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What is subjective data?
subjective data (i.e., what the person says about himself or herself during history taking)
What is objective data?
objective data (i.e., what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
What form the database?
Subjective and objective data, with the patient's record and laboratory studies, these elements form the database.
What is the nursing process?
The standards of practice in nursing, traditionally termed the nursing process, include six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation
What is a nursing diagnoses?
Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state.
What does most recently approved North American Nursing Diagnosis Association (NANDA) 2009-2011 list include?
(1) actual diagnoses, existing problems that are amenable to independent nursing interventions; (2) risk diagnoses, potential problems that an individual does not currently have but is particularly vulnerable to developing; and (3) wellness diagnoses, which focus on strengths and reflect an individual's transition to a higher level of wellness.
What does it mean to set priorities?
When there is more than one diagnosis you have to set priorities. In the hospital the initial problem is usually related to the reason for admission. However, the acuity of illness often determines the order of priorities of the person's problems.
What are second-level priority problems?
are those that are next in urgency—those requiring your prompt intervention to forestall further deterioration, for example, mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security.
What is the first principle of setting priorities?
Make a complete list of current medications, medical problems, allergies, and reasons for seeking care. Refer to them frequently because they may affect how you set priorities.
What is step one in setting priorities?
- Assign high priority to First-level priority problems (immediate priorities): Remember the “ABCs plus V”:
- • Airway problems
- • Breathing problems
- • Cardiac/circulation problems
- • Vital sign concerns (e.g., high fever)
What is the exception with ABC's plus V?
With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately
What is step #2 for setting priorities?
- Next, attend to Second-level priority problems:
- • Mental status change (e.g., confusion, decreased alertness)
- • Untreated medical problems requiring immediate attention (e.g., a diabetic who has not had insulin)
- • Acute pain
- • Acute urinary elimination problems
- • Abnormal laboratory values
- • Risks of infection, safety, or security (for the patient or for others)
What is step three in setting priorities?
- Address Third-level priority problems (later priorities):
- • Health problems that do not fit into the above categories (e.g., problems with lack of knowledge, activity, rest, family coping)
What is EBP?
Evidence-based assessment. EBP is more than the use of best-practice techniques to treat patients. “EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician's experience, as well as the patient preferences and values, to make decisions about care and treatment
What are the four types of data you establish?
- 1. Complete
- 2. Focused
- 3. Follow up
- 4. Emergency
Describe each database.
- 1. complete (total health) database- complete health history and full exam. describes past and current health state.
- 2. Focuses or problem-centered data base- for limited or short term problem. a mini database, smaller in scope and more targeted than complete. concerns one problem.
- 3. Follow-up- the status of any identified problems should be evaluated at regular intervals. what change has occurred? is it better or worse?
- 4. Emergency database- rapid collection of data. diagnosis must be swift and sure. person gets question and simultaneously get his airway, breathing, circulation and consciousness assessed.
What is holistic health?
Consideration of the whole person is the essence of holistic health. Holistic health views the mind, body, and spirit as interdependent and functioning as a whole within the environment.
What is EHR?
Electronic health recording.This eliminates handwritten clinical data as well as provides access to patient education materials and Internet searches. patient can sit idly while examiner interacts silently with the computer. you should type data into computer after you get the narrative story from patient face to face
What is an open-ended question?
- Use for narrative information
- Calls for long paragraph answers
- Elicits feelings, opinions, ideas
- Builds and enhances rapport
- Tell me all about your headaches.
What are direct or closed questions?
- Use for specific information
- Calls for short one- to two-word answers
- Elicits cold facts
- Limits rapport and leaves interaction neutral
- Are your headaches on one side or both?
What are the first 5 verbal responses?
(facilitation, silence, reflection, empathy, clarification) involve your reactions to the facts or feelings the person has communicated. Your response focuses on the patient's frame of reference. Your own frame of reference does not enter into the response.
What are the last 4 verbal responses?
last four responses (confrontation, interpretation, explanation, summary), you start to express your own thoughts and feelings. The frame of reference shifts from the patient's perspective to yours.
What is the difference between
In the first five responses, the patient leads; in the last four responses, you lead.
What is a facilitation response?
These responses encourage the patient to say more, to continue with the story (“mm-hmm, go on, continue, uh-huh”)
What is a silence response?
Silence is golden after open-ended questions. Your silent attentiveness communicates that the patient has time to think, to organize what he or she wishes to say without interruption from you.
What is a reflection response?
This response echoes the patient's words. Reflection is repeating part of what the person has just said.
What is an empathy response?
A physical symptom, condition, or illness often has accompanying emotions. An empathic response recognizes a feeling and puts it into words.
What is a clarification response?
Use this when the person's word choice is ambiguous or confusing (e.g., “Tell me what you mean by ‘tired blood.’ ”). Clarification also is used to summarize the person's words, simplify the words to make them clearer, and then ask if you are on the right track.
What is a summary response?
This is a final review of what you understand the person has said. It condenses the facts and presents a survey of how you perceive the health problem or need. It is a type of validation in that the person can agree with it or correct it. Both you and the patient should participate.
What are the 10 traps of interviewing?
- 1. Provide false assurance or reassurance
- 2. Giving unwanted advise
- 3. using authority
- 4. Using avoidance language
- 5. Engaging in distancing
- 6. Using professional Jargon
- 7. Using leading or biased questions,
- 8. Talking too much
- 9. Interrupting
- 10. Using "why" questions
Nonverbal skill in interviewing
Learn to listen with your eyes and ears. nonverbal modes include physical appearance, posture, gestures, facial expression, eye contact, voice, and touch. These are important to establish rapport and conveying information, especially about feelings.
Closing the interview
ended gracefully. ask the person if they have any questions or anything else they want to mention or any other areas I should have asked about?
What is the health history sequence?
- 1 Biographic data
- 2 Reason for seeking care
- 3 Present health or history of present illness
- 4 Past history
- 5 Family history
- 6 Review of systems
- 7 Functional assessment or activities of daily living (ADLs)
What is mental status?
Mental status is a person's emotional (feeling) and cognitive (knowing) function. Optimal functioning aims toward simultaneous life satisfaction in work, in caring relationships, and within the self. Mental health is relative and ongoing. Everyone has “good” days and “bad” days. Usually, mental status strikes a balance, allowing the person to function socially and occupationally.
What is a mental disorder?
is apparent when a person's response is much greater than the expected reaction to a traumatic life event. A mental disorder is defined as a significant behavioral or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability, or death or a loss of freedom.
What do mental disorders include?
Mental disorders include organic disorders and psychiatric mental illness
What are organic disorders?
(due to brain disease of known specific organic cause [e.g., delirium, dementia, alcohol and drug intoxication and withdrawal])
What are psychiatric mental illness?
(in which an organic etiology has not yet been established [e.g., anxiety disorder or schizophrenia]).
How do you assess mental status?
Consciousness, language, mood and affect, attention, memory, abstract reasoning, thought process, thought content, and perceptions.
What is delirium?
Delirium is an acute confusional change or loss of consciousness and perceptual disturbance
What is dementia?
dementia is a gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake, and is not reversible.
What is flat affect?
lack of emotional response, no expression of feelings, voice monotonous and face immobile
What is depression?
Sad, gloomy, dejected; symptoms may occur with rainy weather, after a holiday, or with an illness; if the situation is temporary, symptoms fade quickly
What is Depersonalization?
Loss of identity, feels estranged, perplexed about own identity and meaning of existence
What is elation?
Joy and optimism, overconfidence, increased motor activity, not necessarily pathologic
What is Euphoria?
Excessive well-being, unusually cheerful or elated, which is inappropriate considering physical and mental condition, implies a pathologic mood
What is Anxiety?
Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown
What is fear?
Worried, uneasy, apprehensive; external danger is known and identified
What is irritability?
- Annoyed, easily provoked, impatient
- Person internalizes a feeling of tension, and a seemingly mild stimulus “sets him (or her) off”
What is rage?
- Furious, loss of control
- Person has expressed violent behavior toward self or others
What is Ambivalence?
- The existence of opposing emotions toward an idea, object, person
- A person feels love and hate toward another at the same time
What is Lability?
- Rapid shift of emotions
- Person expresses euphoric, tearful, angry feelings in rapid succession
What is Inappropriate affect?
- Affect clearly discordant with the content of the person's speech
- Laughs while discussing admission for liver biopsy
What is a phobia?
Strong, persistent, irrational fear of an object or situation; feels driven to avoid it
What is hypochondriasis?
Morbid worrying about his or her own health, feels sick with no actual basis for that assumption
What is obsession?
Unwanted, persistent thoughts or impulses; logic will not purge them from consciousness; experienced as intrusive and senseless
What is compulsion?
Unwanted repetitive, purposeful act; driven to do it; behavior thought to neutralize or prevent discomfort or some dreaded event
What are delusions?
Firm, fixed, false beliefs; irrational; person clings to delusion despite objective evidence to contrary
What causes delirium?
- Delirium may be due to a general medical condition: systemic infections, metabolic disorders (e.g., hypoxia, hypercarbia, hypoglycemia), fluid or electrolyte imbalances, liver or kidney disease, thiamine deficiency, postoperative states, hypertensive encephalopathy, or following seizures or head trauma.
- Delirium also may be substance-induced (i.e., due to a drug of abuse, a medication, or toxin exposure).
What are mood disorders?
- major depressive episode
- manic episode
What is major depressive episode?
- A. Five (or more) of the following symptoms present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of interest or pleasure.
- - depressed mood, diminished interest or pleasure, weight loss, insomnia, psychomotor agitation, fatigue, worthlessness, diminished ability to think, or thoughts of death
- B. symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What is a manic episode?
- A. period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week
- B. three or more of the following symptoms have persisted
- - inflated self-esteem, decreased need for sleep, more talkative than usual, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal directed activity or psychomotor agitation, or excessive involvement in pleasurable activities that have high potential for painful consequences.
- C. mood disturbance is sufficiently severe to cause marked impairment in occupational functioning
- D. symptoms are not due to direct physiologic effects of a substance or general medical condition
What are the skills requisite for the physical examination?
are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order.
What is palpation?
follows and often confirms points you noted during inspection. Palpation applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.
are different parts of the hand better suited fro assessing different factors?
- fingertips= for fine tactile discrimination as of skin texture, welling, pulsation, determining presence of lumps
- grasping action of fingers and thumb= detect the position, shape and consistency of an organ or mass
- dorsa (backs) of hands and fingers=best for determining temperature because the skin here is thinner than on the palms
- Base of fingers or ulnar surface of the hand=best for vibration
What is percussion?
is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.
when do you use percussion?
- Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors.
- Signaling the density (air, fluid, or solid) of a structure by a characteristic note.
- Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm deep—a deeper mass would give no change in percussion.
- Eliciting a deep tendon reflex using the percussion hammer.
What is auscultation?
- Auscultation is listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen.
- most body sounds are very soft and must be channeled through a stethoscope for you to evaluate them. The stethoscope does not magnify sound but does block out extraneous room sounds.
What are the 2 end-pieces of a stethoscope?
the diaphragm and a bell
When do you use the diaphragm?
You will use the diaphragm most often because its flat edge is best for high-pitched sounds—breath, bowel, and normal heart sounds. Hold the diaphragm firmly against the person's skin—firm enough to leave a slight ring afterward
What do you use the bell on the stethoscope for?
The bell endpiece has a deep, hollow, cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly against the person's skin—just enough that it forms a perfect seal
What is a nosocomial infection?
(an infection acquired during hospitalization) hospitals have sites that are reservoirs for virulent microorganisms. Some of these microorganisms are resistant to antibiotics, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or multidrug-resistant tuberculosis, or are microorganisms for which there is currently no known cure, such as human immunodeficiency virus (HIV).
What is a general survey?
a study of the whole person, covering the general health state and any obvious physical characteristics. It is an introduction for the physical examination that will follow; it should give an overall impression, a “gestalt,” of the person
what are the 4 points that will add up to he general survey?
Consider these four areas: physical appearance, body structure, mobility, and behavior.
What is BMI?
Body mass index (BMI) is a practical marker of optimal healthy weight for height
vital sign: temperature
The various routes of temperature measurement reflect the body's core temperature. The normal oral temperature in a resting person is 98.6°, with a range of 96.4° to 99.1° F. The rectal temperature measures 0.7° to 1° F higher
What influences normal temperature?
- A diurnal cycle of 1° to 1.5° F, with the trough occurring in the early morning hours and the peak occurring in late afternoon to early evening.
- The menstruation cycle in women. Progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° to 1.0° F rise in temperature that continues until menses.
What is hyperthermia?
or fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma, surgery, or malignancy. Neurologic disorders (e.g., a cerebral vascular accident, cerebral edema, brain trauma, tumor, or surgery) also can reset the brain's thermostat at a higher level, resulting in heat production and conservation.
What is hypothermia?
is usually due to accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage.
What is an advantage of an electric thermometer?
swift and accurate measurment
When would you take temperature rectally?
Take a rectal temperature only when the other routes are not practical like a comatose or confused pt, person in shock, or they cant open their mouth because of oxygen tubes
What is TMT?
- The tympanic membrane thermometer senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus (the internal carotid artery); thus it is an accurate measurement of core temperature.
- The tympanic membrane thermometer is a noninvasive, nontraumatic device that is extremely quick and efficient. The probe tip has the shape of an otoscope, the instrument used to inspect the ear.
How should you report temperature?
- Report in degrees Celsius unless your agency uses the Fahrenheit scale. convenient equivalents:
- 104.0 ° F = 40.0 ° C; 98 .6 ° F = 37 .0 ° C; 95 .0 ° F = 35 .0 ° C
Vital sign: pulse
- Palpating the peripheral pulse gives the rate and rhythm of the heartbeat, as well as local data on the condition of the artery
- if regular, count the number of beats in 30 seconds and multiply by 2. The 30-second interval is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. However, if the rhythm is irregular, count for a full minute.
rate of the pulse
In the adult at physical and mental rest, clinical evidence shows the normal heart range at 50 to 90 beats per minute (bpm).34 This differs from the conventional rate limits—60 to 100 bpm—that were established by consensus in the 1950s and never formally examined
What is bradycardia?
an adult with a heart rate less than 50 bpm
What is tachycardia?
a more rapid heart rate, over 90 bpm
Force of a pulse
shows the strength of the heart's stroke volume. A “weak, thready” pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock). A “full, bounding” pulse denotes an increased stroke volume (e.g., as with anxiety, exercise, and some abnormal conditions).
How is the pulse force recorded?
- recorded using a three-point scale:
- 3+—Full, bounding
- 1+—Weak, thready
Vital sign: respirations
- it is normally relaxed, regular, automatic, and silent
- it is more rapid in infants and children
Vital sign: BP
Blood pressure is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle.
What is systolic pressure?
The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole.
What is diastolic pressure?
The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction.
What is the pulse pressure?
The pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume
What elevates BP?
- Emotions. The BP momentarily rises with fear, anger, and pain as a result of stimulation of the sympathetic nervous system.
- Stress. The BP is elevated in persons feeling continual tension because of lifestyle, occupational stress, or life problems.
What are some common errors in BP measurement?
- Falsely High
- if person just was active or is anxious, below level of heart, looking up at meniscus, cuff too narrow for extremity, cuff wrap too loose
- Falsely High diastolic
- person supports arm, faulty leg position, too slowly, too quickly, failure to wait 1-2 min before repeating entire reading
- Falsely Low
- above level of heart, looking down on meniscus
- Falsely Low diastolic
- too quickly, pushing stethoscope too hard on artery, inflating not high enough
What is orthostatic hypotension?
a drop in systolic pressure of more than 20 mm Hg or orthostatic pulse increases of 20 bpm or more occurs with a quick change to a standing position. These changes are due to abrupt peripheral vasodilation without a compensatory increase in cardiac output. Orthostatic changes also occur with prolonged bedrest, older age, hypovolemia, and some drugs.
- measure it in infants at each well-child visit up to age 2 then yearly up to age 6
- use plastic measuring tape
- head measures about 32 to 38 cm
axillary route with children
The axillary route is safer and more accessible than the rectal route; however, its accuracy and reliability have been questioned
Oral route for temperature in children
Use the oral route when the child is old enough to keep his or her mouth closed. This is usually at age 5 or 6 years, although some 4-year-old children can cooperate. When available, use an electronic thermometer because it is unbreakable and it registers quickly.
Rectal route for temperature in children
Use this route with infants or with other age-groups when other routes are not feasible, such as with the child who is unable to cooperate, agitated, unconscious, critically ill, or prone to seizure.
Pulse in children
Palpate or auscultate an apical rate with infants and toddlers. In children older than 2 years, use the radial site. Count the pulse for a full minute to take into account normal irregularities,
What is the pulse oximeter?
a noninvasive method to assess arterial oxygen saturation. A sensor attached to the person's finger or earlobe has a diode that emits light and a detector that measures the relative amount of light absorbed by oxyhemoglobin (Hbo2) and unoxygenated (reduced) hemoglobin (Hb). The pulse oximeter compares the ratio of light emitted with light absorbed and converts this ratio into the percentage of oxygen saturation.
What is hypotension?
In normotensive adults: <95/60 mm Hg
What are the 2 main processes of pain?
nociceptive and or neuropathic
What is neuroanatomic pathway
Specialized nerve endings called nociceptors are designed to detect painful sensations from the periphery and transmit them to the CNS
What is the anterolateral spinothalamic tract?
makes the pain signals cross over to the other side of the spine and ascend to the brain
What is nociceptive pain?
Nociceptive pain develops when nerve fibers in the periphery and in the central nervous system are functioning and intact.
What is neuropathic pain?
pain that does not adhere to the typical and rather predictable phases in nociceptive pain. Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. It is this type of pain that is most difficult to assess and treat. Pain is often perceived long after the site of injury heals
What is breakthrough pain?
pain that starts again or escalates before the next scheduled analgesic dose. Pain breaks through when it is expected to be controlled by pain medications.
Do infants have the same capacity for pain as adults?
What is a numeric rating scale?
Numeric rating scales ask the patient to choose a number that rates the level of pain for each painful site, with 0 being no pain and the highest anchor 10 indicating the worst pain ever
What is nutritional status?
refers to the degree of balance between nutrient intake and nutrient requirements. This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic
What is optimal nutrition status?
is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands due to growth, pregnancy, or illness.
What type of person has optimal nutritionalstatus?
are more active, have fewer physical illnesses, and live longer than persons who are malnourished.
What is undernutrition?
occurs when nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands.
Who is vulnerable to have undernutrition?
infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults—are at risk for impaired growth and development, lowered resistance to infection and disease, delayed wound healing, longer hospital stays, and higher health care costs.
What is over-nutrition?
caused by the consumption of nutrients especially calories, sodium, and fat—in excess of body needs. A major nutritional problem today, overnutrition can lead to obesity and is a risk factor for heart disease, type 2 diabetes, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers, and osteoarthritis