NUR 216 - EXAM 1 (Modules 1-3)

Pain in the objective perspective.

"Her grimacing expression may indicate she is in pain."

Pain in the subjective perspective.

"The pain in my back is an 8/10."

What is an assessment?

-A data collection process -A continuous process -A method to establish a baseline

What 6 characteristics do you assess when looking at a patients 'Physical Appearance'?

-Age -Sex -Level of Consciousness (x1, x2, x3, x4) -Skin Color -Facial Features -Overall any signs of distress?

List 3 factors that can decrease your oxygen saturation.

-Asthma -COPD -Emphysema

List 3 factors that can decrease your heart rate.

-Being a runner -Beta Blockers -Sedating Medications

List 6 components of the Health History.

-Biographical Data -Current Health Status -Past Health History -Family History -Review of Systems -Psychosocial History

List 3 factors that can decrease your temperature.

-Burn Victims -Hypothyroidism -Alcohol/Drug Use

List 4 'Cognitive' skills you must implement in the assessment process.

-Critical Thinking Skills -Inductive & Deductive Reasoning Skills -Clinical Decision Making Skills -Problem Solving Skills

What is the 'Working Phase' of the interview process?

-Data collection, structured -Longest phase

What 2 locations can you obtain a blood pressure?

-Either arm -Either thigh

What is the 'Termination Phase' of the interview process?

-End of interview -Summarize and restate findings

List 5 'Communication' skills nurses must implement at all times.

-Eye Contact -Eye Level -Personal Space -Active Listening -LISTEN to them!!!

What 5 characteristics do you assess when looking at a patients 'Behavior'?

-Facial Expressions -Mood & Affect -Speech -Dress -Personal Hygiene

What different locations can you obtain an oxygen saturation?

-Forehead -Ear -Finger -Toe

What 4 characteristics do you assess when looking at a patients 'Mobility'?

-Gait -Foot placement -Range of Motion -Base

List 3 factors that can increase your temperature.

-Infection -Hormones -Exercise

What are the steps to a 'Physical Assessment' in order of performance?

-Inspection -Palpation -Percussion -Auscultation

What are the steps to a 'Physical Assessment' in order of performance for the abdomen?

-Inspection -Auscultation -Percussion -Palpation

What is the 'Introductory Phase' of the interview process?

-Introduce self -Put patient at ease -Explain purpose of interview -Explain time frame

List 3 factors that can decrease your Blood Pressure.

-Loss of Fluid -Anemia -Hemorrhage

List 3 factors that would cause you to NOT be able to do an arm blood pressure.

-Mastectomy -Amputation -Ports (PICC, Fistula, etc)

List 2 factors that can decrease your respiration rate.

-Opioids -Anesthesia

List 3 factors that can increase your respiration rate.

-Pain -Asthma -COPD

List 3 factors that can increase your Blood Pressure.

-Preeclampsia -Obesity -Increased Salt

What is measured when obtaining respirations?

-Rate -Depth -Rhythm

What is measured when obtaining a heart rate?

-Rate -Rhythm -Quality -Strength

List 4 'Ethical' skills.

-Responsible & accountable for practice -Patient advocate -Respect patients' rights -Assure confidentiality

What tools do you need to measure a blood pressure?

-Sphygmomanometer -Stethoscope

What 5 characteristics do you assess when looking at a patients 'Body Structure'?

-Stature -Symmetry -Posture -Position -Body Build, Contour

List 3 factors that can increase your heart rate.

-Stress -Pain -Exercise

List the different pulse sites.

-Temporal -Carotid -Brachial -Radial -Femoral -Popliteal -Posterior Tibial -Dorsalis Pedis

What different locations can you obtain a temperature on a patient?

-Temporal -Tympanic -Oral -Axillary -Rectal

Observation

-Use your senses -Look at patient and environment

What is considered a treatable fever?

102.2 (F) 39 (C)

What is the normal respiration range?

12-20 breaths per minute

Prehypertension Range

120-129/<80

What is a normal blood pressure?

120/80 mmHg

Stage 1 Hypertension Range

130-139/80-89

What is the normal heart rate range?

60-100 beats per minute

What is the normal oxygen range?

95-100 %

What is the normal temperature range?

96.8-100.4 (F) 36-38 (C)

Stage 2 Hypertension Range

>140/>90

Hypertension Crisis Range

>180/>100

What is a close ended question? Give an example.

A question that requires a "yes" or "no" answer. Ex. "Do you have a headache?"

What is an open ended question? Give an example.

A question that requires more than a "yes" or "no" answer. Ex. "What does the pain in your foot feel like?"

What are 'Interpersonal/Affective' skills?

Affective skills needed to develop caring, therapeutic nurse-patient relationships.

What is secondary subjective data? Give an example.

Anyone, other than the client, reports feelings/thoughts. Ex. Spouse states, "She complained of pain in her abdomen this morning."

What is secondary objective data? Give an example.

Anyone, other than the nurse, reports seeing, feeling, smelling, or hearing. (DO NOT taste). Ex. AP states, "Her urine smells odorous."

What is the nursing process?

Assessment Diagnosis Planning Implementation Evaluation (ADPIE)

What is the "A" in the nursing process?

Assessment - gather information and review the patients history

What is a focused assessment?

Based around the patients immediate problems.

What is a 'General Survey'?

Begins the moment you first encounter a patient. Includes Physical Appearance, Behavior, Body Structure, and Mobility.

What side of the stethoscope would you use if you wanted to hear low pitched sounds?

Bell

What are your fingertips used to palpate?

Best for fine sensations

What is the dorsal aspect of your hand used to palpate?

Best for temperature

What is the ulnar surface of your hand used to palpate?

Best for vibrations

What is BMI?

Body Mass Index; indicator of obesity or malnutrition.

What is primary subjective data? Give an example.

Client reports feelings/thoughts Ex. "I have a headache"

What is a comprehensive assessment?

Consists of a complete nursing history and physical examination.

What is the "D" in the nursing process?

Diagnose - identify problem list

What side of the stethoscope would you use if you wanted to hear high pitched sounds?

Diaphragm

What are the 2 types of interviews?

Directive or Non-directive

What is the "E" in the nursing process?

Evaluate - were desired outcomes and goals achieved?

What is the "I" in the nursing process?

Implementation - perform nursing actions

What is 'Tertiary' Priority data?

Important, but do not require immediate attention.

What tools do you need to measure a pulse?

Index & Middle Fingers

How do you obtain a proper height?

Instruct the patient remove their shoes and to stand straight, with their feet shoulder width apart.

How do you obtain a proper weight?

Instruct the patient to remove any heavy clothing and to record their weight at the same time and on the same scale device everyday.

What is 'Primary' or 'Top' Priority data?

Life-threatening problems

What is Auscultation?

Listening through a stethoscope to hear heart sounds, lung sounds, bowel sounds, and vascular sounds.

What is primary objective data? Give an example.

Nurse reports seeing, feeling, smelling, or hearing. (DO NOT taste). Ex. "I can see redness and swelling of her right lower extremity."

What is the "P" in the nursing process?

Plan - develop SMART goals, desired outcomes, and action plans

What tools do you need to measure oxygen saturation's?

Pulse Oximeter

What is 'Secondary' Priority data?

Require prompt attention to prevent further progression or deterioration.

What is Inspection?

Sight/Smell; observe symmetry, abnormalities, distress, unusual odors, direct vs. indirect

What are 'Psychomotor' skills?

Skills needed to perform the 4 techniques of physical assessment.

What is Percussion?

Tapping the person's skin with short, sharp strokes to assess density, size/shape, tenderness, & deep reflexes of underlying structures; Direct (immediate), indirect (mediate), fist/blunt.

What tools do you need to measure a temperature?

Thermometer

What is Palpation?

Touch; texture, temperature, swelling, pain presence, organ location, etc. Can be light (less than 1/2 inch), deep (greater than 1/2 inch), or ballottement (used to assess partially free-floating objects).

BMI Table

Underweight <18.5 Normal Weight 18.5-24.9 Overweight 25-29.9 Obese >30

What is the BMI formula?

Weight(lbs)/Height(in)^2x703

When does the order to a 'Physical Assessment' change?

When assessing the abdomen.