NURS 261: EXAM 1
63 Cards in this Set
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What are the three levels of health promotion?
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Primary - focusing to preventing disease occurrence, Secondary - early identification of disease before it becomes symptomatic, Tertiary - Minimize severity and disability
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What are the different types of health assessments, and when would each be performed?
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Comprehensive - performed at onset of care in PCS or on admission to a hospital, or LTC facility; Problem-based/ focused assessment - walk-in clinic or emergency; Episodic/ follow-up: follow up appointment; Shift - for hospitalized patients for each shift; Screening: focus on disease dete…
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What are the purposes of a nursing health assessment?
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detecting changes in patient's condition, ongoing process for evaluating effectiveness of care plan, developing a therapeutic relationship, understanding patient's experience of illness, basis for planning nursing care, maintaining a safe patient care situation
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What are the steps in clinical decision making?
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Problem formation, data input, data interpretation also known as noticing, interpreting, responding, reflect
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What are the different stages of health literacy and how can you assess the patient's health literacy?
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Below basic, basic, intermediate, proficient; asking questions
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What techniques enhance data collection?
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Active listening, facilitation, clarification, restatement, reflection, confrontation, interpretation, and summary
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What are the different types of health history, and when is each used?
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Comprehensive - hospital admission; Focused - specific problem; Episodic - follow up or issue that are currently being treated
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What are the components of a health history?
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Biographic data, reason for seeking care, history of present illness, present health status, past health history, family history, personal and psychosocial history, and review of systems
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What are the factors in symptom analysis?
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Onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, treatment, and severity
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How does the nurse assess pain?
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OLDCARTS
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What are the components of mental status, and how are they assessed?
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Orientation, memory, calculation, communication, judgement and reasoning, abstract reasoning; mini-cog (mental status, dementia if score below 2)
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What are the differences between subjective and objective data?
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S: client's perspective, health history, symptoms, and pain; O: Provider's perspective, physical exam, signs, and mental status
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What assessment techniques are used to evaluate vital signs, and what are the common errors in vital sign measurement?
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Inspection, palpation, percussion, and auscultation; incorrect technique that results in incorrect data
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How is a genogram used for assessing risks, and planning health promotion and health protection?
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it is useful in tracing diseases with genetic links
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What is a 10 minute assessment, and how does it address the differences between health assessment in an outpatient setting, versus a hospital setting?
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A physical assessment that incorporates all the body systems. Focused in the hospital as opposed to detailed in outpatient
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Give an example of how each physical assessment technique is used: inspection, palpation, percussion, and auscultation.
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Inspection: visual exam of body including movement and posture; Palpation: feel texture, consistency of skin; percussion: evaluating borders of internal organs; Auscultation: listening for lung sounds
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What is the usual order of physical assessment techniques?
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Inspection, palpation, percussion, and auscultation
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Give an example of each component of a SOAP note: subjective, objective, assessment, and plan.
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S: patient reports pain of 5 on right inner forearm; O: BP is 120/80; red raised rash noted; A: given cream to reduce rash symptoms; P: return in 7 days to monitor
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Describe normal findings for an assessment of the integumentary system.
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uniform and consistent, dry, warm, even, and intact, elastic, scalp is smooth, hair is shiny and soft, no isolated hair loss; nails are smooth and rounded
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Identify common symptoms of the integumentary system.
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itchiness, rash, pain or discomfort, lesions, changes in skin color, thinning hair, dry skin, lesions
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List at least four differences in the integument that occur as part of normal aging.
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inelasticity, excessive dryness, changes in hair texture or distribution, and changes in nail thickness
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Discuss how skin color may affect assessment and potential for injury.
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certain variations in skin color can be a sign for an underlying problem
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Describe at least one health promotion topic for the integumentary system.
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Skin cancer prevention: sunscreen should be worn at all times when outdoors
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What are the health history questions related to the integumentary system?
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history of skin cancer, presence of chronic illnesses
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What are the eight characteristics used in describing a lesion?
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location, distribution, color, pattern, border, elevation, size, characteristics
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What are the early signs of melanoma, also known as the signs of a worrisome lesions?
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Asymmetry, irregular Border, uneven or multiColor, Diameter greater than 0.6 cm, Evolving or changing appearance, altered sensation, Feeling in lesion ABCDEF
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What is the Braden Scale, and how is it used? What are the six factors that make up the scale?
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used for predicting pressure sore risks for people in the hospital; sensory perception, moisture, activity, mobility, nutrition, and friction and shear
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Describe how to evaluate a patient's hearing and vision.
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Vision - PEERL and eye chart; Hearing - Rinne and Whisper test
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What are the health history questions that are related to the HEENT?
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chronic illnesses, take any medications, any head injuries, last routine exam, what are daily practices
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Identify the commonly reported problems of the head, eyes, ears, nose, and throat.
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headaches, ringing or ache in ears, tender sinuses, itchy or watery eyes
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Describe how to assess the sclera, cornea, and conjunctiva, and normal findings
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inspect them; sclera should be white and clear, cornea should have a symmetrical light reflection, and conjunctiva should be a light pink
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Document expected findings for the nose and mouth
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symmetric nostrils, no discharge, no pain, can differentiate between smells; teeth are intact, tongue is smooth and midline, patient can swallow
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What is an evidence-based health promotion topic for the HEENT system?
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increase hearing screenings
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Describe age-related changes in the head, eyes, ears, nose and throat for children, and older adults
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cataracts, loss of smell, hearing loss, glaucoma
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What does SBAR stand for?
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Situation, Background, Assessment, Recommendation
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Identify the anatomical landmarks for auscultating the anterior and posterior chest.
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left apex, right middle anterior thorax, left lower anterior thorax
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Identify the anatomical landmarks of the thorax
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above the clavicles, at the 11th rib, c7 t12
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Discuss the health history questions specific to the lungs and respiratory system
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family history of lung disease, environmental or lifestyle conditions and practices, use of oxygen or inhaler
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List the commonly reported problems of the lungs and respiratory system
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cough, shortness of breath, chest pain with breathing
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Describe at least one health promotion topic for the lungs and respiratory system
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tobacco use, environment, exercise
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Document the expected findings of the assessment of the lungs and respiratory system
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12 to 20 breaths per minute, smooth pattern with even respiratory depth
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Describe the physical assessment of the lungs, including inspection, palpation, and auscultation
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general appearance and posture should be relaxed but upright; breathing should be quiet and effortless; during auscultation, lung sounds should be clear
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Describe the events of the cardiac cycle
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P - atrial depolarization; QRS - Ventricular depolarization and atrial re-polarization; T - Ventricular repolarization
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Identify the health history questions related to the heart and peripheral vascular system
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history of diabetes, consume any alcoholic beverages, genetic heart defects, do you exercise
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What are the commonly reported problems of the cardiac and peripheral vascular system
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chest pain, shortness of breath, cough, urinating during the night, fatigue, fainting, and swelling of the extremities
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What are the associated manifestations of chest pain that may help explain the cause of chest pain?
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shortness of breath, nausea, weakness, dizziness, fever, palpitations, high heart rate
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Describe evidence-based health promotion topics for the cardiovascular system
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Cardiovascular disease, low salt and fat diet, cardio exercise
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Describe the routine exam of the peripheral vascular system, including pulses that should be palpated
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temporal and carotid pulses for amplitude, inspecting jugular vein for pulsations, brachial and radial pulses for rate, rhythm, amplitude, and contour; can palpate ulnar if needed; palpate femoral, popliteal, posterior tibial, and dorsalis pedis for amplitude; inspect all surfaces for sk…
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Identify the anatomical landmarks used in assessment of the heart and peripheral vascular system
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Apical pulse at LMCL 5ICS
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Describe the five areas for auscultating the heart, including their associated anatomical landmarks, and which normal sounds are dominant at each
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Aortic valve - 2nd ICS, RSB; pulmonic valve - 2nd ICS, LSB; Erb's point - 3rd ICS, LSB; Tricuspid valve - 4th ICS, LSB; Mitral valve - 5th ICS, LMCL
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Define "splitting of the heart sounds, and identify the causes of a split S1 and split S2
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Occurs when the mitral and tricuspid valves do not close at the same time creating two different sounds (it's a murmur)
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Define the scale used to describe amplitude of peripheral pulses
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Pulses should be easily palpable, smooth upstroke; 0 is absent, 1+ if diminished, barely palpable, 2+ if normal, 3+ full volume, and 4+ if full volume, bounding hyperkinetic
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Define the scale used to describe the level of pitting edema
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1+ if the pit is barely palpable - about 2mm; 2+ if pit rebounds in a few seconds - about 4mm; 3+ if pit rebounds in 10-20 seconds - about 6mm; 4+ if pit rebounds in more than 30 seconds; about 8mm
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Define sensitivity and specificity of tests and/or assessment techniques in terms of true positives and true negatives
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Sensitivity measures the proportion of true positives that are correctly identified as such; specificity measures the proportion of true negatives that are correctly identified as such; true positives are associated with sensitivity while true negatives are associated with specificity
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How do you select effective assessment techniques using a table of likelihood ratios?
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Calculate the odds of the test will identify an existing or an non-existing disease or condition; if greater than one, the test result is associated with the disease
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What are the major organs contained in the abdominal cavity?
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stomach, liver, gallbladder, spleen, pancreas, small intestine, kidneys, large intestine, and adrenal glands
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What are some examples of health history questions related to the abdomen and GI system?
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any chronic diseases or current medications, frequency of bowel movements
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What is the order for assessment techniques of the abdomen, including the rationale for the order
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Inspect, Auscultate, palpate
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What are the commonly reported problems of the abdomen and GI system
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abdominal pain, nausea and vomiting, indigestion, abdominal distention, changes in bowel habits, jaundice
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Describe one evidence based health promotion topic related to the abdomen and GI system
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Colorectal Cancer, diet, exercise
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Describe the anatomical landmarks used in the assessment of the abdomen
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xiphoid process, costal margin, midline, umbilicus, McBurney's point, Poupart's ligament, ASIS, Superior margin of pubis
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Identify at least two uses of auscultation in the abdominal exam
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arterial and venous vascular sounds (bruit) and bowel sounds
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Identify structures that may be palpated during assessment of the abdomen, and where each may be found
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RUQ - liver and gallbladder; LUQ - left lobe of liver, stomach; RLQ - bladder if distended; LLQ - bladder if distended, sigmoid colon
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NURS 261: EXAM 1