |
|
|
What does Gordon's assess in Activity and Exercise?
|
Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.
The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems. |
|
|
What does Gordon's assess in Cognition and Perception?
|
Assessment is focused on the ability to comprehend and use information and on the sensory functions.
Data pertaining to neurologic functions are collected to aid this process.
Sensory experiences such as pain and altered sensory input may be identified and further evaluated. |
|
|
What does Gordon's assess in Sleep and Rest?
|
Assessment is focused on the person's sleep, rest, and relaxation practices.
Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.
Zzz and R&R! |
|
|
What does Gordon's assess in Self-perception and Self Concept?
|
Assessment is focused on the person's attitudes: - Self- Identity - Body image - Sense of self-worth.
The person's level of self-esteem and response to threats to his or her self-concept may be identified. |
|
|
What does Gordon's assess in Roles and Relationships?
|
Assessment is focused on the person's roles in the world and relationships with others.
Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. |
|
|
What does Gordon's assess in Sexuality and Reproduction?
|
Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions.
Concerns with sexuality may be identified.
Do I get enough sexy times? Are they good? Do I like boys/girls/both/none? |
|
|
What does Gordon's assess in Coping and Stress Tolerance?
|
Assessment is focused on the person's perception of stress and on his or her coping strategies.
Support systems are evaluated, and symptoms of stress are noted.
The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated. |
|
|
What does Gordon's assess in Values and Belief?
|
Assessment is focused on the person's values and beliefs (including spiritual beliefs)
Also the goals that guide their choices or decisions. |
|
|
What are some things tapped for in Percussion?(Think percussion instruments/Drums!)
|
- Map location/size of organs by noting sound changes between them
-Density of a structure
- Abnormal masses (near surface/superficial vibrates, deep gives NO PERCUSSIVE CHANGE)
- Seeing if there is underlying pain due to inflammation
- Percussion hammer for deep tendon reflex (knee kicking thingy we did in Biol 121 prac!) CAN BE DIRECT OR INDIRECT |
|
|
Difference between Direct and Indirect percussion |
Direct - One hand on area (Have NOT done in pracs! LESS COMMON! More like POKING
Indirect - One we do in class - tapping middle finger! MOST COMMON |
|
|
What are the stethoscope components?
|
|
|
|
Main goal of an interview of a patient?
|
Gaining subjective data
- objective you can sometimes source solo but subjective is ONLY EVER from a PATIENT'S POINT OF VIEW |
|
|
What are the percussive sounds and what do they sound like?
|
* Normal resonance/ Resonant the sound produced by percussing a normal chest.
* Impaired resonance (mass, consolidation) lower than normal percussion sounds.
* Dull (consolidation) similar to percussion of a mass such as a liver.
* Stony dull the sounds produced on percussion from the pleximeter with no contribution from the underlying area. |
|
|
What is the difference between light and deep palpation? Both we press with front of fingers! |
Light palpation is used to feel abnormalities that are on the surface. MORE COMMON Gently press down about 1 to 2cm.This helps identify the texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.
-------
Deep Palpation is used to feel internal organs and masses. Firmly press down into the area of the body about 4 to 5cm. This helps identify the size, shape, tenderness, symmetry and mobility. Deep palpation can be uncomfortable and dangerous (RUPTURING!) for the patient, especially when assessing the abdomen or painful areas.
*Another way to palpate is to put one hand on top of another when pressing down. This is called the bimanual technique, and it allows better control of the applied pressure. Like in CPR - so we don't poke and rupture/break things as easy but less accurate depending on location! |
|
|
What is Critical Thinking? |
- CT is thinking that assesses itself with a view to improving it. - It is self-directed, self-disciplined,self-monitored & self-corrective - Thinking critically is one approach to turning information into knowledge. - Critical thinking is a process using reflection and analysis.
BE SELF CRITICAL AND IMPROVE! ALL UP TO YOU! |
|
|
What is Physical Assessment's Indications ?(Excepts from Textbook)
|
- usually an admission procedure, which includes a thorough assessment. - to formulate a database incorporating - It is dependent on the integration of several competencies (assessment of the various systems, clinical documentation) and cannot be used in isolation
historical and current data - to provide an opportunity for the nurse to develop a trusting relationship with a patient - an opportunity to explore data obtained from the patient during the health history - a key nursing function |
|
|
What is Physical Assessment's Gathered Equipment? Why gather before a procedure?(Excepts from Textbook)
|
* Gather items required FIRST to maximise efficiency, reduce patient apprehension and increase their confidence in their nurse.
Required for proper physical assessment : ● a sphygmomanometer, stethoscope, BP cuff, thermometer, pulse oximeter and watch ● height and weight scales ● a penlight and pupil measurement gauge ● pen and paper (or the health history form of the facility)
ALSO PREPARE ENVIRONMENT - Ensure ambient temperature is comfortable without drafts - sufficient lighting - quiet, stable environment - Patient privacy is protected (curtains/blankets) - warmth with gowns and blankets. |
|
|
Why is Therapeutic Communication important during a physical assessment?
|
- Increase patient compliance - Increase patient comfort - Build rapport - Be clear and direct to avoid miscommunication - Allows the nurse to explain hospital policy and procedure |
|
|
Why is hand hygiene important during a physical assessment? Or any procedure performed?
|
- Most effective method of infection control. - reduces cross-contamination. - Thorough hand hygiene removes transient organisms from the hands of the nurse. |
|
|
How long should hand WASHING last?
|
Usually 1min according to world health
CORRECT ME IF I AM WRONG PLSE |
|
|
When should we NOT obtain a full health history of a patient?
|
- If they are in potential danger
- If suffering from acute distress |
|
|
What type of data is primarily obtained from a patient? |
Subjective data
- can only come from the patient alone |
|
|
What is data obtained from friends/relatives/other people called?
|
Secondary Data
|
|
|
When noting secondary data, what else do we need to do?
|
Note that it IS secondary data and who it is from so we can refer back to that individual if need be.
This will also flag this data as potentially non-reliable so it doesn't get mixed up with more factual medically obtained data |
|
|
What does a patient health history consist of?
|
Demographics of the patient including : - Age/date of birth - Occupation - Marital or family status - Current medical conditions - Medications (include over the-counter and herbal supplements being taken and reasons for taking them) - Allergies and reactions to the allergen/severity - Patterns of daily living - All current data affecting the care given during hospitalisation. |
|
|
What is patient historical data?
|
Information about past events such as :
-Experiences with previous hospitalisation - Illness or medical conditions - Exposure to infections - Previous experience of surgery or anaesthesia - Family history - History of medication- History of substance use/abuse - Social history - Cultural background - Any pertinent information that might impact on their nursing care (e.g., the patient is the primary carer for his/her spouse).
ALWAYS ADD ANY INFORMATION THAT MAY IMPACT CARE! COVER YA BUM! |
|
|
What data can be obtained from a patient interview using the powers of observation?(NOT inspection! Moreso speech)
|
- The level of anxiety, mood, level of discomfort - Any communication and intellectual disability - Interpersonal relationships - Some idea of body image/confidence and self-concept. |
|
|
What type of things can inspection reveal? (Examples)
|
Inspecting the visible skin allows the nurse to assess colour and gives the clue to cardiac perfusion or respiratory difficulties.
Comparison of body areas (e.g. favouritism of limbs or uneven gait... guarding from pain)
Other diseases and conditions are sometimes readily visible on the face.
Observing personal hygiene, dress, eye contact, suitability of clothing, make-up and demeanour gives insights into the mental status of the patient. |
|
|
What happens in an abbreviated health history?
|
Only seven dimensions of the problem are explored 1. Timing of the symptoms –Onset (when the symptom was first noticed) - Duration (how long the symptom lasts) - Frequency (continuously, intermittently, regularly and irregularly) - Occurrence
2. Location of the pain or other symptoms - asking the patient to point at the area affected. - ask about radiation or movement of the pain to other parts of the body and is again asked to point along the path that the radiation takes.
3. Quality of the pain or symptom – asking the patient to describe the sensation using adjectives such as sharp, dull, burning or whatever fits the sensation.
4. Quantity or intensity of the symptom – patient to describe the extent of the symptom, for example number of times, amount, size and how the symptom has altered activities of daily living or interfered with the patient ’ s life (e.g., coughing, sputum production). The use of a Visual Analogue Scale or numerical rating scale can assist in quantifying pain.
5. Precipitating factors – the nurse asks about the initial time the symptom occurred and what triggered the symptom. Are there any activities that bring the symptom or sensation on (e.g., exercise-induced breathlessness)?
6. Aggravating factors and alleviating factors – the patient is assisted to recall if there is anything that makes the symptom better or worse. Stress, activity, rest and medication are often noted.
7. Associated symptoms – these are elicited by asking about anything that happens in conjunction with the symptom (e.g., sharp chest pain with coughing). |
|
|
Two most popular mnemomics for an abbreviated health history?
|
COLDSPA and PQRST |
|
|
What is COLDSPA?
|
An abbreviated health history mnemomic
Character Onset Location Duration Severity Pattern Associated factors/Affects |
|
|
What does the C in COLDSPA stand for? |
Describe the CHARACTER of the sign or symptom
(appearance, sound, feeling, smell, or taste if applicable) |
|
|
What does the O in COLDSPA stand for?
|
When did it begin? When was the ONSET? |
|
|
What does the L in COLDSPA stand for?
|
Where is the LOCATION of the sign/symptom?Does it radiate?Does it occur anywhere else? |
|
|
What does the D in COLDSPA stand for?
|
What is the DURATION like?How long does it last?Does it reoccur? On/off or always? |
|
|
What does the S in COLDSPA stand for?
|
What the the SEVERITY like?How bad is it?How much does it bother you?
|
|
|
What does the P in COLDSPA stand for? |
PATTERN
What makes it better or worse? |
|
|
What does the A in COLDSPA stand for? |
Associated Factors/Affects
What other symptoms occur with it? |
|
|
What is PQRST?
|
An abbreviated health history mnemomic
P = Provocation/Palliation Q = Quality/Quantity R = Region/Radiation S = Severity Scale T= Timing (and duration) |
|
|
What is the P in PQRST? |
P = Provocation/Palliation
What where you doing when the pain started? What caused it? What makes it better? Worse? What seems to trigger it? Stress? Position? Certain activities? What relieves it? Medications, massage, heat/cold, changing position, being active, resting?
What aggravates it? Movement, bending, lying down, walking, standing? |
|
|
What is the Q in PQRST?
|
Q = Quality/Quantity
What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching. |
|
|
What is the R in PQRST? |
R = Region/Radiation
Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot? |
|
|
What is the S in PQRST?
|
S = Severity Scale
How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? |
|
|
What is the T in PQRST? |
T – Timing
When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? When did you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever been awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally? |
|
|
What is a Neurological health history? |
This is an important aspect of the neurological evaluation.
The patient should be put at ease and allowed to tell their story in their own words.
Secondary information may be of use here (from family etc) especially if the patient is confused.
Specific questions clarify the quantity, intensity, distribution, duration and frequency of each symptom.
Disabilities should be described quantitatively (e.g., can only walk 10 metres) and the effects on the patient ’ s daily routine.
Past medical history and a complete review are essential because neurological complications are common in other disorders (UTI's). Family history is important because of genetic components.
Social, occupational and travel history provides information about unusual infections and exposure to toxins and parasites.
Gather information for a mental status assessment during the health history and physical assessment. (eg/ mini mental state examination)
If there are any indications that the patient requires further assessment = complete mental status assessment is carried out. |
|
|
What is a Respiratory health history? |
• Medical history:
• Surgical history:
• Allergies:
• Injuries and accidents:
Special needs:
• Childhood illnesses:
• Family health history: |
|
|
What is a Cardiovascular history? |
Fundamental to a cardiovascular assessment.
A family history is taken - many cardiac disorders (e.g., coronary artery disease, systemic hypertension) have a heritable basis.
Symptoms commonly occur in more than one cardiac condition and in non-cardiac disorders so a complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of non-cardiac disorders which may affect the heart. |
|
|
Some major cardiac symptoms include : |
- Chest pain or discomfort - Dyspnoea - Weakness & fatigue - Light headedness and syncope (fainting) - Palpitations (unpleasant sensations of excessively strong, rapid and/or irregular heartbeats - aware of own heartbeat) |
|
|
What is an abdominal history?
|
Of particular importance is the location of pain, its characteristics, history of similar pain and associated symptoms.
Many drugs cause gastrointestinal (GI) upsets (e.g., immunosuppressants can cause gastric erosion, anticoagulants increase the chances of bleeding and haematoma formation).
Alcohol intake can predispose some patients to pancreatitis. Known medical conditions and previous abdominal surgeries are important to ascertain.
Women of child-bearing age should be asked about their menstrual cycle and pregnancy status. |
|
|
What are some abdominal symptoms?
|
- gastro-oesophageal reflux - nausea - vomiting - diarrhoea - constipation - jaundice - melaena (black, "tarry" faeces) - weight loss and mucous or blood in the stool. |
|
|
What is Melaena? |
Black "tarry" faeces - Associated with upper gastrointestinal bleeding- Blood in faeces is partially digested, hence 'tarry' |
|
|
What should you do with equipment after performing an assessment?With a patient?
|
Clean and replace equipment - respect co-workers and hygiene practices
- Ensure patient is back into a comfortable position, with buzzer within comfortable reach. |
|
|
What is conducted in a full physical assessment?
|
Is a combination of a systemic and head-to-toe assessments Obtain vital signs Obtain height and weight Assess neurological functioning Assess the cardiovascular functioning Assess the respiratory functioning Assess the gastrointestinal functioning Assess the genitourinary functioning Assess the musculoskeletal system |
|
|
How do you document information obtained if a hospital has no forms?
|
If no forms exist, document the data that you have gathered in a systematic manner. |
|
|
What is Syncope?
|
Fainting
|
|
|
What are Palpitations?
|
Unpleasant sensations of excessively strong, rapid and/or irregular heartbeats - Consciously aware of own heartbeat
|
|
|
What is Stridor?
|
A high-pitched 'bird-call like' breath sound resulting from turbulent/occluded air flow in the larynx or lower in the bronchial tree
https://www.youtube.com/watch?v=EMKxnyPs7K8 |
|
|
What is Dyspnoea?
|
Shortness of breath or breathlessness is the feeling or feelings associated with impaired breathing
|
|
|
How do you establish an environment suitable for conducting a physical assessment?
|
- CONSENT IS 1#! Talk to person/rapport - Ensure ambient temperature is comfortable without drafts - sufficient lighting - quiet, stable environment - Patient privacy is protected (curtains/blankets)- warmth with gowns and blankets. - curtains ARE NOT SOUNDPROOF! Keep it down! |
|
|
What are the TWO components of critical thinking?
|
1. Reflective component – thinking about what you are doing /have done; how well it is working/worked with the situation at hand; - where what you do fits into the bigger scheme of things.
2. Analytic component – involves the ability to use complex reasoning - ability to consider things from different perspectives. |
|
|
What are the key elements to clinical reasoning?
|
• Purposeful. • Problem-solving strategy. • Based on a combination of data, information, evidence and assumptions. • Conducted from some point of view. •Based on data, information, and evidence. • Expressed through, and shaped by,concepts and ideas. • Thoughts of implications and consequences. |
|
|
What is clinical reasoning?
|
Clinical reasoning is an advanced form of decision making implemented in clinical practice settings. • It is characterised by rapid processing. • It incorporates pattern recognition and hypothetico-deductive reasoning. • It is implemented by expert and intuitivepractitioners. • Disciplined, creative, and reflective approach. • Used concurrently with critical thinking. • Purpose: Establish potential strategies for patients to reach their desired health goals.
NURSES USE IT THEIR WHOLE CAREERS- ESSENTIAL! |
|
|
What is psychosocial assessment? |
Assessing one's psychological development in, and interaction with, a social environment
– Includes spiritual, cultural More for obtaining a patient's mental status which affects their social status! |
|
|
What is family assessment ? |
• Records the health status of patient and |
|
|
What is community assessment?
|
- Describes the state of health of local people - Enables the identification of the major risk factors and causes of ill health - Enables the identification of the actions needed to address these. - the collection of relevant information that will inform the nurse about the state of health and health needs of the population; - analysis of this information to identify the major health issues. |
|
|
What are the 10 characteristics of a Primary Complaint?
|
1. Location: Primary area where symptom occurs or originates.
2. Radiation: Spread of symptom or primary complaint.
3. Quality: Way it feels to the patient.
4. Quantity: Describes the severity, volume,number or extent of primary complaint.
5. Associated signs and symptoms: Positive findings and pertinent negatives.
6. Aggravating factors: Factors that worsen the severity.
7. Alleviating factors: Factors that decrease the severity.
8. Setting: The location / environment where the complaint occurs.
9. Timing: Onset, duration and frequency of complaint.
10.Impact on quality of life |
|
|
What is PHH?
|
Past Health History
The total sum of a patient's health status prior to the presenting problem.
Provides information on patient’s health status from birth to present. |
|
|
How long does a full/complete health history take to do?
|
30 min to one HOUR |
|
|
What are the three main types of Health History?
|
• Complete health history
• Focused history
• Emergency health history
Just remember what states your patient will be in and it makes sense!
Your patient will be ok, distressed/in a bit of danger or OMG HELP! |
|
|
How many times does the heart contract per minute?
|
Contracts 60-100 times per minute |
|
|
How many litres does the heart pump per minute?
|
4-5 L
|
|
|
How big is the heart?
|
About the size of a clenched hand
|
|
|
Where is the heart located?
|
In the thoracic cavity between lungs and above diaphram
|
|
|
What are the layers of the Pericardium Sac?
|
Parietal layer (close to fibrous tissue) Visceral layer (inside - also known as epicardium)
*Parents are on top* |
|
|
What are the 3 layers of the heart?
|
Outer to Inner: Epicardium Myocardium Endocardium |
|
|
chambers of the heart
|
Right and left artia Right and left ventricles
Left and right chambers are separated laterally by walls known as vertical septa |
|
|
What is the 'eighth' stage of the clinical reasoning cycle?
|
8. Reflection and ReviewReflection on action
• It worked! vs It didn't work :'(
• What did I learn? eg/ yes, paracetamol helps fevers
Reflection in action •This worked better than that, this could be improved on etc |
|
|
What does the cardiac cycle involve?
|
Systole and Diastole |
|
|
What is a Sign?
|
an object, quality, or event whose presence or occurrence indicates the probable presence or occurrence of something else.
SOMETHING THAT CAN BE OBSERVED EXTERNALLY - OBJECTIVE DATA |
|
|
anatomic landmarks on the chest
|
A physical or mental feature which is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient.
SOMETHING ONLY A PATIENT CAN COMMUNICATE! - SUBJECTIVE DATA |
|
|
anatomic landmarks blood vessels
|
• Clarity • Accuracy • Precision • Relevance (Including connections) • Depth • Breadth (Wide enough/Explored enough?) • Logic • Fairness (Patient focus still maintained?) |
|
|
Warning signs of potential cardiovascular problems (name at least 5)
|
» Change in colour of lips, face or nails » Chest discomfort (e.g. uncomfortable pressure, squeezing, fullness or pain) » Breaking out in a cold sweat » Light headedness » Shortness of breath » Oedema » Extremity pain » Fatigue » Feeling of doom » Numbness in the extremities » Pain that limits self-care » Palpitations » Syncope » Tingling in the extremities |
|
|
Aneurysm
|
localised abnormal diolation of a blood vessele
|
|
|
Systole
|
– Isovolumic contraction [Ventricular Systole]
– Early systole [Aortic & Pulmonary valves open and blood is ejected]
– Late systole [Reduced blood flow ejected]. |
|
|
patient profile |
Patient profile:
– Age – Gender – Ethnicity. |
|
|
What is the Nursing Process?
|
Linked to clinical thinking & reasoning :
The nursing process is frequently described as a four-, five- or six-step process:
– APIE: – ADPIE: – APOPIE: |
|
|
Common chief complaints:
|
Common chief complaints:
– Chest pain – Syncope – Palpitations – Peripheral oedema – Extremity pain. |
|
|
What is APIE?
|
Assessment Planning Implementation Evaluation |
|
|
What is ADPIE?
|
Assessment Diagnosis Planning Implementation Evaluation |
|
|
What is APOPIE?
|
Assessment Patient problem Outcomes identification Planning Implementation Evaluation |
|
|
What are good sources of information regarding a patient? |
- Health history – Physical assessment – Diagnostic and laboratory data -THE PATIENT/SUBJECTIVE DATA
- Possible sources of information include: patient, family, neighbours, friends, bystanders, old charts, medical records, and healthcare colleagues. |
|
|
When palpating the heart, things to observe may include : |
Observe for pulsations or bulges at:
– Aortic area – Pulmonic area – Midprecordial area– Tricuspid area– Mitral area.• Normal findings: No visible pulsations except for the point of maximum impulse (PMI) in the mitral area. |
|
|
What is Planning?
|
Involves evaluating subjective data obtained during the health history to narrow the focus of the physical examination.
Involves consideration of the environment and equipment required. |
|
|
What are three approaches to physical assessment?
|
Head-to-toe Body systems Functional Health Patterns (Gordon) |
|
|
What is Prioritization?
|
The nurse prioritises patient actual and potential problems and opportunities for health promotion.
• Prioritising care should be done in collaboration with the patient.
• Maslow’s Hierarchy of Needs is frequently used to assist prioritisation. |
|
|
How do we Inspect of jugular venous pressure? |
– Patient position (supine position with head elevated 30 to 45 degrees)
– Normal findings (JVP < 4 cms)
– Abnormal findings (Visually Distended and Bulging). |
|
|
What is a concept map?
|
Concept maps are used to organise patient data, analyse relationships in the data, establish priorities, build on previous knowledge, identify what you do not understand and enable you to take a holistic view of the patient’s situation. |
|
|
What is Jugular Venous Pressure? |
Jugular venous pressure/aka (JVP) and jugular venous pulse)
Indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different forms of heart and lung disease. |
|
|
What are Clinical/Critical pathways?
|
CLINICAL (OR Critical) Pathways
• Identify crucial nursing interventions for each step of the pathway. • Recognise variances from plan of care early. • Uses assessment, planning, implementation, and evaluation phases of nursing process. |
|
|
test arterial health
|
Explores information about patient’s lifestyle that can affect health.
• Introduce this area of questioning with statements such as:
– ‘Now I would like to ask you some questions about your lifestyle. This information is important because of the effects that different practices can have on your health.
SENSITIVE AREAS : Explain why this information is important! |
|
|
Hypokinetic/weak pulse
|
• Ask questions after rapport and trust established with the patient.
• Use direct eye contact.
• Use a matter-of-fact tone when asking questions.
• Adopt a non-judgemental approach.
• Use communication technique of 'normalising' when appropriate - make their behaviour seem normal/not a big deal |
|
|
How to explore Alcohol intake with a patient and why :
|
Thorough assessment to include:• Quantity of alcohol consumed• Frequency of consumption• Type of alcohol (including homemade)• Age at first drink• Length of time consuming current amount• Pattern of current consumption• History of loss of consciousness or blackouts• Drink alone or with others• Drink and drive• Drinking during pregnancy• Self-perception of drinking |
|
|
How to explore tobacco/cigarette intake with a patient and why : |
**If tobacco is used nurses must encourage patients to consider quitting**
Assessment to include: • Packs per day/year history • Type of tobacco used • Age started to use tobacco • Quantity used daily • Previous attempts to quit • Self-perception of tobacco use • Live or work with smoker. |
|
|
How to explore drug use with a patient : |
– Prescription and over-the-counter medications
• Goal is to obtain data on what substances are used and the pattern of substance use. |
|
|
What are the warning signs of Domestic or Intimate Partner Violence (IPV)?
|
• Frequent injuries/accidents/burns • Previous injuries for which patient did not seek care • Refusal to discuss injury • Presence of significant other who answers for patient • Significant other with history of violence or substance abuse. |
|
|
What is IPV?
|
Intimate Partner Violence
|
|
|
How to conduct an IPV assessment
|
– Includes physical, psychological, emotional, sexual, and financial abuse or coercion – Use technique of normalising – Ask whether patient feels safe in current environment – If applicable, use resources to assist patient to move to a climate where he or she can receive help and feel safe – Document findings concisely and accurately. |
|
|
How to explore Sexual Practices of a patient and why : |
Sexual practice histories focus on healthy sexual practices as well as the transmission of communicable diseases.
Assessment includes: • Sexual orientation • Past sexual practice • Age at first sexual experience • Number of partners • Birth control method • Measures to prevent exchange of body fluids • Oral or anal intercourse • Presence of STD in a partner • Satisfaction with sexual performance and needs • Use of medications to help sexual performance. |
|
|
What should a full social history include?
|
• Travel history • Work environment • Home environment: – Physical environment – Psychosocial environment.
• Hobbies and leisure activities • Stress • Education • Sexual Practices • Intimate Partner Violence • Drug/Alcohol intake • Cigarette use |
|
|
What are the 5 health promotion activities? |
• Sleep • Diet • Exercise • Use of safety devices • Health check-ups |
|
|
What is Review of Systems?
|
Head to toe (Cephalocaudal) assessment approach
Includes : – Sign- and symptom-related questions – Disease-related questions |
|
|
What is RoS?
|
Review of Systems
|
|
|
What does Cephalocaudal mean?
|
Head to Toe
|
|
|
What should you do when concluding a assessment? |
• Ask patient whether there is additional information to discuss. • Thank patient. • Tell patient the next step in their assessment and when to expect it.
• Include use of assistive devices. |
|
|
Health assessments are used to target known, actual or potential health issues and risks for:
|
• An individual • groups of “like” people • whole populations |
|
|
Individual vs. community health promotion illness/disease prevention programs
|
The collection of subjective and objective data that enables the nurse to plan care that is specific to the needs of the individual client. A community awareness program must meet the needs of an identified large group of people |
|
|
What are the Assessment-Specific Documentation Guidelines?
|
1. Record all data that contribute directly tothe assessment (positive assessmentfindings and pertinent negatives). 2. Document any parts of the assessmentthat are omitted or refused by patient. 3. Avoid using judgmental language. 4. Avoid evaluative statements; cite specificstatements or actions you observe. 5. State time intervals precisely. 6. Use specific measurements. 7. Draw pictures when appropriate. 8. Refer to findings using anatomic landmarks. 9. Use the face of a clock to describe findings that are in a circular pattern. 10.Document any change in patient’s condition during a visit or from previous visits. 11.Describe what you observed, not what you did. |
|
|
Australian Health Priorities 2013 |
Arthritis Asthma Cancer Cardiovascular Disease Dementia Diabetes Injury Mental Health Obesity |
|
|
Assessment of Impact of illness
|
• Health care costs • Loss of earnings • Disability • Loss of productivity |
|
|
What is the epidemiology of arthritis?
|
In fact more than half of people with arthritis – or around 1.9 million people - are of working age.
In Australia, 1 in 2 women and 1 in 3 men over 60 years will have an osteoporotic fracture. |
|
|
What is Diaphoresis? |
Sweating (Excessive) |
|
|
What is an Example of a concept map? |
|
|
|
What are Maslow's Hierarchy of Needs? |
|
|
|
What does IBL stand for? |
Inquiry based learning |
|
|
Mrs Jones needs a focused pulmonary assessment every 2 hours.Identify the steps in that assessment.
|
*VS: B/P, heart rate and rhythm, resp rate, temp.* general: overall comfort/distress level.Obtain subjective data: *Ask Mrs Jones how she has been doing in the past 2 hours. *How does she assess her breathing, cough, SOA, fatigue, and anxiety? * Ask specifically about color & amount of sputum production and hempotysis. * If she has been using a sputum cup, be sure to observe amount, color, and consistency. * Empty cup so that what accumulates in the next 2 hours can also be assessed.Obtain objective data using:* Inspection: circumoral color, quality & depth of respirations, chest excursion, intercostal and supraclavicular movement, watching especially for retraction.* Palpation: check for fremitus.* Percussion: check for dullness (comparing one level on right side to same level on left side before proceeding down to the next level). Especially note differences in pitch at level of RLL (in Mrs Jones's case).* Auscultation: any audible wheezing? Auscultate trachea and bronchial areas, then bilaterally side-to-side, comparing one level on right side to same level on the left side before proceeding.
|
|
|
How might a focused assessment affect a patient's nursing diagnosis?
|
Diagnoses may remain the same.Diagnoses may improve: i.e. an ineffective airway clearance may become an actual diagnosis of ineffective airway clearance.Diagnoses may worsen: i.e. a potential for ineffective airway clearance may become an actual diagnosis of ineffective airway clearance.New diagnoses may be added: i.e. patient may experience pain upon inspiration.(Although pain is a nursing diagnosis, pain upon inspiration is a collaborative diagnosis. The physician needs to be notified as pleurisy or pleural effusion may be developing, which are complications of pneumonia.)
|
|
|
What are the steps involved in the planning phase of the nursing process?How does this phase rate to nursing diagnosis?To interventions?To evaluation?
|
Planning involves identifying outcomes that are framed within patient goals.Both the patient goals and the outcomes are specific to the nursing diagnosis under consideration.Planning also involves identifying interventions designed to achieve the expected outcomes.The interventions are also diagnosis specific.Evaluation involves comparing the outcomes attained with the outcomes expected.
|
|
|
On what basis would you assign tasks to a NA and to an LPN/LVN?
|
Assign activities of daily living to NAs.Assign procedures for which the LPN/LVN is educated the LPN/LVN.
|
|
|
How do you evaluate outcomes?
|
Compare the expected and attained outcomes.If the expected outcomes were attained, fine.If they were not attained, check the accuracy of the measures.If the measures were accurate, reassess the patient.Consider the effectiveness of the intervention and change or adjust to obtain the desired outcome.Individualize for each patient.
|
|
|
Identify the types of information that make up a nursing database for a patient.
|
* background.* presenting problem.* past health history.* family history.* social/environmental history.* psychological history.* lifestyle.* access to health care.
|
|
|
Identify the parts of an Initial Nursing Assessment.
|
* nursing history.* review of systems.* physical examination.
|
|
|
List the parts of the Review of Systems.
|
* general.* skin, head, face, neck, eyes, ears, nose, throat, mouth/teeth, oropharynx.* breast.* respiratory.* cardiovascular.* gastrointestinal.* renal/urinary/reproductive.* musculoskeletal.* neurological.* mental health.* hospitalizations, surgeries, trauma (head injuries, fractures, etc).
|
|
|
Assessments: |
* are ongoing.* are supplemented with information from significant others when appropriate.* need to be updated on the basis of focused assessments performed at regular intervals each day and whenever a change in patient's status is noted.
|
|
|
When analyzing assessment data, identity patient _____ , as well as nursing diagnoses.
|
strengths
|
|
|
When analyzing assessment data, identity ______ in addition to the patient's actual diagnoses and strengths. |
potential health problems
|
|
|
When analyzing assessment data, identity _____ associated with the diagnoses.
|
risk factors
|
|
|
When analyzing assessment data, identity _____ that will play a role in a patient's nursing care.
|
developmental factors
|
|
|
When analyzing assessment data, identity problems that require:
|
* collaboration with other health professionals* implementation of dependent interventions.
|
|
|
STRUCTURE THAT SUSPENDS THE SMALL INTESTINES FROM THE POSTERIOR BODY WALL
|
MESENTERY
|
|
|
FINGER-LIKE EXTENSIONS OF THE INTESTINAL MUCOSA THAT INCREAE THE SURFACE AREA
|
VILLI
|
|
|
COLLECTIONS OF LYMPHATIC TISSUE FOUND IN THE SUBMUCOSA OF THE SMALL INTESTINE
|
PEYER'S PATCH
|
|
|
FOLDS OF THE SMALL INTESTINE WALL
|
PLICAE CIRCULARES
|
|
|
TWO ANATOMICAL REGIONS INVOLVED IN THE PHYSICAL BREAKDOWN OF FOOD
|
ORAL CAVITYSTOMACH
|
|
|
ORGAN THAT MIXES FOOD IN THE MOUTH
|
TONGUE
|
|
|
COMMON PASSAGE FOR FOOD AND AIR
|
PHARYNX
|
|
|
THREE EXTENSION/ MODIFICATIONS OF THE PERITONEUM
|
GREATER OMENTUMLESSER OMENTUMMESENTERY
|
|
|
LITERALLY A FOOD CHUTE; HAS NO DIGESTIVE OT ABSORPTIVE ROLE
|
ESOPHAGUS
|
|
|
FOLDS OF THE STOMACH MUCOSA
|
RUGAE
|
|
|
SACLIKE OUTPOCKETINGS OF THE LARGE INTESTINE WALL
|
HAUSTRA
|
|
|
PROJECTIONS OF THE PLASMA MEMBRANE OF A CELL THAT INCREASE THE CELL'S SURFACE AREA
|
MICROVILLI
|
|
|
PREVENTS FOOD FROM MOVING INTO THE SMALL INTESTINE ONCE IT HAS ENTERED THE LARGE INTESTINE
|
ILEOCECAL VALVE
|
|
|
SEROSA OF THE ABDOMINAL CAVITY WALL
|
PARIETAL PERITONEUM
|
|
|
ORGAN PRIMARILY INVOLVED IN WATER ABSORPTION AND FECES FORMATION
|
PARIETAL PERITONEUM
|
|
|
AREA BETWEEN THE TEETH AND LIPS/CHEEKS
|
VESTIBULE
|
|
|
BLIND SAC HANGING FROM THE INITIAL PART OF THE COLON
|
APPENDIX
|
|
|
ORGAN IN WHICH PROTEIN DIGESTION BEGINS
|
STOMACH
|
|
|
MEMBRANE ATTACHED TO THE LESSER CURVATURE OF THE STOMACH
|
LESSER OMENTUM
|
|
|
ORGAN IN WHICH THE STOMACH EMPTIESORGAN THAT RECEIVES PANCREATIC JUICE AND BILEORGAN RESPONSIBLE FOR MOST FOOD AND WATER ABSORPTION
|
SMALL INTESTINES
|
|
|
TAKING FOOD INTO DIGESTIVE SYSTEM BY WAY OF MOUTH
|
INGESTION
|
|
|
chewing to pulverize food and mix it with saliva
|
mastication
|
|
|
swallowing of food to move it from mouth to stomach
|
deglutition
|
|
|
passage of molecules of food through mucous membrane of small intestine (into circulatory and lymphatic systems for distribution)
|
absorption
|
|
|
rhythmic, wavelike intestinal contraction that move food through digestive tract
|
peristalsis
|
|
|
salivary glands
|
1. parotid gland2. submandibular gland3. sublingual gland
|
|
|
4 layers/tunics of alimentary canal from innermost to outermost
|
1. mucosa2.submucosa3. muscularis externa4. serosa
|
|
|
secrete mucus throughout GI tract
|
goblet cells
|
|
|
thin, binding layer of connective tissue
|
lamina propria
|
|
|
replaces serosa (outerlayer of GI tract) it is a fibrous connective tissue that binds esophagus to surrounding structures
|
adventitia
|
|
|
depression between cheeks and lips externally area of gums and teeth internally
|
vestibule
|
|
|
connects lips to gum, inside of mouth
|
labial frenulum
|
|
|
transverse ridges along hard palate area, serve as friction ridges for tongue during swallowing
|
palate rugae
|
|
|
reflexively closes nasopharynx when we swallow, prevents food and fulid from entering nasal cavity
|
uvula
|
|
|
permanent dental formula: human
|
I2/2,C1/1P2/2,M3/3
|
|
|
restricts backflow of food
|
esphageal sphincter
|
|
|
opening through diaphragm for esophagus(above stomach)
|
esphageal hiatus
|
|
|
receives bolus from esophagus, churns bolus with gastric juice, intitiates digestion of proteins, most distensible portion of GI tract
|
stomach
|
|
|
food material that is moved into small intestine
|
chyme
|
|
|
upper, narrow region of stomach
|
cardia
|
|
|
large central portion of stomach
|
body
|
|
|
dome shaped portion of stomach that contacts diaphragm
|
fundus
|
|
|
funnel shaped terminal portion of stomach
|
pylorus
|
|
|
junction with small intestine (prevents backflow)
|
pyloric sphincter
|
|
|
attached to greater curvature
|
greater omentum
|
|
|
between pyloric sphincter and ileocecal valve,
|
small intestine
|
|
|
muscularis layer has 3 layers of smooth muscles, names based upon direction of fiber arrangement
|
1. oblique(inner)2. circular(middle)3. longitudinal(outer)
|
|
|
supports and attaches small intestine, contains blood vessels, nerves and lymph vessels
|
mesentary
|
|
|
longitudinal folds of mucosa, gradually smooth out as stomach fills, many gastric glands
|
gastric rugae
|
|
|
3 sections of small intestine
|
duodenumjejunumileum
|
|
|
deep folds in mucosa and submucosa
|
plicae circulares
|
|
|
cover villi,give wall of intestine carpetlike appearance, promote absorption
|
microvilli
|
|
|
largest internal organ of body
|
liver
|
|
|
saclike organ attached to inferior surface of liver
|
gallbladder
|
|
|
yellowish, green fluid used in digestive process, expelled into cystic duct
|
bile
|
|
|
soft, lobulated, glandular organ, secretes pancreatic juice into duodenum
|
pancreas
|
|
|
secrete glucagon and insulin
|
islets of langerhans
|
|
|
emulsifies fats
|
bile salts
|
|
|
bile pigment
|
bilirubin
|
|
|
dilated pouch below ileocecal valve, valve prevents backfow of chyme
|
cecum |
|
|
Olfactory |
I Sensory Smell
Assess: Hold soap, coffee, or alcohol pad under nose & ask to identify |
|
|
Optic
|
II Sensory Visual
Assess: snellen chart ; newspaper/magazine - have them read it; or ask what they see in their room |
|
|
Oculomotor
|
III Motor
Contracts eye muscles to control eye movements; constricts pupil; elevates eyelid.
Assess: use penlight to assess for PERRLA |
|
|
Trochlear
|
IV Motor Contracts one eye muscle to control inferomedial eye movement (below & center)
Assess: PERRLA/follow finger as you point down |
|
|
Trigeminal
|
V Sensory & Motor
Carries impulse of pain, touch, & temperature from face to brain(clenching & lateral jaw movements)
Assess: Clench teeth, Palpate temporal & masseter muscle, perform sharp/dull test on forehead, cheeks,& chin |
|
|
Abducens
|
VI Motor Lateral eye movements
Assess: positions test/follow finger or penlight with eyes, without moving head |
|
|
Facial |
VII Sensory & Motor
Taste on anterior 2/3 of tongue (sweet & salty); stimulates salivary glands & tears; smiling, frowning, & closing eyes
Assess: Smile, frown, raise eyebrows, puff out cheeks |
|
|
Acoustic/Vestibulocochlear |
VIII Sensory
Sensory fibers for hearing and balance
Assess: whisper test, weber test, rinne test |
|
|
Glossopharyngeal
|
IX Sensory & Motor
Taste on posterior 3rd of tongue (sour & bitter) & sensory fibers of pharynx, elicits gag reflex; secretory fibers to parotid glands/swallowing movements
Assess: Tongue depressor, look at uvula & soft palate & say "AH"; warn client: touch depressor to pharnyx (gag); drink water |
|
|
Vagus
|
X Sensory & Motor
Sensations from throat, larynx, heart, lungs, bronchi, G.I. tract, & abdominal viscera; promotes swallowing, talking, & production of digestive juices
Assess: same as glossopharyngeal |
|
|
Spinal Accessory
|
XIMotor
Inner neck muscles (SCM,trapezius) that promote movement of shoulders & head rotation; some movement of larynx
Assess: shrug shoulders against resistance; turn head rt & lt against resistance |
|
|
Hypoglossal |
XII Motor Innervates tongue muscle that promotes movement of food & talking
Assess: stick out tongue, move to rt & lt against depressor (look for tremors); have them say "L,T,D,N" |
|
|
health history resp
|
– Patient profile – Chief complaint – Past health history – Family health history – Social history. |
|
|
• Patient Profile:
|
– Age – Gender – Ethnicity. |
|
|
risk factors lung cancer
|
» Smoking tobacco » Passive tobacco exposure » Smokers with COPD » Hereditary predisposition for some smokers » Occupational or environmental exposure to known carcinogens (e.g. asbestos, radon, heavy metals) |
|
|
• Common chief complaints: (resp)
|
– Dyspnoea – Cough – Sputum – Chest pain – Inspiratory/ expiratory wheeze |
|
|
• Characteristics of chief complaints: (resp)
|
– Quality – Quantity – Associated manifestations – Aggravating factors – Alleviating factors – Setting – Timing. |
|
|
Past Health History (resp)
|
Medical history: – Respiratory specific – Non-respiratory specific.
• Surgical history: – Lobectomy, pneumonectomy, tracheostomy, wedge resection, pneumothorax, broncoscopy
• Allergies: – Asthma, hypersensitivities, allergic responses.
• Medications: – Antibiotics, bronchodilators, cough expectorant, cough suppressant, oxygen, steroids.
• Communicable diseases: – Common cold, tuberculosis, flu,HIV/ AIDS, hantavirus.
• Injuries and accidents: – Chest trauma, near drowning.
Special needs: – Oxygen-dependant, ventilator-dependent.
• Childhood illnesses: – Pertussis, measles, bronchiectasis.
• Family health history: – Allergies, alpha 1-antitrypsin deficiency, asthma, bronchiectasis, cancer, cystic fibrosis, emphysema, sarcoidosis, TB |
|
|
social history (resp)
|
• Alcohol, tobacco and drug use • Travel history • Work and home environment • Hobbies and leisure activities • Stress • Economic status. |
|
|
health promotion (resp)
|
• Sleep • Diet • Exercise • Use of safety devices • Health check-ups. |
|
|
assessment resp before
|
1. Greet the patient and explain the assessment. 2. Ensure the examination room is warm and the patient is relaxed and comfortable. 3. Use a quiet room free from interruptions. 4. Ensure well-lit environment. 5. Instruct the patient to remove all their clothes from the waist up and don a gown. 6. Place the patient in an upright sitting position. 7. Expose the entire area being assessed. 8. When palpating, percussing or auscultating the anterior thorax of female or obese patients, ask them to displace the breast tissue. 9. Visualise the underlying anatomic structures to permit an accurate description of the location of any pathology. 10.Always compare right and left sides. 11.Use a systematic approach. Proceed from the lung apices to the bases, right to left to lateral. |
|
|
equiptment (resp)
|
• Stethoscope • Tape measure • Washable marker • Watch with second hand • Examination table • Pen light. |
|
|
INSPECTION - Overview (resp)
|
Overall appearance
- Anxious, sweaty, in pain, posture (tripod, upright), drooling, COLOUR (cyanosis, pale, grey, flushed)
Chest movement - symmetry, use of accessory muscles, tracheal position
Respirations - Rate, rhythm (I:E ratio), depth, effort (accessory muscle usage) Chest shape
How they speak (sentences, phrases, words), obvious wheeze/stridor
Scars indicating previous surgery or injury |
|
|
inspection resp
|
• Shape of thorax: – Transverse diameter – Anteroposterior (AP) diameter
– Variations: • Barrel chest • Pectus carinatum (pigeon chest) • Pectus excavatum (funnel chest).
– Abnormalities of the spine: • Scoliosis, kyphosis. |
|
|
inspection resp
|
• Symmetry of chest wall • Presence of superficial veins • Costal angle • Angle of the ribs • Intercostal spaces • Muscles of respiration. • Patterns: – Cheyne-Stokes – Biot’s or ataxic – Apneustic • Symmetry • Audibility • Patient position: – Upright – Supine – Orthopnoea.
•Mode of breathing. – Agonal. |
|
|
respitation rates
|
– Eupnoea: 12–20 breaths per minute – Tachypnoea: > 20 breaths per minute – Bradypnoea: < 12 breaths per minute – Apnoea: no respiration for 10 or more seconds. |
|
|
define Cheyne-Stokes
|
an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. |
|
|
Biot's respiration is:
|
Biot's respiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. |
|
|
define Apneustic
|
an abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release. |
|
|
define Agonal
|
an abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and myoclonus (spasmodic jerky contraction of groups of muscles)
Possible causes include cerebral ischemia, extreme hypoxia or even anoxia. |
|
|
resp inspection depth
|
• Depth: – Shallow – Hyperpnoea (increased depth of breathing when required to meet metabolic demand of body tissues, such as during or following exercise, or when the body lacks oxygen (hypoxia), for instance in high altitude or as a result of anemia)
– Air trapping (an abnormal retention of air in the lungs where it is difficult to exhale completely.
It is observed in obstructive lung diseases such as asthma, bronchiolitis obliterans syndrome and chronic obstructive pulmonary diseases such as emphysema and chronic bronchitis.)
– Kussmaul’s (breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure.)
– Sighing. (emit a long, deep audible breath expressing sadness, relief, tiredness, or similar.) |
|
|
Assessing Patients with Respiratory Assistive Devices |
• Oxygen therapy: – Mode of delivery – Percentage of oxygen – Flow rate – Humidification.
• Pulse Oximeter: – Alarm settings – Probe position.
• Oxygen should be administered as a drug
• Incentive spirometer: – Frequency of use, volume achieved, number of repetitions.
• Peak flow meter: – Correct technique used.
• Oxygen has: – safe dose ranges – adverse physiological effects – toxic manifestations • For hypoxemia O2 should be administered to SaO2 > 90%
• Continued high doses = patient at risk |
|
|
Complications of O2 Therapy
|
• Hypoventilation / CO2 narcosis – Normal resp. drive CO2 – Hypercapnia with COPD, have O2 drive – Increased FiO2 suppresses respiratory drive in some COPD patients who are CO2 retainers – COPD administer carefully • Low concentration • Monitor • Absorption Atelectasis – O2 replaces N2 which is holding the alveolar Pulmonary O2 toxicity – High FiO2 - parenchyma changes – > 50 % considered toxic
• After a few hours, tracheobronchitis evidents • Decreased mucociliary action • >6 hours of 100% FiO2, non productive cough, substernal pain, malaise, nausea...... • More prolonged exposure; Acute Respiratory Distress Syndrome Retrolental Fibroplasia – Infants – Fibrosing of retinal vessels open |
|
|
define Spirometer
|
an instrument for measuring the air capacity of the lungs. |
|
|
INSPECTION OF SPUTUM |
• Colour • Odour • Amount • Consistency. |
|
|
Palpation (resp)
|
• General palpation assesses the thorax for pulsations, masses, thoracic tenderness and crepitus • Anterior palpation: – Begin at apex of right lung – Palpate areas of tenderness last – Repeat procedure on left lung. • Posterior palpation • Lateral palpation • Thoracic expansion: – Expansion – Symmetry. • Tactile fremitus: (refers to assessment of the lungs by either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words (vocal fremitus), although there are several other types.) – Anterior – Posterior – Lateral.
• Tracheal position. • Temperature • Subcutaneous emphysema Indirect or mediate percussion is used to assess the underlying structures of the thorax Anterior thoracic percussion Posterior thoracic percussion Right and left lateral thoracic percussion Diaphragmatic excursion.
• Place middle finger of non-dominant hand on skin, with pressure through the DIP joint. Tap DIP joint with middle finger of dominant hand
Areas of increased density sounds dull in comparison to an air filled cavity For example, ribs or areas of consolidation will sound very dull in comparison to normal lung tissue which is quite resonant |
|
|
AUSCULTATION (Resp)
|
• Terminology can be confusing – describe what you hear • Compare one lung to another • Must have pt relaxed where able – Sitting upright arms forward – Inhalation relaxed thru open mouth – Exhalation not forced
• The aim of respiratory auscultation is to identify the presence of: – Normal breath sounds – Abnormal lung sounds – Adventitious (or added) lung sounds – Adventitious pleural sounds.
• Anterior thoracic auscultation • Posterior thoracic auscultation • Lateral thoracic auscultation. |
|
|
Breath Sounds |
– Bronchia breath sounds are tubular, hollow sounds which are heard when auscultating over the large airways (e.g. second and third intercostal spaces). They will be louder and higher-pitched than vesicular breath sounds.
– Bronchovesicular Inspiration to expiration periods are equal with bronchovesicular lung sounds. These are normal sounds in the mid-chest area or in the posterior chest between the scapula. They reflect a mixture of the pitch of the bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound.
– Vesicular. Vesicular breath sounds are heard across the lung surface. They are lower-pitched, rustling sounds with higher intensity during inspiration. During expiration, sound intensity can quickly fade. Inspiration is normally 2-3 times the length of expiration.
|
|
|
Each breath sound is unique in its: |
– Pitch – Intensity – Quality – Duration – Location. |
|
|
There are 5 adventitious breath sounds |
– Fine crackle – Course crackle – Wheeze – Pleural friction rub – Stridor. |
|
|
describe the adventitious breath sounds |
Air entry - Good vs diminished air entry to...
Fine crackles - early CCF, sounds like rubbing hair between fingers over your ear, indicates alveoli collapsing & reinflating
Coarse crackles - Pneumonia/infection, lower bubbling/snoring sound Expiratory wheeze - asthma, tight airways Inspiratory wheeze - foreign body, upper airway sound, or severe asthma
Pleural rub - inflamed pleura Stridor – upper airway obstruction |
|
|
voice sounds
|
• Bronchophony , also known as bronchiloquy, is the abnormal transmission of sounds from the lungs or bronchi. Bronchophony is a type of pectoriloquy. It is a general medical sign detected by auscultation.
• Egophony is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis. It is due to enhanced transmission of high-frequency noise across fluid, such as in abnormal lung tissue, with lower frequencies filtered out.
• Whispered pectoriloquy. refers to an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields on a patient's torso. Usually spoken sounds of a whisperedvolume by the patient would not be heard by the clinician auscultating a lung field with a stethoscope. |
|
|
CNS consists of what 2 structures?
|
Brain and Spinal cord
|
|
|
PNS consists of
|
Cranial nerves autonomic nervous systemperiferal nervous system |
|
|
Neurons
|
generate and conduct nerve impulses.When neurons are damaged they are not replaced, although we are born with extras.
(Axons can regenerate-better in peripheral-less likely in CNS.) |
|
|
neurogilia
|
support neurons. They nurish and protect neurons.There are more neuroglias than neurons. |
|
|
Nerve Impulse
|
Series of action potentials. It is a chemical interaction of K+ and chloride movement in and out of axons.
Neurotransmitters can excite or inhibit. |
|
|
Cerebrum
|
Area of higher level of functioning(complex mental function).
Includes Basal ganglia, thalamus, hypothalamus, and the limbic system. |
|
|
Basal ganglia
|
Learned and automatic movements Ex: blinking. (Part of Cerebrum)
|
|
|
Thalamus
|
Relay station between skeletal muscle and sensory input. (Part of Cerebrum)
|
|
|
Hypothalamus
|
Regulates temp and some aspects of autonomic and endocrine. (Part of Cerebrum) |
|
|
Limbic System
|
Inner surface of cerebral hemisphere, has to do with emotions. (Part of Cerebrum) |
|
|
Parts of Brainstem
|
Midbrain, Pons and Medulla
|
|
|
Midbrain and Pons functions
|
Relay center for vasomotor impulses, control alertness and awareness. |
|
|
Medulla
|
Basic life support.
Respiratory and cardiac functions.
Cardiac-slowing center.
Tip: if you don't have it, you die. |
|
|
Cerebellum
|
Controls equillibrium & Coordination.
|
|
|
How do you test function of the cerebellum?
|
There are 2:
1. Romberg sign - stand with eyes closed. Normal person can stand 20 seconds without swaying.
2. have patient hold hands out in front flipping hands between pronate and supinate. Watch for drifting. |
|
|
The peripheral nervous system includes....?
|
1. Spinal nerves (31 pairs)2. Cranial nerves (12)3. Autonomic Nervous System (Sympathetic and parasympathetic) |
|
|
What is the function of the spinal nerves?
|
They inervate specific body regions and are motor sensory in nature.
|
|
|
The autonomic nervous system controls...?
|
Cardiac and other smooth muscles, involentary actions.It is composed of the sypathetic and parasympathetic systems. |
|
|
Sypathetic Nervous system
|
The fight of flight response.Skeletal muscle vessels dialte, heart rate increases, the liver excretes extra glucose, the thyroid is stimulated, increased sweating and kidney vessels constricts.
|
|
|
Parasympathetic Nervous System
|
Inhibits. Acts to reserve energy
|
|
|
Circulation to the brain
|
To the brain is by the corotid and others in the back of the neck (patebral) and venous return is through the jugular.
|
|
|
what kind of symptoms would a patient describe for you to reccomend doing a nurological assessment.
|
hearing loss, decreased taste/smell, incontinence, difficulty sleeping, chewing, swallowing, change in sexual performance, or ADL's. Also headaches, numbness/tingling, tremors, memory loss, personality/behavior changes.
|
|
|
Most Neurologic Diseases affect _____?
|
Mobility and coordination(dizziness, unsteady gait)
|
|
|
Nursing Assessment, current medications that alter the nervous system
|
Sedatives, analgesics, stimulants, anti-seizure, mood elevators, antidepressants
|
|
|
Neurological Examination: Cerebral Function
|
Cortical and Discriminatory interpretation-ability to see an object, recognize it's name and know it's function
|
|
|
Neurological Examination: The Motor System
|
Symmatry of muscle strength, muscle tone-palpate and look for spasticity, rigidity, flaccidity and involuntary movements |
|
|
Neurological Examination: Sensory function
|
1.Pain and temperature (they are transmitted by the same nerve endings), if one is intact no need to test the other.
2.Touch-likely normal if pain and temp are intact.
To test use touch discrimination. |
|
|
Touch discrimination
|
Have patient close their eyes. Touch each extremity randomly with finger and ask them to point to where the are being touched.
Then touch each side of the body at the same time.
Last part the patient is touched in 2 places and moved closer tother. |
|
|
Glascow coma scale |
Eye opening 1-4 Motor response 1-6 Verbal Response 1-5 |
|
|
Parkinson’s disease |
a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people.
It is associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine. |
|
|
define Motor neurone disease
|
a progressive disease involving degeneration of the motor neurons and wasting of the muscles. |
|
|
define stroke
|
brain attack is the loss of brain function due to a disturbance in the blood supply to the brain. |
|
|
Traumatic Brain
|
nondegenerative, noncongenital insult to the brain from an external mechanical force.
Possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness. |
|
|
Alzheimer’s disease
|
progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain. It is the commonest cause of premature senility. |
|
|
organic brain syndrome
|
is a general term that describes decreased mental function due to a medical disease other than a psychiatric illness. It is often used synonymously (but incorrectly) with dementia. |
|
|
define acute
|
In medicine, an acute disease is a disease with a rapid onset and/or a short course.
Acute may be used to distinguish a disease from a chronic form, such as acute leukemia and chronic leukemia, or to highlight the sudden onset of a disease, such as acute myocardial infarction. |
|
|
define chronic
|
(of an illness) persisting for a long time or constantly recurring. |
|
|
why use a nuro assessment
|
• Neurological assessment can help to detect neurological disease or injury. • Neurological assessment aids injury and disease monitoring • Neurological assessment can determine success of treatments and care |
|
|
CNS |
• Purpose: – Controls all body functions and thought processes. • Tasks: – Maintains homeostasis – Receives, interprets, reacts to stimuli – Controls voluntary and involuntary processes, including cognition. |
|
|
layers of protection
|
• Protective layers: – Scalp – Skull – Meninges: • Dura mater • Arachnoid mater •Pia mater |
|
|
DIENCEPHALON
|
• Diencephalon is composed of the thalamic structures: Thalamus Epithalamus Hypothalamus
• The hypothalamus is important in:– Body temperature regulation – Pituitary hormone control – Autonomic nervous system responses. |
|
|
Temporal:
|
Hearing– Memory– Speech perception |
|
|
occipital
|
Vision (optic...) |
|
|
Parital |
Somatic sensory and movement opposite sides...
stroke in the left somatosensory means a loss of feeling in the right hand side of the body.
|
|
|
What is the Limbic system responsible for? |
emotional brain... see a spider... PANIC! |
|
|
motor pathway of brain
|
Motor pathways of CNS – Pyramidal tract – Extrapyramidal tract. |
|
|
sensory pathways
|
Sensory pathways – Spinothalamic tracts – Posterior column. |
|
|
What vessels supply blood to the brain? |
• Internal carotid arteries • Vertebral arteries • Circle of Willis |
|
|
How many spinal nerves are there/where are they located? |
31 pairs of spinal nerves – 8 cervical –12 thoracic – 5 lumbar – 5 sacral – 1 coccygeal. |
|
|
reflexes
|
A reflex action is a specific response to an adequate stimulus, and occurs without conscious control.
• Monosynaptic reflexes. When a reflex arc consists of only two neurons in an animal (one sensory neuron, and one motor neuron), it is defined as monosynaptic.
Monosynaptic refers to the presence of a single chemical synapse.
• Polysynaptic reflexes Monosynaptic vs. polysynaptic
When a reflex arc consists of only two neurons in an animal (one sensory neuron, and one motor neuron), it is defined as monosynaptic.
Monosynaptic refers to the presence of a single chemical synapse. |
|
|
types of reflexes
|
– Muscle stretch or deep tendon reflexes (DTR)
– Superficial reflexes
– Pathological reflexes. |
|
|
Health history required regarding Neurological Assessment |
– Patient profile – Chief complaint – Past health history – Family health history – Social history. |
|
|
What should we include in a patient profile? |
• Patient Profile: – Age – Gender – Race. |
|
|
Common chief complaints: |
– Headache – Seizure – Syncope – Tremor – Pain – Paresthesia (Pins n Needles) - Disturbances in gait (a person's manner of walking) – Visual changes – Vertigo – Memory disorders – Difficulty with swallowing or speech |
|
|
Characteristics of chief complaints required regarding Neurological Assessment |
– Quality – Quantity – Associated manifestations – Aggravating factors – Alleviating factors – Setting – Timing. |
|
|
Past medical history required regarding Neurological Assessment |
Medical history: – Neurologic specific – Non-neurologic specific.
• Surgical history • Medications: – Antidepressants, narcotics, anti-anxiety and anti-seizure medications.
• Communicable diseases • Injuries and accidents. |
|
|
Family history required regarding Neurological Assessment |
Family health history: – Congenital defects – Headaches – Alzheimer’s disease. |
|
|
Social history required regarding Neurological Assessment |
• Alcohol, tobacco, drug use • Sexual practice • Travel history • Work and home environment • Hobbies and leisure activities • Stress • Ethnic background. |
|
|
Before you start a Neurological assessment |
Greet the patient and explain the assessment.
Maintain a quiet, unhurried, self-confident demeanour.
Provide a warm, quiet, well-lit environment.
After the mental status exam, ask the patient to remove all street clothes and provide a gown.
Begin the assessment with the patient in a comfortable position. |
|
|
What equipment do we need for a Neurological assessment?
|
• Cotton-tipped applicators/Cotton wisp • Penlight • Tongue blade • Vials containing odorous materials • Vials with solutions for tasting • Vision chart • Snellen chart or Rosenbaum pocket screener. |
|
|
A complete assessment of the neurological system includes assessment of:
|
– Sensation– Cranial nerves– Motor function.
|
|
|
cognitive assessment
|
• Physical appearance and behaviour:– Posture and movements– Dress, grooming and personal hygiene– Facial expression– Affect. |
|
|
where can you find questions to assess a persons cognition unrelated to a nurological assessment
|
falls risk assessment |
|
|
cognition communication
|
Communication: – Articulation, fluency, rate of speech – Ability to read, write, follow simple commands
– Assess for : aphasia dysarthria ( difficult or unclear articulation of speech that is otherwise linguistically normal.) dysphonia, ( difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.)
aphonia, apraxia, agraphia, alexia. |
|
|
levle of consciousness
|
Glasgow Coma Scale– Motor responses and strength. |
|
|
• Cognitive abilities and mentation:
|
– Attention – Memory – Judgement – Insight – Spatial perception – Calculation – Abstract reasoning – Thought processes and content. |
|
|
normal findings cognition
|
Posture erect, gait smooth, body movements symmetrical.
• Clean, well-groomed, clothing appropriate for age and weather.
• Facial expressions symmetrical and appropriate to conversation content. Affect appropriate to situation and cultural norms.
• Able to produce spontaneous, coherent speech. • Alert, oriented to person, place, time. • Intact cognitive abilities. |
|
|
sensory assessment
|
Sensation should be tested early in the neurological assessment. • Cooperation of the patient is required. • Fatigue may affect the reliability of findings.
• Sensory assessment is divided into 3 sections: – Exteroceptive sensations – Proprioceptive sensation – Cortical sensations.
Exteroceptive sensation: – Light touch, superficial pain, temperature.
Proprioceptive sensation: - Motion, position, vibration, extinction.
Cortical sensation: – Stereognosis, graphesthesia, discrimination, extinction. |
|
|
Sensory Assessment: Normal Findings
|
• Able to accurately perceive light touch, superficial pain, temperature. • Able to identify changes in position of body, vibration, common objects. • Cranial nerves intact. • Cerebellar function intact, gait stable. |
|
|
motor system |
Extrapyramidal rigidity: – Decerebrate rigidity (a postural change that occurs in some comatose patients, consisting of episodes of opisthotonos, rigid extension of the limbs, internal rotation of the upper extremities, and marked plantar flexion of the feet; produced by a variety of metabolic and structural brain disorders).
– Decorticate rigidity (a unilateral or bilateral postural change, consisting of the upper extremities flexed and adducted and the lower extremities in rigid extension; due to structural lesions of the thalamus, internal capsule, or cerebral white matter.) – Pronator drift. (refers to a pathologic sign seen during a neurological examination. [ 1] Jean Alexandre Barré is credited with having first described it thus it is sometimes known as the Barré test. A positive result indicates spasticity.)
• Cerebellar function: – Coordination – Station – Gait. |
|
|
define Lethargy
|
a lack of energy and enthusiasm. |
|
|
define Obtundation
|
refers to less than full alertness (altered level of consciousness), typically as a result of a medical condition or trauma.
The root word, obtund, means "dulled or less sharp" cf. obtuse angle. |
|
|
define Stupor
|
a state of near-unconsciousness or insensibility. |
|
|
define Coma
|
a prolonged state of deep unconsciousness, caused especially by severe injury or illness. |
|
|
define Vertigo
|
a sensation of whirling and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve; giddiness. |
|
|
define Syncope
|
emporary loss of consciousness caused by a fall in blood pressure. |
|
|
define Seizure
|
in which the nerve cell activity in your brain is disturbed, causing aseizure during which you experience abnormal behavior, symptoms and sensations, including loss of consciousness. |
|
|
define Aura
|
An aura is a perceptual disturbance experienced by some with migraine or seizures before either the headache or seizure begins.
It often manifests as the perception of a strange light, an unpleasant smell or confusing thoughts or experiences. |
|
|
define Paresthesia
|
an abnormal sensation, typically tingling or pricking (‘pins and needles’), caused chiefly by pressure on or damage to peripheral nerves. |
|
|
define Dysarthria
|
difficult or unclear articulation of speech that is otherwise linguistically normal. |
|
|
define Dysphasia
|
language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage. |
|
|
define Paralysis
|
the loss of the ability to move (and sometimes to feel anything) in part or most of the body
typically as a result of illness, poison, or injury. |
|
|
define Convulsion
|
- a sudden, violent, irregular movement of the body
- caused by involuntary contraction of muscles and associated especially with brain disorders such as epilepsy, the presence of certain toxins or other agents in the blood, or fever in children |
|
|
define Nystagmus
|
rapid involuntary movements of the eyes.
|
|
|
define Anosmia
|
the loss of the sense of smell, either total or partial. It may be caused by head injury, infection, or blockage of the nose.
|
|
|
define Ptosis
|
drooping of the upper eyelid due to paralysis or disease, or as a congenital condition. |
|
|
define Ataxia
|
the loss of full control of bodily movements. |
|
|
define Opisthotonos
|
spasm of the muscles causing backward arching of the head, neck, and spine
eg/ in severe tetanus, some kinds of meningitis, and strychnine poisoning. |
|
|
define Decorticate rigidity
|
a unilateral or bilateral postural change
- upper extremities flexed and adducted - lower extremities in rigid extension; due to structural lesions of the thalamus, internal capsule, or cerebral white matter. |
|
|
define decerebrate rigidity
|
a postural change that occurs in some comatose patients,
consisting of episodes of : - rigid extension of the limbs - internal rotation of the upper extremities - marked plantar flexion of the feet;
produced by a variety of metabolic and structural brain disorders. |
|
|
define abbey scale |
For measurement of pain in people with dementia who cannot verbalise. |
|
|
normal pupils will? |
|
|
|
What is aphasia?
|
Disturbance of the comprehension and expression of language caused by dysfunction in the brain |
|
|
What is dysarthria? |
Difficult or unclear articulation of speech that is otherwise linguistically normal |
|
|
What is dysphonia? |
Difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords
|
|
|
What is aphonia? |
It is the inability to produce voice |
|
|
What is apraxia? |
Is a disorder of motor planning
|
|
|
What is agraphia? |
An acquired neurological disorder causing a loss in the ability to communicate through writing, either due to some form of motor dysfunction or an inability to spell. |
|
|
What is alexia? |
Is a brain disorder in which a person is unable to understand written words |
|
|
What is Paresthesia |
Pins n Needles! |
|
|
What does the Glasgow Coma Scale look like? |
|
|
|
What is the vestibular system? |
The sensory system that provides the leading contribution about movement and sense of balance. |
|
|
What is Proprioception? |
The sense of the relative position of neighbouring parts of the body and strength of effort being employed in movement. |
|
|
What is Eupnoea? |
12–20 breaths per minute
|
|
|
What is Tachypnoea:? |
> 20 breaths per minute
|
|
|
What is Bradypnoea? |
< 12 breaths per minute Abnormally low breathing rate |
|
|
What is Apnoea? |
No respiration for 10 or more seconds. |
|
|
What are the respiration patterns? |
– Cheyne-Stokes
|
|
|
What is the Cheyne-Stokes respiratory pattern? |
Cheyne–Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called apneoa
Seen in patients with heart failure, strokes, hyponatremia, traumatic brain injuries and brain tumors. |
|
|
What is a Biot’s or ataxic respiratory pattern? |
An abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apneoa
Biot's respiration is caused by damage to the pons due to strokes or trauma or by pressure on the pons
It can be caused by opioid use |
|
|
What does Ataxic mean? |
"Without order"
disorganised movement/clumsy/unco-ordinated |
|
|
What are Apneustic repiratory patterns? |
is an abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release.
It is caused by damage to the pons or upper medulla & removal of input from the vagus nerve
It is an ominous sign, with a generally poor prognosis.
It can also be temporarily caused by some drugs, such as ketamine.
|
|
|
Digital Clubbing is associated with....? |
Respiratory Disease |
|
|
Is blood pressure readings Objective or Subjective data? |
Objective |
|
|
The difference between the apical pulse and radial pulse is called? |
Pulse deficit
|
|
|
Name 3 cancers that meet the |
Breast, cervical & bowel
|
|
|
What does the Waterlow |
Pressure areas |
|
|
What does a pulse |
The oxygen carrying capacity of haemoglobin
|
|
|
What does a pulmonary |
Lung volume and airflow |
|
|
Orthopnoea is |
Lying supine |
|
|
What is Orthopnoea? |
Shortness of breath (dyspnea) which occurs when lying flat |
|
|
What is platypnea? |
Refers to shortness of breath (dyspnea) that is relieved when lying down, and worsens when sitting or standing up |
|
|
What self assessment can
|
Breast |
|
|
What is the target population |
Over 50 years old |
|
|
Clinical handovers are |
Continuity of patient care! |
|
|
Communication can |
Non verbal & verbal |
|
|
What does empiric/empirial mean? |
Based on observation or experimentation, not fact |
|
|
What are one of the worst consequences of |
Missed medications |
|
|
With ageing, why is blood pressure usually higher? |
The arteries tend to become more rigid (less elastic).
This may change a person’s blood pressure pattern, with a higher systolic pressure and a lower diastolic pressure.
The higher systolic pressure is important because it can further accelerate the rigidity of the arteries.
|
|
|
What is an example of an Ecomap? |
|
|
|
What is an Ecomap? |
An ecomap is a flow diagram that maps family and community systems' process over time |
|
|
Patient assessments can be conducted by : |
Social Workers |
|
|
When food is swallowed, the epiglottis : |
Closes |
|
|
What two common tools used in family assessment? |
Genogram - picture of the family generational and intergenerational relationships
- identifies the connections within families and with outside systems |
|
|
What is an example of a Genogram? |
|
|
|
What is a Genogram? |
Graphic representation of a family tree that displays detailed data on relationships among individuals. |
|
|
Genogram vs Ecomap? |
Genogram is arguably more detailed |
|
|
The normal sound expected on percussion throughout most of the lung fields is what? |
Resonance |
|
|
What type of tumour is found in benign prostatic hyperplasia? |
A smooth, firm, symmetrical prostate enlargement |
|
|
What order should IPPA be done during an ABDOMINAL ASSESSMENT?
|
IAPP |
|
|
The most sensitive indicator of change to a patient's neurological state is : |
LOC |
|
|
What internal organ damage can a patient's serum level help assess for? |
Liver damage
antigens, hormones, and any exogenous substances (e.g., drugs and microorganisms). |
|
|
How often should men perform self testing of the testicles? |
Monthly for early detection of prostate cancers |
|
|
What does a barrel chest indicate on a patient with COPD? |
- Loss of lung elasticity |
|
|
What is a Wood's lamp commonly referred to as? |
A Black light |
|
|
What is a Wood's Lamp used to detect? |
Ringworm |
|
|
What do Assymetrical borders on a cancerous legion suggest? |
That it is malignant |
|
|
if palpating the liver, what sort of sound should be heard? |
Dull |
|
|
What is a patient jumping from topic to topic referred to as? |
Flight of Ideas |
|
|
What are Macules? |
Flat Lesions on the skin |
|
|
What are Pustules? |
Small, inflamed, blister-like lesions |
|
|
What are plaques? |
Broad, raised areas of the skin. |
|
|
What are Papules? |
Small, firm, round lesions on the skin |
|
|
What is the NORMAL colour of a tympanic membrane? |
Gray : |
|
|
Dull or stabbing chest pain with a sudden onset lasting anywhere from 1 min for up to days is a sign of : |
Acute Anxiety |
|
|
What is cholecystitis? |
Definition : inflammation of the gall bladder |
|
|
Eating fatty foods then having a gripping, sharp pain is likely to be : |
cholecystitis |
|
|
What type of chest pain is associated with MI? |
Tightness and pressure |
|
|
What is a normal change to the breasts during menopause? |
Breasts become flabbier and smaller, and nipples flatten and become less erectile. |
|
|
Clear, thin nasal drainage may indicate : |
A cerebrospinal fluid leak |
|
|
What is the best way for a nurse to assess a patient with Scoliosis? |
Ask the patient to bend forward |
|
|
What is Scoliosis? |
Abnormal lateral curvature of the spine |
|
|
Threats of violence towards ex-spouses are consistently associated with : |
Personality Disorder |
|
|
Where do you find the Apical Pulse? |
At the fifth intercostal space near the left of the midclavicular line |
|
|
If percussing the costovertibral angle and pain is felt, what organ needs investigation? |
The kidneys |
|
|
What is Stereognosis? |
The mental perception of depth or three-dimensionality by the senses,
Usually in reference to the ability to perceive the form of solid objects by touch. |
|
|
What is Graphesthesia? |
Is the ability to recognize writing on the skin purely by the sensation of touch. |
|
|
What is Aphasia? |
Inability (or impaired ability) to understand or produce speech, as a result of brain damage. |
|
|
What is Apraxia? |
Inability to perform particular purposive actions, as a result of brain damage. |
|
|
When measuring girth in a patient with abdominal bleeding, where would you take the measurement from? |
The fullest point |
|
|
When palpating a person's breast, what finger(s) should be used? |
The middle three in a gentle circular pattern |
|
|
What colour is Hemoturia? |
Brown or Red |
|
|
What is Cerumen? |
Ear wax |
|
|
What can cerumen impaction cause? |
Conductive hearing Loss |
|
|
What is the Babinski Reflex? |
- is one of the reflexes that occurs in infants. Reflexes are responses that occur when the body receives a certain stimulus.
- occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. |
|
|
Why would you palpate the inguinal region of a construction worker? |
To check for any hernation, as they are prone to them |
|
|
When is the best time of month to palpate a female breast that is yet the hit menopause? |
Seven to ten days after the cycle begins each month |
|
|
When auscultating the chest of a man with heavy amounts of chest hair, what should the nurse do? |
wet the hair because friction caused by chest hair can mimic abnormal breath sounds |
|
|
What is normally heard in the lower portion of a healthy lung with a stethoscope? |
Vesicular breath sounds
Are soft, low-pitched, and prolonged during inspiration. |
|
|
What percussive sound is normally heard with healthy lungs? |
Resonance |
|
|
A serum albumin test is for : |
Recording the levels of protein in the body |
|
|
Define Agnosia |
inability to interpret sensations and hence to recognize things, typically as a result of brain damage.
Agnosia is the ability to identify common objects and occurs in three forms: visual, auditory or body image. |
|
|
What can a perineal sore be an indicator of? |
Herpes |
|
|
Is a 32-day menstrual cycle acceptable/within normal range? |
It is. |
|
|
What does the inability to lift and extend an arm for 30 seconds indicate? |
Weakness of shoulder girdle muscles on that side. |
|
|
What do ulcerations on lower left of a leg mean? |
Chronic Venous Insufficiancy |
|
|
What is the method of choice in |
Family therapy |
|
|
What is an observable characteristic of pneumothorax? |
tracheal deviation |
|
|
What is Tracheal Deviation |
When the trachea shifts to a side instead of being in the middle |
|
|
What are the quadrants of the Abdomen? |
|
|
|
What is the pulse in the top of the foot? |
Dorsal Pedis |
|
|
Flexing a wrist for 30sec then having pain may indicate : |
Carpal Tunnel Syndrome |
|
|
Why should deep abdominal palpitation not be performed if there is abdominal rigidity? |
This may indicate peritoneal inflammation, and palpation could lead to pain or organ rupture. |
|
|
What sound is heard during pneumothorax? |
Hyper resonance
The pleural space on the affected side is increased, more air = vibrations |
|
|
Should lubricants be used during a PAP smear? |
No, only warm water or results could be affected |
|
|
What is the Olfactory nerve? |
I
Smell |
|
|
What is the best way to check muscle tone? |
Range of motion test |
|
|
What is Romberg's test? |
A test used in an exam of neurological function, and also as a test for drunken driving.
The exam is based on the premise that a person requires at least two of the three following senses to maintain balance while standing: - proprioception (the ability to know one's body in space); - vestibular function (the ability to know one's head position in space) -Vision (which can be used to monitor [and adjust for] changes in body position). |
|
|
What is Hypoxia? |
Deficiency in the amount of oxygen reaching the tissues. |
|
|
What is hypoxaemia? |
An abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. |
|
|
How long should you take respiratory rate for? |
A full minute if it is regular two minutes or more if it is irregular |
|
|
Is the Glasgow Coma Scale a mental exam? |
No. it is for Loss Of Consciousness ONLY |
|
|
Does every healthy person have even pupil size normally? |
Anisocoria occurs in 17% of the population can can be completely normal/harmless |
|
|
What is Anisocoria? |
Uneven pupil size |
|
|
How do you test eyes in an unconscious patient? |
Move their head side to side. If eyes move with the head, theres trouble - should still be looking at the ceiling |
|
|
How do you test extraocular movements? |
Pen light going in different directions |
|
|
What are the differences between light and deep palpation?
|
Deep palpation-Roughly 4-5cm depth, used for assessing the underlying organs for shape, symmetry, tendernessLight palpation- Roughly 1-2cm depth, used for assessing the surface of the patient/the skin etc
|
|
|
What are some safety precautions when undertaking a physical assessment?
|
Make sure the patient is at an appropriate level to perform the assessment.Make sure adequate hand hygiene has been carried out.Use adequate PP
|
|
|
What is an appropriate environment for a physical assessment?
|
Comfortable for both the patient and the nurse/the environment is a private setting/a sterile setting/an environment free from any danger or harm
|
|
|
What do you use the bell side of the stethoscope for?
|
For lower pitch sounds such as bowel sounds and heart murmours
|
|
|
What are some ethical considerations in a health history?
|
Confidentiality and security of the information collected/consent
|
|
|
What are some factors that may influence how you undertake a health/physical assessment?
|
Age, race, culture, religious preferences, disabilities, language bariers
|
|
|
How many regions are there to inspect in an abdominal assessment?
|
Nine.
|
|
|
What sorts of things are you looking for in an inspection during an abdominal assessment?
|
Symmetry, pigmentation/colour, scars, stirae, peristalsis, pulsations, bowel sounds, tenderness or if the bladder or stomach are misshapen.
|
|
|
When undertaking a musculoskeletal assessment, what components are you assessing?
|
Gait, mobility, range of motion, muscle strength/size and shape, joint contour
|
|
|
What is scoliosis?
|
An abnormal sideways curvature of the spine.
|
|
|
What is Kyphosis?
|
Excessive concave curvature of the spine (hunchback).
|
|
|
What is Dystonia?
|
Neurological disorder in which muscular spasms occur.
|
|
|
What is Acromegaly?
|
Abnormal human growth hormone produced
|
|
|
What is Festinating gait?
|
Shuffling/rapid short steps instead of regular strides (common in parkinson's disease patients)
|
|
|
What is ataxia?
|
Lack of coordination of muscles
|
|
|
What is Akylosing spondylitis
|
Inflammatory arthritis in the joints, including the spine
|
|
|
What is tetany
|
Muscle twitching and spasms of the hands and feet
|
|
|
What is chorea
|
Involuntary movement
|
|
|
What are contractures
|
Chronic loss of joint movement due to change in the tissues
|
|
|
What are the functions of the skeletal system?
|
Protection, stability, storage (minerals and all that) and production (in da marrow and junk)
|
|
|
What is hypotonicity?
|
Having less than normal tissue tone
|
|
|
What is spacticity?
|
Stiff or rigid muscles
|
|
|
What is Kussmaul's respiratory rhythm? |
is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure |
|
|
What is Hyperpnea? |
increased depth of breathing when required to meet metabolic demand of body tissues, such as during or following exercise |
|
|
What do different types of respirations LOOK like? |
|
|
|
What should happen (with a prescription) if SaO2 is UNDER 90%? |
O2 should be given! |
|
|
What is FiO2? |
Simply put, if you take the air that someone is breathing and find out how much of it (percentage-wise) is oxygen, you get the FiO2 |
|
|
What is narcosis? |
A state of altered conciousness |
|
|
What is Atelectasis ? |
Atelectasis is a condition in which one or more areas of your lungs collapse or don't inflate properly. |
|
|
What is absorption Atelectasis ? |
O2 replaces N2 (nitrigen gas) which is holding the alveolar open |
|
|
What is Retrolental Fibroplasia? |
An unusual eye disease occurring in premature infants, usually from being given high concentrations of oxygen |
|
|
What is malaise? |
A feeling of general discomfort or uneasiness, of being "out of sorts", often the first indication of an infection or other disease. |
|
|
What does a peak flow meter look like? |
|
|
|
What does an incentive Spirometer look like? |
|
|
|
What is an incentive spirometer? How does it work? |
A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia.
Teaches you how to take slow deep breaths. |
|
|
What is Tactile fremitus? |
fremitus is the feeling of vibration when an area is touched |
|
|
What is Subcutaneous emphysema? |
is when gas or air is in the layer under the skin. |
