ha exam 1

describe each step of the nursing process

● Assessment ○ collecting data ○ using evidence-based techniques ○ documenting ● Diagnosis ○ compare clinical finding with normal and abnormal variation and developmental events ○ interpret data ○ validate ○ document ● Outcome Identification ○ identifying the expected outcome and individualizing it with the client ● Planning ○ establishing priorities ○ set timeline for outcomes ○ interventions ○ integrate care plan ● Implementation ○ implementing in a safe and timely manner ○ evidence based interventions ○ collaborating with colleagues ○ health teaching and promotion ● evaluation ○ progress toward the outcomes ○ ongoing assessment to revise diagnosis ○ outcomes ○ plan

list the steps of the nursing process

● Assessment ● Diagnosis ● Outcome Identification ● Planning ● Implementation ● Evaluation

Define nutritional status.

● Balance between nutrient intake and nutrient requirements. ● Optimal nutritional status ○ sufficient intake of nutrients to support body needs and any increased metabolic states based on life circumstances. ● Undernutrition ○ nutritional reserves are depleted and/or nutrient intake is insufficient to meet added metabolic demands. ● Overnutrition ○ consumption of nutrients in excess of body needs.

Compare and contrast healthy and unhealthy findings of bones, joints and muscles.

● Bones ○ Healthy ■ Hard ■ Rigid ■ Very dense ○ Unhealthy ■ Pain ■ Deformity ■ Trauma ● Joints ○ Healthy ■ Permits mobility ○ Unhealthy ■ Pain ■ Stiffness ■ Swelling ■ Heat ■ Tenderness ■ Limitation of movement ● Muscles ○ Healthy ■ Account for 40-50% of body weight ■ Voluntary movement ○ Unhealthy ■ Pain (cramps) ■ Weakness

Outline the nurse's role in reporting abuse and neglect.

● Child ○ name of child ○ name of parent ○ alleged abuser ○ if the child is in a life threatening situation ○ how the abuse/neglect became known ○ if you witnessed the abuse ○ other witnesses and contact info ○ your name and contact info ● Elder ○ name of elder ○ alleged abuser ○ if the elderly person is in a life-threatening situation ○ how the abuse/neglect became known ○ if you witnessed the abuse ○ other witnesses and contact info ○ your name and contact info

Outline ways to screen for child and elder abuse and neglect.

● Child ○ could the child have suffered the injury that is being reported based on his/her development level? ○ is the child crawling, pulling to stand, or walking? ○ what other developmental issues are being faced at home? (ex- tantrums, potty training) ○ IF CHILD IS VERBAL ■ a history should be obtained away from the caregivers through open ended questions or spontaneous statements ■ keeping questions short and using age-appropriate language and familiar words can help enrich the history taking ○ has the child had any previous hospitalizations or injuries ○ does the child suffer from any chronic medical conditions? ○ does the child take any medication that may cause bruising ○ does the child have a history of regular visits to the hospital? ○ was there a delay in seeking care for anything other than a minor injury? ○ is there a history of substance abuse in the family ○ are there any financial or social stressors in the home? ○ what are the typical methods of discipline used in the home? ● Elder ○ has anyone ever touched you inappropriately without your consent? ○ has anyone ever made you do things you didn't want to do? ○ has anyone taken things that were yours without first asking? ○ has anyone ever physically hurt you? ○ has anyone ever scolded or threatened you? ○ have you ever signed any documents you did not understand? ○ are you afraid of anybody at your home or who enters your home? ○ are you alone a lot? ○ has anyone ever failed to help you take care of yourself when you needed help?

List the 4 common types of databases and assessments encountered in clinical practice.

● Complete (total Health) ● Focused or problem- centered ● Follow-up ● Emergency ● databases consists of: ○ subjective data ○ objective data ○ patient records ○ lab/other diagnostic test results

Describe the cognitive processes used by nurses to arrive at clinical judgments.

● Critical thinking is the process of purposeful thinking. ● Alfaro-LeFevres's skills identify: ○ assumptions ○ develop ○ organize ○ comprehend ○ validation ○ differentiate from normal and abnormal ○ inferences and valid conclusions ○ cluster related cues ○ relevant from irrelevant ○ patterns and missing data ○ promote health ○ patient centered outcome ○ specific interventions ○ evaluate correct thinking ○ comprehensive care plan and need medications ○ diagnose actual and potential health problems and strengths ○ set priorities. ● diagnostic reasoning in clinical judgement ○ analyze data and draw conclusions ○ attend to cues ○ develop diagnostic hypothesis ○ gather relevant info ○ evaluate each hypothesis with new data ● clinical reasoning models ○ diagnostic reasoning ○ nursing process ○ critical thinking

Explain how to assess for homicide risk.

● Danger Assessment Sheet ○ 1. Has the physical violence increased in severity or frequency over the past year? ○ 2. Does he own a gun? ○ 3. Have you left him after living together during the past year? ■ 3a. (If have never lived with him, check here___) ○ 4. Is he unemployed? ○ 5. Has he ever used a weapon against you or threatened you with a lethal weapon? (If yes, was the weapon a gun?) ○ 6. Does he threaten to kill you? ○ 7. Has he avoided being arrested for domestic violence? ○ 8. Do you have a child that is not his? ○ 9. Has he ever forced you to have sex when you did not wish to do so? ○ 10. Does he ever try to choke you? ○ 11. Does he use illegal drugs? By drugs, I mean "uppers" or amphetamines, "meth", speed, angel dust, cocaine, "crack", street drugs or mixtures. ○ 12. Is he an alcoholic or problem drinker? ○ 13. Does he control most or all of your daily activities? For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? (If he tries, but you do not let him, check here) ○ 14. Is he violently and constantly jealous of you? (For instance, does he say "If I can't have you, no one can.") ○ 15. Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him) ○ 16. Has he ever threatened or tried to commit suicide? ○ 17. Does he threaten to harm your children? ○ 18. Do you believe he is capable of killing you? ○ 19. Does he follow or spy on you, leave threatening notes or messages, destroy your property, or call you when you don't want him to? ○ 20. Have you ever threatened or tried to commit suicide?

Define mental status.

● Emotional (feeling) & cognitive (knowing function) ○ Any stressful or traumatic life event can tip the balance resulting in dysfunction.

Describe widespread color changes including pallor, erythema, cyanosis & jaundice.

● Erythema: excess blood flow ○ In light skin: increased redness ○ In dark skin: deepening of coloration ● Cyanosis: ○ In light skin: dusky blue color: nail beds, lips, face ○ In dark skin: Dark, but dull; lifeless skin, bluish color appears if severe, check conjunctivae, oral mucosa and nail beds ● Jaundice: ○ In light skin: yellow sclerae, hard palate mucous membranes in the skin ○ In dark skin: check sclera near the limbus (where corean & scera meet), best seen at the junction of hard & soft palates and in the palms

Describe external variable that influence skin color.

● False pallor ○ Fear or anger ○ Cold temperatures or mist tents ○ Cigarette smoking ○ Prolonged elevation ○ Immobilization ○ Pressure ● False erythema (redness) ○ Embarrassment ○ Hot temperatures ○ Dependent positions ○ Vigorous exercise or work

Explain the structure and function of the musculoskeletal system.

● Functions ○ To stand erect ○ biped ○ motion ○ protect vital organs ○ blood production ○ mineral storage ● structure ○ skeleton ■ 206 bones, hard, dense, rigid, bone ■ active organ and non static ■ bones are connected together by joints ○ Joints ■ functional unit ■ permits mobility ■ non-synovial joints ■ synovial joints ■ ligaments and tendons ■ bursa ● enclosed sac ● located in areas of potential friction ● separate ● lubricate and cushion ■ synovial fluid, cartilage ○ Muscles ■ account for 40-50% of body's weight ■ voluntary movement ■ fasciculi: muscle fiber bundles ○ spine ■ 33 stacked bones: 7 cervical, 12 thoracic, 5 lumbar, 3-4 coccygeal vertebrae ■ S curve with cervical and lumbar spine concave (anterior) ■ thoracic and sacrococcygeal convex (posterior)

Outline how to measure height, weight and waist circumference

● Height ○ use a wall mounted device or measuring pole. align extended headpiece with top of head. the pt should be shoeless, standing straight with gentle traction under the jaw and looking ahead. ● weight ○ use standardized balance or electronic standing scale. instruct patient to remove shoes and heavy outer clothing before standing on scale. when sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time. Record in kg and in pounds ● waist circumference ○ excess abdominal fat is an important independent risk factor for disease, over and under that of BMI. with person standing, locate the hip bone and the top of its right iliac crest. place measuring tape around waist, parallel to the floor, at level of iliac crest. tape should be snug but not pinch in the skin.

Outline developmental considerations when performing assessment techniques.

● Infant ○ establishing trust ○ parent always present ○ flat on padded table, or in parents lap ○ perform least distressing things first ○ timing 1-2 hours after feeding ● Toddler ○ position infant sitting in parent lap ○ symbols ○ praise toddler ● Preschool child ○ verbal communication ○ talk and explain to child in steps ● School age child ○ small talk ○ demonstrate ○ head to toes ● Adolescent ○ communicate with some care without treating them like a child ● Adult ○ use physical touch, do not mistake diminished vision or hearing as confusion

outline the phases of a client interview

● Introduce the Interview ● building rapport ● The working phase ● Closing ● clients best interest comes first ● use different techniques to gather different data ● use language client understands ● 3 major phases ○ intro ○ working ○ closing

Outline key subjective data to collect regarding the musculoskeletal system for health assessment.

● Joints ○ any problems with your joints ○ which joints and one or both sides ○ what does pain feel like: ■ aching ■ stiff ■ sharp or dull ■ shooting ○ when did the pain start ○ what time of day does pain occur ○ how long does it last and how often ○ is pain aggravated by: ■ movement ■ rest ■ position or weather ○ is pain relieved by: ■ rest ■ meds ■ application of heat or ice ○ any stiffness ○ swelling ○ heat ○ redness ○ any limitations ○ which activities gives you problems ● Muscles ○ any problems with muscles, such as pain or cramping ○ which muscles ○ in calf muscles is the pain with walking or does it go away with rest ○ are your muscle aches associated with fever, chills, flu, any weakness ○ where is the weakness ○ how long have you noticed weakness ○ do muscles look smaller in those areas ● Bones ○ any bone pain ○ is the pain affected by movement ○ any deformity ○ any accidents/trauma ○ when did it occur ○ any back pain ○ in which part of back ○ is pain felt anywhere else like shooting down leg ○ any numbness or tingling, limping ● Function assessment (ADL) ○ bathing ○ toileting ○ dressing ○ grooming ○ eating ○ mobility ○ communicating ● self care behavior ○ tell me about your exercise program, any pain during it? ○ have you had any recent weight gain ○ describe daily diet ○ are you taking any meds for musculoskeletal symptoms ○ if they have chronic illness ask how illness has affected interaction with family, friends, and the way they view themselves

Identify skin changes associated with the aging process.

● Parchment skin: ○ Loss of collagen ○ Danger of Skin Injury ● Reduced response to environmental changes ● Reduced vascularity with increased capillary fragility may result in senile purpura ● Increased specking and uneven coloring ● Reduced subcutaneous fat & muscles ● Wrinkles: Thinning skin

Define intimate partner violence, child abuse and neglect, and elder abuse and neglect (physical and financial).

● Partner Violence ○ physical and/ or sexual violence, or threat of such violence ○ psychological/ emotional abuse and/or coercive tactics when there has been prior physical and/ or sexual violence between persons who are spouses or nonmarital partners (dating, boyfriend/ girlfriend), or former spouses or non marital partners ● Child ○ Neglect- failure to provide for a child's basic needs (physical, educational, medical, and emotional). ○ Abuse (physical)- physical injury due to punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. even if the parent or caregiver did not intend to harm the child, such acts are considered abuse when done purposefully. ○ Abuse (sexual)- fondling a child's genitals, incest, penetration, rape, sodomy, indecent exposure, and commercial exploitation through prostitution or the production of pornographic materials. ○ Abuse (emotional)- any pattern of behavior that harms a child's emotional development or sense of self-worth. it includes frequent belittling, rejection, threats, and withholding of love and support. ● Elder ○ Abuse (physical)- violent acts that result or could result in injury, pain, impairment, and/or disease ○ Abuse (psychological)- behaviors that result in mental anguish ○ Abuse (financial)- intentional misuse of the elderly person's financial/ material resources without the informed consent of the person. ○ Neglect (physical)- failure of the family member and/or caregiver to provide basic goods and/or services such as food, shelter, healthcare, and medications ○ Neglect (psychological)- failing to provide basic social stimulation ○ Neglect (financial)- failure to use the assets of the elderly person to provide services needed by the elderly person

Outline key subjective data to collect for skin, hair and nail assessment.

● Past history of skin disease (allergies, hives, psoriasis, eczema) ○ Any past skin disease or problem? ○ How was it treated? ○ Any family history of allergies or allergic skin problems? ○ Any birthmarks, tattoos? ● Change in pigmentation ○ Any change in skin color or pigmentation? ■ A generalized color change (all over), or localized? ● Change in mole (size or color) ○ Any change in a mole: color, size, shape, sudden appearance of tenderness, bleeding, itching? ■ Any "sores" that do not heal? ● Excessive dryness or moisture ○ Any change in the feel of your skin: temperature, moisture, texture? ■ Any excess dryness? Is this seasonal or constant? ● Pruritus ○ Any skin itching? Is this mild (prickling, tingling) or intense (intolerable)? ■ Does it awaken you from sleep? ● Excessive bruising ○ Any excess bruising? Where, how and how long? ● Rash or lesion ○ Onset. When did you first notice it? ○ Location ● Medications ● Hair loss ● Change in nails ● Environmental or occupational hazards ● Self-care behavior

Specify strategies to collect information about specific dietary needs or restrictions

● Perform a Mini Nutritional Assessment.

Explain how to perform Phalen's test and Tinel's sign and the clinical significance of positive finding.

● Phalen's Test ○ ask person to hold both hands back to back while flexing the wrists 90 degrees ○ Acute flexion of the wrist 60 degrees produces no symptoms in the normal hand ○ produces numbness and burning in person with carpal tunnel ● Tinel's sign ○ direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand ○ burning and tingling along distribution of median nerve is positive tinel sign for carpal tunnel syndrome

Outline components of a general survey

● Physical appearance ○ age ○ sex ○ LOC ○ Skin color ○ facial features ● Body structure ○ stature ○ nutrition ○ symmetry ○ posture ○ position ○ body build ○ contour ● Mobility ○ gait ○ range of motion ● Behavior ○ facial expression ○ mood and affect ○ speech ○ dress ○ personal hygiene

Using the acronym RESPECT, specify how to provide culturally appropriate health care

● Realize that you must understand your own heritage and that of your clients ● Examine the client within the context of their cultural health and illness practice ● Select simple questions and slow down the pace of your questions ● Pace questions throughout the physical exam ● Encourage clients to discuss the meanings of health/illness with you ● Touch the clients within cultural boundaries of their heritage

Outline key observations to make during skin, hair and nail inspection and palpation.

● SKIN ○ Color - General Pigmentation (Observe the skin tone) ■ Freckles (ephelides), moles (nevus) and birth marks ■ Widespread color change- not any color change over the entire body, skin, such as pallor (white), erythema (red), cyanosis (blue), and jaundice (yellow) ○ Temperature ■ Hypothermia ■ Hyperthermia ○ Moisture ■ Diaphoresis ■ Dehydration ○ Texture- normal skin feels smooth and firm, with an even surface ○ Thickness ○ Edema ○ Mobility and Turgor ■ Pinch up a large fold of skin on the anterior chest under the clavicle. Mobility is the skin's ease of rising, and turgor is its ability to return to place promptly when released. This reflects the elasticity of the skin. ○ Vascularity or Bruising ○ Lesions ● HAIR ○ Color, Texture, Distribution and Lesions ● NAILS ○ Shape and Contour ○ Normal: 160 degrees, Curved: 160 degrees or less, Early clubbing: 180 degrees ● Consistency ● The surface is smooth and regular, not brittle or splitting. Nail thickness is uniform. The nail firmly adheres to the nail bed, and the nail base is firm to palpation. Color ● Capillary refill

Describe health interventions for the general population of adults based on age.

● Screening ● Health counseling and education ● Immunizations ● Chemoprophylaxis ● Interventions for high risk populations

Specify strategies for screening for signs of abuse in women over age 14 years.

● Setting ○ frequency of IPV ● Primary care ○ every first visit for a new chief complaint ○ every new patient encounter ○ every new intimate relationship ○ all periodic examinations ● Emergency department and urgent care ○ all women, all visits ● OB/GYN ○ each prenatal and postpartum visit ○ each new intimate relationship ○ all routine gynecologic visits ○ all family planning visits ○ all visits in STI and abortion clinics ● Mental health ○ every initial assessment ○ each new intimate relationship ○ annually if ongoing or periodic treatment ● Inpatient ○ part of all admission and discharge

Develop a health promotion plan for young, middle-aged, and older adults.

● Setting priorities for patient education ● Desired learning outcomes/ objectives ● Determining timing of education ● Selecting instructional materials, including printed materials ● Active participation works best

State examples of culture-bound syndromes

● Shenkui (china)- asian heritages ○ anxiety or panic symptoms, believed to be caused by excessive semen loss. feared because it represents loss of vital essence and believed to be life threatening ● Dhat (india)- asian heritages ○ semen-loss syndrome, characterized by severe anxiety and hypochondria concerns about semen discharge ● African Heritages ○ low blood, high blood, thin blood ● Hysteria (greece)- european heritages ○ bizarre complaints and behavior because the uterus leaves the pelvis for another part of the body ● Involutional paraphrenia (germany) ○ paranoid disorder occurring in midlife ● rodina (russia) ○ malaise, depression ● Ghost (American Indian/alaska) ○ tremor, hallucinations, sense of danger ● HI-Wa itch ○ insomnia, depression, loss of appetite, unwanted separation from a loved one ● Empacho (iberian) ○ food forms into ball and clings to stomach or intestines, causing pain and cramping ● Mal ojo (evil eye) ○ fitful sleeping, crying, diarrhea in children caused by a stranger's attention ● Susto ○ anxiety, trembling, phobia from sudden fright

Develop a health promotion plan for optimal mental health.

● Simultaneous life satisfaction in work, in caring relationships, and within the self.

Describe the structure and function of the skin.

● Skin Functions ○ Protection ■ Skin minimizes injury from physical, chemical, thermal, and light-wave sources ○ Prevents penetration ■ Skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body ○ Perception ■ Skin is vast sensory surface holding the neurosensory end-organs for touch, pain, temperature, and pressure. ○ Temperature regulation ■ Skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation. ○ Identification ■ People identify one another by unique combinations of facial characteristics, hair, skin color, and even fingerprints. ○ Communication ■ Emotions are expressed in the sign language of the face and in the body posture. Vascular mechanisms such as blushing or blanching also signal emotional states ○ Wound repair ■ Skin allows cell replacement of surface wounds ○ Absorption and excretion ■ Skin allows limited excretion of some metabolic wastes, byproducts of cellular decomposition such as minerals, sugar, amino acids, cholesterol, uric acid, and urea ○ Production of vitamin D ■ The skin is the surface on which ultraviolet light converts cholesterol into vitamin D.

Describe strategies that nurses can use to promote client health promotion

● Stretching exercises ● Lifting weights ● Strengthening exercises ● Meticulous attention to body mechanics ● Use lifting devices whenever possible ● Look for environmental hazards to prevent falling

Outline key points to include when teaching clients skin self-examination techniques

● Teach all adults to examine their skin once a month, using the ABCDE rule. ○ Undress completely, check forearms, palms, space between fingers and study the backs. ○ Face mirror; bend arms at elbow; study arms in mirror ○ Face mirror and study entire front of body. Start at face, neck, torso, working down to lower legs. ○ Pivot to the right side facing mirror. Study sides of upper arms; working down to ankles. Repeat with left side. ○ With back to mirror, study buttocks, thighs, lower legs ○ Use the handheld mirror to study upper back. ○ Use the handheld mirror to study scalp, lifting the hair. ○ Sit and study insides of each leg and soles of feet.

Outline components of the Mini Mental State Exam.

● Time Orientation ● Place Orientation ● Registration of 3 words ● Serial 7s calculation (countdown from 100 by 7) ● Recall of 3 words ● Naming of an object ● Repetition: No ifs , ands or buts ● Comprehension ● Reading Instruct to do what they read below: Close your eyes ● Writing a sentence suggest about the weather ● Intersecting polygons drawing

Outline the health effects of violence, neglect and abuse.

● Violence (injury) ○ cutaneous- from blunt, squeezing, or sharp mechanisms ■ BLUNT FORCE INJURY- MOST COMMON FORM OF IPV (struck by a hand, closed fist or slap) ○ laceration- when blunt force injuries cause skin to tear. ○ cut or incision- when a sharp instrument is used to slice through tissue. ○ strangulation- being choked by hands or any cordlike object. ● Health care problems ○ In controlled investigations women have been found to have significantly more chronic health problems, including significantly more neurologic, gastrointestinal, and gynecologic symptoms and chronic pain. ● Neglect ○ dehydration ○ malnutrition ○ unintentional neglect ■ when persons are occupied otherwise and cannot involve themselves with the person affected ○ self neglect ● Abuse ○ maltreatment can affect a child's quality of life and overall health into adulthood. ○ can lead to physical, psychological, emotional, social, and cognitive dysfunction ○ risk factors for maltreatment ■ parents history of domestic abuse ■ young, single, nonbiological parents ■ community violence ■ substance abuse in family ■ lack of family cohesion ■ social isolation of families

Explain how a general survey could direct the professional nurse to plan for and execute a health assessment.

● a general survey studies the whole person, covering the general health state and any obvious physical characteristics

List assessment findings using forensic terminology.

● abrasion ○ a wound caused by rubbing the skin or mucous membrane ● avulsion ○ the tearing away of a structure or part ● bruise ○ superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface, without the skin itself being broke; (AKA-contusion) ● ecchymosis ○ a hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membrane, forming a non elevated rounded or regular, blue or purplish patch ● hematoma ○ a localized collection of extravasated blood, usually clotted in an organ, space, or tissue. ● hemorrhage ○ the escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ ● incision ○ a cut or wound made by a sharp instrument; act of cutting ● laceration ○ tearing or splitting of boy tissue, usually from a blunt impact over a bony surface ● lesion ○ a broad term referring to any pathological or traumatic discontinuity of tissue or loss of function of a part ● patterned injury ○ an injury caused by an object that leaves a distinct pattern on the skin/organ or an injury caused by a unique mechanism of injury. ● pattern of injuries ○ injuries, usually bruises and fractures, in various stages of healing ● petechiae ○ minute, pinpoint, non raised, perfectly round, purplish red spots caused by intradermal or submucosal hemorrhage, which later turn blue or yellow ● puncture ○ the act of piercing or penetrating with a pointed object or instrument ● stab wound ○ a penetrating, sharp, cutting injury that is deeper than it is wide ● traumatic alopecia ○ loss of hair from pulling and yanking or by other traumatic means ● wound ○ a general term referring to a bodily injury caused by physical means

Compare and contrast active and passive range of motion (ROM).

● active ○ ask for this while stabilizing the body area proximal to that being moved. ● passive ○ if you see a limitation attempt this with the person's muscles relaxed and with you moving the body part

Explain how nurses decide when each type of data base should be performed.

● based on why the patient is being seen

Outline the dimensions found in a health screening health assessment.

● biographic data ○ name ○ address ○ phone number ○ age ○ DOB ○ birthplace ○ gender ○ marital status ○ race ○ ethnicity ○ occupation ● reason for seeking care ● present health or history of present illness ● past history ● family history ● review of systems ● functional assessment or activities of daily living (ADLs)

Specify the 7 categories of patient information found in a complete health history.

● biographical data ○ name ○ address ○ DOB ○ gender ○ marital status ○ ethnicity ○ job ● reason for seeking care ● past health info of present illness ● past history ● family history ● review of symptoms ● functional assessment or abilities to perform ADLs

Compare and contrast the biomedical (or scientific), naturalistic (or holistic) and magico-religious perspectives of illness and health.

● biomedical ○ also called scientific theory, based on assumption that all events in life have a cause and effect, that the human body functions more or less mechanically ● naturalistic (holistic) ○ these people may believe that the forces of nature must be kept in natural balance or harmony, believe that human life is only one aspect of nature and apart of the general order of the cosmos ● magico-religious ○ the world is seen as an arena in which supernatural forces dominate

Describe the following anthropometric measurements: Body mass index, waist-to-hip-circumference

● bmi ○ weight (kg)/height (m)2 or weight(lbs)/height(inches)2 x 703 ● waist-to-hip ○ waist circumference/hip circumference

Outline the purpose of a spiritual assessment.

● client spirituality can be helpful resource when coping with illness, permanent disability or death

Summarize USDA Dietary guidelines.

● control total calorie intake to manage body weight ● increase physical activity and reduce time spent in sedentary behaviors ● consume less than 2300 mg/day of sodium ● consume less than 10% of calories from saturated fatty acids; replace with monounsaturated and polyunsaturated fatty acids ● consume less than 300 mg/day of cholesterol ● consume at least half of all grains as whole grains ● increase vegetable and fruit intake ● reduce calories from solid fats and added sugars ● increase intake of fat-free or low-fat milk/milk products ● choose foods with potassium, fiber, calcium, and vitamin D, including vegetables, fruits, whole grains, and milk/milk products.= ● choose a variety of protein foods, including seafood, lean meat, poultry, eggs, beans, peas, soy products, and unsalted nuts and seeds ● if alcohol is consumed, do so in moderation

Compare and contrast cultural sensitivity, cultural competence and cultural appropriate service.

● cultural sensitivity ○ basic knowledge and understanding of cultural populations ● culturally appropriate ○ background knowledge to provide appropriate health care to diverse cultures ● cultural competence ○ takes a lifetime to achieve, understand and able to attend to the total context of the individual client's total situation ■ own personal heritage ■ heritage of nursing profession ■ heritage of the health care system ■ heritage of client/client family

Explain how culture, ethnicity, religion, socialization and time orientation affect perceptions of health, wellness, and illness.

● culture is: ○ learned art, laws, customs ○ universal phenomenon ○ within cultures groups of people share different beliefs, values, and attitudes ● ethnicity includes: ○ learned values ○ race ○ physical and outward attributes ○ language ○ place of origin ○ food ○ pertains to a social group within a social system that claims to possess the same traits ● religion is: ○ the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creators and rulers of the universe ○ plays an important role in how people practice their health care ● socialization is: ○ the process of being raised within a culture and acquiring the characteristics of that group

Specify the BEST practices for documenting signs of physical abuse.

● documentation in the health record must include: ○ detailed, unbiased progressed notes ○ the use of injury maps ○ photographic documentation ● are best obtained VERBATIM ● critical to document exceptionally poignant statements made by the victim that identify the reported perpetrator and severe threats of harm made by the reported perpetrator. ● if patient is unconscious or cognitively impaired, the taking of photographs without consent is generally viewed as ETHICALLY SOUND, because it is a noninvasive, painless intervention that has high potential to help a suspected abuse victim ● when document H&P of child abuse and neglect, use the words the child has given to describe how his or her injury occurred

Define dull, flat, resonant, hyperresonant & tympanic percussion notes and where they should be found in a healthy person.

● dull ○ soft amplitude and high pitched with muffled thud and short duration, ex spleen or liver ● flat ○ very soft amplitude and high pitched with a dead stop of sound (absolute dullness) very short, ex thigh muscles, tumor, and bone ● Resonant ○ medium loud amplitude and low pitch, clear and hollow, moderate duration, over normal lung tissue ● Hyperresonant ○ louder amplitude, lower pitch, booming, longer duration, normal over child lung ● Tympanic ○ loud amplitude and high pitch, musical and drum like, sustained longest, over air filled viscus such as stomach or intestine

Outline developmental tasks associated with adults of all ages.

● early adulthood ○ gaining independence from parent's home ○ establishing a career and vocation ○ forming an intimate bond with another person and selecting a life mate ○ setting up and managing a household ○ learning to cooperate in a marriage of lifelong relationship ○ making friends and establishing a social groups ○ assuming civic responsibility ○ beginning a parental role ○ forming a meaningful philosophy of life ● middle adulthood ○ accepting and adjusting to physical changes ○ reviewing and redirecting career goals ○ attaining desired career performance ○ developing hobby and leisure activities ○ adjusting to aging parents/death of parents ○ helping adolescent children in their search for identity ○ accepting and relating to spouse as a person ○ coping with an empty nest ● late adulthood ○ adjusting to changes in physical strength and health, ○ forming a new role as in-law and grandparents ○ affiliating with one's age group ○ adjusting to retirement and reduced income ○ developing post retirement activities that enhance self-worth and usefulness ○ arranging safe and satisfactory living quarters ○ adjusting to the death of spouse ○ family members ○ friends ○ conducting a life review ○ preparing for one's own death

Create a health promotion plan for optimal nutrition.

● eat a variety of foods from all the basic food groups to ensure nutrient adequacy ● consume the recommended amounts of fruits/vegetables, whole grains, and fat-free or low-fat milk products or equivalents ● limit intake of foods high in saturated or trans fats, added sugars, starch, cholesterol, salt, and alcohol ● match calorie intake with calories expended ● be physically active for at least 30 mins almost every day of the week ● follow food safety guidelines for handling, preparing, and storing foods.

Outline factors that interfere with the accuracy of oral temperature measurement, and blood pressure measurement.

● eating or drinking right before take temp can cause inaccurate results ● smoking right before can also make inaccurate results

Outline questions to ask to collect subjective data about a person's nutritional status.

● eating patterns ○ number of meals/snacks per day? ○ kind and amount of food eaten? ○ fad, special, or alternative diets? ○ where is food eaten? ○ food preferences and dislikes: ○ religious or cultural restrictions? ○ able to feed self? ● usual weight ○ what is your usual weight? ○ 20% below or above desirable weight? ○ recent weight change? ○ how much lost or gained? ○ over what time period? ○ reason for loss or gain? ● changes in appetite, taste, smell, chewing, and swallowing ○ type of change? ○ when did change occur? ● recent surgery, trauma, burns, infection? ○ when? type? how treated? ○ conditions that increase nutrient loss (e.g., draining wounds, effusions, blood loss, dialysis)? ● chronic illnesses ○ type? ○ when diagnosed? ○ how treated? ○ dietary modifications? ○ recent cancer chemotherapy or radiation therapy? ● nausea, vomiting, diarrhea, constipation ○ any problems? ○ due to? ○ how long? ● food allergies or intolerances ○ any problematic foods? ○ type of reaction? ○ how long? ● medications and/or nutritional supplements ○ prescription medications? ○ nonprescription? ○ use over a 24-hr period? ○ type of vitamin/mineral supplement? amount? duration of use? ○ herbal and botanical products? ○ functional foods or food enhanced with nutrients? ○ specific type/brand and where obtained? ○ how often used? ○ who recommended? ○ how does it help you? ○ any problems? ● self-care behaviors ○ meal preparation facilities? ○ transportation for travel to market? ○ adequate income for food purchase? ○ who prepares meals and does shopping? ○ environment during mealtimes? ● alcohol or illegal drug use ○ when was last drink of alcohol? ○ amount taken that episode? ○ amount alcohol each day? each week? ○ duration of use? ○ (repeat questions for each drug used.) ● exercise and activity patterns ○ amount? ○ type? ● family history ○ heart disease, osteoporosis, cancer, gout, gi disorders, obesity, or diabetes? ○ effect of each on eating patterns? ○ effect on activity patterns?

identify therapeutic communication techniques

● encourage ● "tell me more" ● silence ● reflections ● empathy ● clarifications ● interpretations ● cause/effect ● explanations ● summary or final review of what was said

Outline ROM for all body joints.

● foot ○ Point toes toward floor ○ Point toes toward your nose ○ Turn soles of feet out, then inward ○ Flex & straighten toes ○ Muscle strength: plantar flex & dorsiflex the feet against resistance ● spine ○ Bend sideways ○ Bend backwards ○ Twist shoulder to one side, then the other ● knee ○ Bend each knee ○ Extend each knee ○ Check ROM during ambulation ○ McMurray's test for meniscal tears found on page 592 in the Jarvis text) ○ Deep knee bends can test both hip & knee strength ● temporomandibular joint ○ vertical and lateral motion. ● shoulders ○ forward flexion ○ hyperextension ○ internal rotation ○ abduction ○ adduction ○ external rotation. ● elbows ○ flexion ○ extension ○ pronation ○ supination. ● wrists and hands ○ evaluate extension and flexion ○ hyperextension ○ flexion ○ ulnar deviation ○ adduction ○ To detect possible carpal tunnel syndrome, perform Phalen's test and assess for Tinel's sign. ● hips ○ flexion and extension with the knee straight and with it bent. ○ internal ○ external rotation ○ abduction ○ adduction.

Outline laboratory study that can be measured to reveal a patient's nutritional status.

● glucose ○ normal fasting young child (0-2): 60-110 mg/dL ○ normal fasting child (2-18): 60-100 mg/dL ○ normal fasting adult: <100 mg/dL ● hemoglobin ○ infants (1-3 days): 14.5-22.5 g/dL ○ infants (2 months +): 9-14 g/dL ○ children (6-12): 11.5-15.5 g/dL ○ adult males: 14-18 g/dL ○ adult females: 12-16 g/dL ● hematocrit ○ infants (1-3 days): 44-72% ○ infants (2 months +): 28-42% ○ children (6-12): 35-45% ○ adult males: 37-49% ○ adult females: 36-46% ● cholesterol ○ low-density lipoprotein (ldl-c or "bad") ■ children and adolescents: <110 mg/dL ■ adults: <130 mg/dL ○ high-density lipoprotein (hdl-c or "good") ■ men: 35-65 mg/dL ■ women: 35-80 mg/dL ● triglycerides ○ age 0-19: 10-100 mg/dL ○ age 20-65: <150 mg/dL ● serum proteins ○ 170-250 mg/dL ● prealbumin ○ 15-25 mg/dL ● c-reactive protein (CRP) ○ <0.1 mg/dL ○ generally not detectable in the blood of healthy individuals

Explain how health screening patient encounters differ from those focused on a symptom

● health Screening ○ tests that look for diseases before you have symptoms ○ can find diseases early, when they're easier to treat ● symptom focused screening ○ a symptom is a subjective sensation that a patient feels from the disorder ○ this type of screening would be guided by how the patient feels, which is not always accurate

Describe how the patient health history and family history relates to health assessment & health promotion.

● health history is important because it may have residual effects on the current health state. ● Previous experience with illness may give cues as to how the person responds to illness and to the significance of illness for him/her. ● family history can highlight diseases and conditions for which a particular patient may be at an increased risk for, this could help the patient to seek early intervention and screening.

Outline questions to ask to get data regarding a person's health beliefs and practices.

● how do you define health? ● how do you rate your health? ● how do you describe illness? ● what do you believe causes illness? ● what did your mother do to keep you from getting sick, and what home remedies did your mother use to restore your health? ● how do you keep yourself from getting sick, and what home remedies do you have? ***(table 2-2 page 24)

Discuss how the changing demographic profile of the United States is impacting health care delivery.

● immigrants are frequently not fluent in english ● 1 in 3 people are members of a minority ● one person is born every 8 seconds ● one person dies every 13 seconds ● mixed ethnicity ● aging population (caucasian group)

Explain how to perform inspection, palpation, percussion & auscultation.

● inspection: ○ take your time ○ carefully watch ○ watch while engaging in convo with client ■ eyes ■ ears ■ nose ■ compare for symmetry covertly as you converse ■ good lighting ■ adequate exposure ■ sometimes instruments are required (objective only*) ● palpation: ○ sense of touch ○ watch clients response ○ use fingertips ○ dorsal of hands and fingers ○ base of fingers ○ Light and deep palpitations ○ Bimanual ○ Warm hands ○ gentle ○ tender areas last ○ light touch before deep. ● percussion: ○ map out size and location of organ ○ determine density ○ detect abnormal tissue mass ○ detect inflammation ○ Stationary hand position and Striking hand ○ determined by: ■ amplitude ■ pitch ■ quality and duration ■ Flat ■ dull ■ resonant ■ hyper resonant ■ tympany ● auscultation: ○ listen to sounds of the body through stethoscope which blocks out extraneous sounds.

Describe how to determine body mass index and specify a healthy BMI

● is a practical marker of optimal healthy weight for height and an indicator of obesity or malnutrition. ● Evidence supports using BMI in obesity risk assessment because it provides a more accurate measure of total body fat compared with the measure of weight alone. ● healthy BMI = level of 19 or greater to less than 25.

Identify the four basic characteristics of culture.

● learned from birth through the processes of language acquisition and socialization ● shared by all members of the same cultural group ● adapted to specific conditions related to environmental and technical factors and the availability of natural resources ● dynamic and ever changing

. Specify health waist circumference measurements for adult men & women

● less than 35 in women and less than 40 in men= decrease risk of DM type 2 and cardiovascular disease ● > or equal to 35 for women and > or equal to 40 in men indicates risk for type 2 diabetes, hypertension, cardiovascular disease

Outline the 8 key characteristics of a symptom.

● location ● character/quality ● timing ● setting ● aggravating or relieving factor ● associated factors ● severity or quantity ● client perception ● PQRSTU ○ provocative or palliative ■ what brings it on, what were you doing when you noticed it, what makes it better and worse ○ quality or quantity ■ how does it look, feel, sound, how intense or severe is it ○ region or radiation ■ where it is, does it spread ○ severity scale ■ how bad is it on a scale of 1-10 ■ is it getting better, worse, staying the same ○ timing ■ onset- when did it first occur ■ duration- how long did it last ■ frequency- how often does it occur ○ understand patient's perception

Explain how to document pain assessments

● location ● initial onset ● quantity ● quality ● aggravating and alleviating factors ● limitations ● usual pain behaviors ● meaning of pain and reason for it.

Explain how to assess for orientation, attention span, recent memory, remote memory and new learning.

● orientation ○ ask the person's: ■ address ■ phone number ■ health history ■ date. ● attention span ○ check their ability to concentrate by noting whether or not they complete a thought without wandering. ○ Note any distractibility or difficulty attending to you. ■ attention span is commonly impaired in people who are: ● anxious ● fatigued ● drug intoxicated ● recent memory ○ 24-hour diet recall or by asking the time the person arrived at the agency. ● remote memory ○ ask the person verifiable past events ■ past health, their first job ■ birthday and anniversary dates ■ historical events that are relevant for that person ● new learning ○ the four unrelated words test ■ pick four words with semantic and phonetic diversity ● example: ○ brown ○ honesty ○ tulip ○ eyedropper. ● have them recall in 5, 10, and 30 mins

Describe various methods used in clinical practice to perform pain assessments.:

● pain level scale asking: ○ do you have pain ○ where is pain ○ when did it start ○ what does it feel like ○ how much pain ○ what makes is better/worse ○ how do you usually react when in pain ○ what does pain mean to you ● Brief pain inventory ● short-form McGill pain questionnaire ● Braden scale

Outline the steps to take an accurate blood pressure.

● palpate brachial artery and with cuff deflated center it about 2.5 cm above brachial artery ● now palpate radial artery ● inflate cuff until you can no longer feel this pulse and then 20-30 mm Hg beyond ● deflate the cuff quickly and completely and wait a min before re-inflating ● place bell of stethoscope over site of brachial artery ● rapidly inflate cuff to the maximal inflation level you determined then deflate slowly and evenly while listening to korotkoff sounds

Describe the National Standards for Culturally and Linguistically Appropriate Services in Health Care.

● promote and support attitudes, behaviors, knowledge, and skills needed for staff to work respectfully and effectively with patients and each other in a culturally diverse work environment ● comprehensive management to address culturally appropriate services ● formal mechanisms for community and consumer involvement ● develop and implement a strategy to recruit ● retain, and promote qualified, diverse, culturally competent administrative, clinical, support staff who are trained and qualified to address the needs of the racial and ethnic communities being served ● required and arrange continuing education and training ● provide access to bilingual staff ● provide oral and written notices ● translate and make signage available ● ensure interpreters and bilingual staff ● ensure clients' spoken language and ethnicity is included in health care ● use variety of methods to collect data ● undertake continuing assessments ● develop structures and procedures to address cross-cultural health care delivery ● prepare an annual progress report ( page 13, table 2-1)***

Describe steps to take when the client says no to question on the Abuse Assessment Screen, but objective findings point to signs of intimate partner violence

● providers must be alert for conditions particularly associated with IPV including: ○ gynecologic problems ■ STIs ■ pelvic pain ■ complaints of sexual dysfunction ○ chronic IBS ○ back pain ○ depression ○ PTSD ■ especially problems sleeping and panic attacks ○ WEB (Women's Experience with Battering) ■ an instrument that can be used in addition to the AAS ○ gentle indirect inquiries ■ ex- i am concerned about your health conditions, is there any chance that stress at home is a contributing factor?

Identify the correct way to time pulse and respiration.

● pulse ○ 60-90, using 3 fingers palpate radial pulse ○ if regular rhythm count number of beats in 30 seconds and multiply by 2. ○ force 0= absent, 1+=weak, 2+=normal ● respiration ○ should be relaxed ○ regular, automatic, silent, don't mention that you are going to count the respirations ○ count for 30 seconds and multiply by 2

Describe the components of a functional assessment for activities of daily living for older adults

● screens the safety of independent living ● the need for home health services ● quality of life ● Do their joint problems create any limits on their usual activities of daily living? ● which ones ○ bathing ○ toileting ○ dressing ○ grooming ○ eating ○ mobility ○ communicating ● walk with shoes on ● climb up stairs ● climb down stairs ● pick up object from floor ● rise from chair ● rise from bed

List clinical signs of malnutrition (Jarvis: pg. 186)

● skin ○ dry ○ flaking, ○ scaly ● hair ○ dull ○ dry ○ sparse ● eyes ○ foamy plaques ○ dryness ○ softening ○ pale/red conjunctivae ○ blepharitis ● lips ○ cheilosis (vertical cracks in lips) ○ angular stomatitis (red cracks at side of mouth) ● tongue ○ glossitis (beefy red) ○ pale ○ papillary atrophy/hypertrophy ○ magenta/purplish colored ● gums ○ bleeding ● nails ○ brittle ○ ridged, or spoon shaped (koilonychia) ○ splinter hemorrhages ● musculoskeletal ○ pain in calves/thighs ○ osteomalacia ○ rickets ○ joint pain, ○ muscle wasting

List the equipment needed for performing health assessments.

● sphygmomanometer ● stethoscope ● thermometer ● pulse oximeter ● paper and pencil ● flashlight or light pen ● otoscope/ophthalmoscope ● tuning fork ● nasal speculum ● tongue depressor ● pocket vision screener ● skin marking pen ● reflex hammer ● sharp object ● cotton balls ● vaginal speculum ● clean gloves ● lubricant ● blood test materials

Specify the impact of spirituality on health.

● spirituality may help with: ○ Anxiety ○ Potential for enhanced family growth ○ Ineffective family coping ○ Altered family processes (birth or death) ○ Fear ○ Grief ○ Hopeless ○ Powerless ○ Altered self-esteem or concept ○ Spiritual distress ○ Potential for enhanced spiritual well-being

Identify any key spiritual considerations for nurses when conducting health assessments.

● tell me what life means to you ● are you in need of religious/spiritual or emotional support ● is this illness causing any major life changes for you or a loved one ● have you had any major stress or change in lifestyle recently ● is there anything we need to know about your religion, culture, background ● spiritual Wellness ○ faith/beliefs ○ life and self-responsibility ○ life satisfaction ○ fellowship and community ○ rituals and practice ○ vocation ○ client expectations

Describe the routes for body temperature measurements and the "normal" values for each route.

● tympanic ○ senese infrared emissions of tympanic membrane ○ shares same vascular supply that is an accurate measurement of core temp ○ useful with toddlers and done very rapidly ● axillary ○ is safer and more accessible than rectal route but accuracy and reliability have been questioned ● oral ○ under tongue ○ accurate and convenient because of rich blood supply ○ use when client is old enough to keep mouth closed, 98.6 F or 37 c ● rectal ○ use only when other routes are not practical ○ use this with infants or others when other routes are not feasible (such as a child who is unable to cooperate)

Trace the anatomy & physiology used for pain perception & interpretation.

● visceral ○ abdominal organs ● deep somatic pain ○ blood vessels, muscles, joints, bone ● cutaneous pain ○ skin surface, subq tissue ● referred ○ at site that is different from source of inflammation or injury (same spinal nerve)

Outline questions to ask for a heritage assessment.

● where were you born? where did you grow up? ● did your parents encourage you to participate in religious or ethnic activities? what kind of school did you go to? did you go to a special religious school after regular school hours? ● have you visited the nations or neighborhoods where your family originated? ● who are the people living in the neighborhood where you now live? ● do you participate in ethnic celebrations from your heritage? ● who lived in your home? were they related to you? ● do you maintain ties to family? ● was your family name changed when the family came to the united states? was the name changed to facilitate assimilation? ● what school did you go to? was it public or private? ● who are your friends, and how often do you spend time with them? ● do you speak or read the language of your parents or grandparents? ● do you identify as an ethnic american or as an american?

Identify some traditional culturally specific health and illness beliefs and practices.

● wide variation exists ○ the same illness may have entirely different meaning in different cultures ○ bodily symptoms can be reported in a wide variety of ways ○ leading to misinterpretation by the health care provider ○ the expression of pain also varies widely among cultures ○ since most western trained health care providers were trained to believe in suffering in silence ○ they may show little sympathy or tend to disregard pain complaints from those loudly expressing their discomfort ● gender and sexual considerations ● privacy issues ● how healthcare professionals are viewed in a particular culture, ● use of titles- ○ be formal until told otherwise ● use of time-clock vs activity ● language ● "what else do i need to know to take good care of you"

List recommended periodic health examinations for adults based on age.

● young adult ○ height and weight ○ blood pressure ○ pap smear (females) ○ chlamydia ○ rubella serology or vaccination history ○ screen for chemical abuse ○ injury prevention ○ substance abuse prevention ○ safe sexual practices, diet and exercise ○ dental health ○ T-dap boosters ○ Hep B ○ MMR ○ Varicella ○ Rubella ○ multivitamin with folic acid for women who are capable of planning for pregnancy ● middle adulthood ○ blood pressure ○ height and weight ○ total blood cholesterol ○ pap smear for women ○ fecal occult blood testing ○ sigmoidoscopy ○ colonoscopy starting age 50 ○ mammogram and clinical breast exam annually ○ chemical or domestic abuse ○ detailed vaccination history for women of childbearing age ○ hazards of substance abuse and how to quit ○ diet and exercise ○ injury prevention ○ safe sexual practices ○ pregnancy prevention if desired ○ dental health ○ tdap boosters if needed ○ multiple vit with folic acid for childbearing women ○ discus hormone therapy of perimenopausal and postmenopausal women ● late adulthood ○ blood pressure ○ height and weight ○ sigmoidoscopy every 5 years or colonoscopy every 10 ○ mammogram and breast exam annually ○ pap smear, vision screening ○ hearing screening ○ balance and mobility assessment ○ signs for chemical abuse ○ diet and exercise ○ injury prevention ○ dental health ○ safe sexual practices ○ cpr training for family

Compare and contrast benign, suspicious and malignant skin lesions.

Benign ● includes freckles (ephelides), moles (nevus) Suspicious ● Includes any skin lesion that was normal and now has change in: ○ color ○ size ○ shape ○ sudden tenderness ○ bleeding ○ itching Malignant ● Malignant melanoma ● Basal cell carcinoma ● Squamous cell carcinoma *Remember A,B,C,D,E,F when assessing skin lesions* ● A- Asymmetry ● B- Border irregularity ● C- Color variation ● D-Diameter. Greater than 6mm (pencil eraser) ● E- Elevation and enlargement (evolution) ● F- Feeling/sensation

Outline subjective data to collect that might indicate abuse of chemical substances.

Outline subjective data to collect that might indicate abuse of chemical substances. ● AUDIT - alcohol use disorders identification test ○ alcohol consumption ○ drinking behavior/dependence ○ adverse consequences from alcohol ● CAGE - cut down, annoyed, guilty, eye opener ○ yes/no questions ○ lifetime alcohol use/dependence ● 4 R's ○ Risk for bodily harm ○ Relationship troubles ○ Role failure (interference) ○ Run-ins with the law ● Questions - In the last 12 months have you... ○ ...not been able to stick to limits? ○ ...not been able to cut down or stop? ○ ...shown tolerance? ○ ...shown signs of withdrawal? ○ ...kept drinking despite problems? ○ ...spent a lot of time drinking? ○ ...spent less time on other matters? ● TWEAK - For at risk women ○ Tolerance - how much ○ Worry - people worry about you ○ Eye-opener ○ Amnesia ○ Kut down (Cut)

Outline components of a fall risk assessment scale.

● Confusion Disorientation Impulsivity ● Symptomatic Depression ● Altered Elimination ● dizziness/ vertigo ● gender ● Any Administered Antiepileptics ● Any Administered Benzodiazepines ● Get Up and Go Test

Explain additional interventions for high-risk populations of adults.

● Confusion Disoriented Impulsive ● depression ● Altered Elimination ● Dizziness / Vertigo ● gender ● Anti - epileptics ● benzodiazepine ● Get Up and Go

Identify subjective and objective data to collect for mental status assessment.

● Consciousness ● Language ● Mood & Affect ● Orientation ● Attention ● Memory ● Abstract reasoning ● Thought process ● Thought content ● Perception

Contrast therapeutic communication with non-therapeutic communication.

● non therapeutic involves ○ giving false reassurance ○ unwanted advice ○ authority ○ avoidance

objective data vs subjective data

● objective data ○ data that is verifiable by the health professional such as skin color. ● subjective data ○ data that is unable to be verified by someone other than the client who is experiencing it.

Identify factors that facilitate and obstruct nurse-patient communication.

● open ending question ○ good for the beginning of interview and introduce new topics while keeping the interview moving. ● Closed questions ○ fill gaps, state specific facts, data collections and effective use. ● Therapeutic communication ○ helps facilitate nurse to patient communication.

define health promotion

promoting client safety

define pain

unpleasant sensory and emotional experience, ALWAYS subjective! ● Nociception is how noxious stimuli are perceived as pain. ○ Transduction ■ injured tissue releases chemical that propagate pain message ■ action potential moves along an afferent fiber to spinal cord ○ transmission ■ pain impulse moves from spinal cord to brain, perception of pain ○ Modulation ■ neurons from brain stem release neurotransmitters that block pain impulse ○ abnormal processing of pain sensations ○ difficult to assess and treat Neuropathic pain is abnormal process of pain sensations ○ Sources of pain include ■ visceral ■ deep somatic pain ■ cutaneous pain ■ referred pain ■ Acute and chronic.

Describe the edema rating scale.

● 4 Point scale for assessing edema ○ Edema ■ swelling (Pitting or Nonpitting) ○ Absent ○ 1+ mild, slight indentation ○ 2+ Moderate pitting, indentation rapidly subsides ○ 3+ Deep pitting, indentation remains for a short time & area looks swollen ○ 4+ Very deep pitting indentation that lasts a long time

Describe the grading scale for muscle strength.

● 5= full ROM against gravity, full resistance ● 4= full ROM against gravity, some resistance ● 3=full ROM with gravity ● 2=full passive ROM (no gravity) ● 1=Slight muscle contraction ● 0=no muscle contraction

Explain the ABCDEF acronym for assessing skin lesions.

● A= Asymmetry ● B= Border irregularity ● C= Color variation ● D= Diameter greater than 6mm (pencil eraser) ● E= Elevation & enlargement (Evolution) ● F= Feeling and/or sensation ● Assess all skin lesions for these signs

Explain strategies for substance abuse prevention.

● Advise and Assist ● state that you believe that they are drinking more than is medically safe ● recommend that they cut down ● offer to help them (referral to AA counselor)

List objective data to collect that would indicate substance abuse.

● Elevated serum protein gamma glutamyl transferase (GGT) ● Elevated serum aspartate aminotransferase ● Breath alcohol analysis ● Alcohol drug levels in the blood (BAC)

Explain the professional nurses' roles in health assessment & health promotion.

● promote client safety(key responsibility, takes thought, assess situation, plan to protect, eventually becomes a reflex) ● protect yourself and client by using critical thinking and following PPE guidelines: ○ hand washing ○ careful use and disposal of sharp equipment ○ leak proof containers for specimen ○ disposal of infectious waste. ● safety is a nursing priority ○ always provide safe and healthy environment ○ safe practice never compromised.

define health assessment

●data collection that uses: ○ all of the senses ○ careful observation ○ the 1st step of the nursing process ○ collecting data related to health that is both objective and subjective.