Health Assessment Exam 1 Ch. 1, 2, 3, 4, 5, 9, 10, 16, & 17
The four groups of periodic health assessment
1.) birth to 10 2.) 11 to 24 3.) 25 to 64 4.) 65 and older
Alaskan natives in Mexican Americans are ____ times more likely Then Caucasians to have high blood pressure
1.3
Compared with Caucasians African-Americans are _____ times More likely to have high blood pressure
1.5
Gordon identified ______ categories of functional health patterns
11
Gloves are worn during anticipated contact with
Body secretions
A ______ Approach is a logical to war for organizing data when documenting and communicating findings this method promote critical thinking and allows nurses to analyze findings as they cluster similar data
Body systems
Organizational for documentation/communication and promote critical thinking
Body systems
Which physical assessment framework promote critical thinking
Body's systems
Percussion is quietest over
Bones
If you suspect the alcohol use might be a difficulty, the _____ is a quick first step questionnaire to use as an assessment tool
CAGE
Wrap hands around sides, thumbs at T9-10 and ask patient to make a deep inhalation
CHEst expansion
Fluid overload and respiratory congestion
CHF
PECTUS EXcavatum
CHest wall caves in
Covers a wide range of violent behaviors against children
Child maltreatment
Retractions are common in
Children
asthma is the most common
Children
Irregular, involuntary actions of muscles of face and extremities
Choreiform movements
A daily cycle of blood pressure occurs with blood pressure increasing light in the afternoon and decreasing in the early morning
Circadian (diurnal) cycle
C in ABCDE stands for
Circulation
Phrases or sentences substituted for word that the person cannot think of. for example when someone says "what you write with" because they cannot think of the term Pen
Circumlocutious
Interjection of great detail and incidental material with no primary significance to the central idea of the conversation
Circumstantiality
Is important when the patients word choice or ideas are unclear.
Clarification
The total size of the heart is approximately that of a
Clenched adult fist
In determining priorities the nurse should use
Clinical experience, knowledge, expertise, and judgment
Multidisciplinary tool that identifies a standard plan for a specific patient population
Clinical pathway
Working phase consist of two types of questions
Closed ended or open ended questions
Specific information. Yes or no answer
Closed ended questions
You end the interview by summarizing and stating what the 2 to 3 most important patterns or problems might be
Closing phase
When charting general appearance and behavior documentation may include which of the following
Clothes disheveled
Chronic hypoxia association
Clubbing
Is NOT a manifestation of asthma, chronic bronchitis, or Emphysema
Clubbing
Is a manifestation of asthma, chronic bronchitis, or emphysema
Clubbing
Is associated with lung cancer
Clubbing
Is commonly associated with diffuse fibrosis of the lungs and is almost always seen in patients with cystic fibrosis
Clubbing
abnormal widening and thickening of the ends of the fingers and toes associated with chronic oxygen deficiency
Clubbing
The ____________ focuses on conscience of the Nurse and respect for the individual and provides direction in the clinical setting
Code of ethics
Suicidal ideation Homicidal ideation and aggressive behavior Altered mood and affect Auditory hallucinations Visual hallucinations
Common symptoms of altered mental health
Complex, ongoing, interactive process that forms the basis for building inspirational relationships.
Communication
It is a system of sending and receiving messages, forming a connection between sender and receiver
Communication
Nearly 70% of all serious often life-threatening errors in healthcare reported to the joint commission involved failures in
Communication
Refers to the code of conduct and good manners that show respect others such etiquette varies between and within cultures
Communication etiquette
A common community assessment from work is
Community as partner assessment model
Mandates that every community assessment and intervention include systematic evaluation to identify the effects of interventions
Community as partner assessment model
The patients radio pulse is weak and thready The next action of the nurse is to
Compare findings to previous findings and opposite extremities
CAM Therapy is used with conventional medicine are often labeled
Complementary
View health more holistic, growing perspective
Complementary and alternative medicine model
Assessment of the patient's beliefs and practices and window cultural safety concerns arise incorporation of the patients believes and practices into the plan of care
Culturally based care
Overview/heritage, communication, family roles and organization, workforce issues, biocultural ecology, Harry ask health behaviors, nutrition, pregnancy and childbirth practices, death rituals, spirituality, and healthcare practices
Culturally based care model
Can influence a persons understanding of communication
Culture
I shared, learn, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world
Culture
I shared, learned, and symbolic system of values, beliefs, and attitudes that shape And influence the way people say and behave in the world is defined as
Culture
Is defined as the traits that a group of people share and pass from one generation to the next including values, beliefs, attitudes, and customs
Culture
Repetitive imitation of another person speech
Echolalia
Overpowering feeling of joy and rapture
Ecstasy
Muscle excursion are needed for
Effective breathing
Healthcare organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area
Standard 2
Healthcare organization should ensure that staff at all levels and across all disciplines receive ongoing education and training and culturally and linguistically appropriate service diversity
Standard 3
Healthcare organizations must offer and provide language assistant services, including multilingual staff and interpreters services, at no cost to each patient/consumer with limited English proficient see at all points of contact, and I timely manner during our hours of operation
Standard 4
Healthcare organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services
Standard 5
Healthcare organizations must've sure the competence of language assistance provided to limited English proficient patient/consumers buy interpreters and bilingual staff. Family and friends should not be used to provide interpretation services except a request by the patient/consumer
Standard 6
Healthcare organizations must make available easily understood patient related materials and post signage in the language of the commonly encountered groups and or groups represented in the service area
Standard 7
Are used on every patient because it is not always known whether a patient is infected
Standard precautions
Nurses use _____ With outpatient to reduce the transmission of pathogen's in both diagnosed and unknown infections
Standard precautions
Millimeters of mercury (Mm Hg)
Standard unit for measuring blood pressure
Must be upheld in every healthcare setting
Standards
Cultural component care
Standards 1-3
Organizational support for cultural competence
Standards 8-14
Language access services
Standards for 4-7
Includes what the patient says directly to you, what you overhear the patient telling someone else, and what family and friends report
Subjective data
Patient is primary source
Subjective data
Therapeutic dialogue
Subjective data
Begins with the health history
Subjective data collection
A patient says that she is having throbbing pain that she rates as a 6 on a 10 point scale this is referred to as
Subjective primary data
A three-year-old boy is brought to the emergency department with strider, nasal flaring, intercostal and supraclavicular retractions, and respiratory rate of 40 breaths per minute what type of situation is this
Emergency
Like threatening or unstable situation
Emergency
Address focus on the immediate and highest priority problems
Emergency and focused assessment
Involves life-threatening or unstable situation, such as a patient in an ED who has experienced a traumatic injury
Emergency assessment
Three types of nursing assessments
Emergency, comprehensive, and focused
The ability to perceive, raleason, and Communicate understanding of another person's feelings without criticism. It is being able to see and feel the situation from the patient's perspective rather than your own perspective
Empathy
Distraction of respiratory capillary beds and alveoli crazy eating large lava and bullae
Emphysema
The polls deficit is the difference between
The apical and radial pulse rates
Ask the patient about the health of close family members to help identify those diseases for which the patient may be at risk and to provide counseling and health teaching
Family history
If the victim is biologically related to the offender or is or was it related to him or her through marriage, adoption, or legal guardian ship
Family violence
Which of the following clusters of symptoms are common in women proceeding an MI
Fatigue, difficulty sleeping, dyspnea
And emotional reaction to an environmental threat
Fear
The nurse auscultates a medium loud wishing sound that softens between S1 and S2 the nurse document this finding as which of the following Sorry
Grade 3 decrescendo systolic murmur
As the diaphragm, internal intercostal muscles, and abdominal muscles relax, pressure in the lungs is
Greater than atmospheric pressure
Auscultate from Apex to base in ____ pattern
H
Split heart sounds Gallups Systolic ejection click Snap Pericardial friction rub
HEArt sounds
Excessive movement, distractive or aggressive activity
HYperkinesias
Very comprehensive assessment tool
Long term care documentation
The resident assessment instrument governs documentation in
Long-term care settings
Increase the proportion of persons with substance abuse and mental disorders who receive treatment
Health goals for patients to maintain and promote health
Reduce the proportion of James adults who have serious mental illness
Health goals for patients to maintain and promote health
Reduce the proportion of adolescent and adult who experienced major depressive episodes
Health goals for patients to maintain and promote health
Physical Assessment
Health history
includes interviewing to collect the patient's past medical and surgical history, risk factors, and current symptoms
Health history
Changes of conversation in an unrelated, Fragmented manner
Loose associations
What do the different formats of progress notes have in common
I'll use the nursing process in some form to show nursing thinking
Perception that others or the media or talking to or about the patient
Ideas of reference
Air and fluid
Louder tones
Normal speech is audible. This is a normal finding describing which quality of speech
Loudness
Using a cuff that is too large causes a falsely
Low Blood pressure
The bell is used with light skin contact to hear
Low-frequency sounds
The health insurance portability and accountability act HIPAA Which gives patients greater control over their ________ became affective in 2003
Medical records
In 2000 the federal government mandated that homecare agencies use the outcome and assessment information say it in the initial and ongoing assessment of our patients they care for in order to qualify for
Medicare and Medicaid reimbursement
Before checking Vital signs you need to assess the patient's
Medications
Represents the spread of depolarization in the atria that causes atrial contraction
P wave
Runs from the 6th rib anteriorly to T3 spinous process posteriorly
OBLIQUE Fissure
COPD, strength lesson, Celia or less mobile, Alviola become Steiffer, musculoskeletal issues
OLDER adults
Determines patient motivation to lose weight
Obesity
O in SOAP stands for
Objective
O in SOAP
Objective assessment findings
Measurable information
Objective data
The physical assessment follows the history and focused interview, and includes
Objective data
Vital signs, auscultation, and visual appearance
Objective data
When documenting ______ it is important to be detailed and descriptive and to note findings without bias
Objective data
_____ is measurable
Objective data
you observe the patient's general appearance, assess vital signs, listen to the heart, lungs, and abdomen, and assess peripheral circulation.
Objective data
Scale Height bar Stethoscope Thermometer Watch with second hand Blood pressure cuff Pulse ox Tape measure for infants
Objective data equipment
Each land is divided almost in half by an _____
Oblique Fissure
Slow, shuffling gait, masklike facial expression, tremors, pill rolling movements of the hands, stooping posture, rigidity
PArkinsonism
Are measured in patients to assess a drop in blood pressure and change in heart rate with position changes
Orthostatic (postural) vital signs
Example of common and specialty or advanced techniques
Orthostatic blood pressure, evaluating pulse deficit, Doppler
Drop in SBP of 15 or greater and drop in DBP of 10 or greater Or increased heart rate indicates
Orthostatic hypotension
Barricks locked into the easier to visualize the ear canal and Tympanic membrane
Otoscope
Determining patient ____ and ____ care
Outcomes Planning
Is the percentage to weird Chima globin is filled with oxygen
Oxygen saturation
What does HIPAA stand for
The health insurance portability and accountability act
The nurse assesses the neck vessels in the patient with heart failure to determine which of the following
The highest level of jugular venous Pulsation
Main trigger for breathing is
Increased level of Carbon dioxide in blood
A 62-year-old woman comes to the clinic with exacerbation of asthma. Which of the following findings indicate worsening status of her asthma
Increased wheezing
BP _____ gradually throughout childhood into adult years
Increases
BP _____ in late in afternoon and _____ in early morning
Increasing Decreasing
Extreme anxiety, acute distress, pallor, cyanosis, and a change in mental status
Indicators of an urgent situation
Bronchophony
LISTEn and have patient says say 99
Alveoli become congested with bacteria and white cells
LOBAR pneumonia
Quick change of expression of mode or feelings
Lability
The left side of the heart is
Larger and more muscular
Are more common in nurses and in frequently hospitalized patients
Latex allergies
Avoid contact whenever possible with
Latex allergy
The right base is higher because of the
Liver
Some examples of the need for fun discrimination include
Locating the pulses, lymph nodes, or small lamps, and for assessing for skin texture and Edema
Organized entry of assessment data ensures a logical and systematic grouping of information
Logical organization
Decreased, slowed activity
Psychomotor retardation
Disorderly mental state in which the patient has difficulty distinguishing reality from internal perception
Psychosis
Contraction of the heart causes blood to flow forward which creates a pressure wave known as
Pulse
Provides an indirect a valuation of the ability of eight heart contraction to a Jake enough blood into the peripheral circulation to create a pulse
Pulse deficit
Is a non-invasive technique to measure oxygen saturation of arterial blood
Pulse oximetry
The difference between SBP and DBP
Pulse pressure
Are described as regular or irregular
Pulses
Practice of verbal and physical violence, humiliation, and shame, usually done in a public or with an audience
Punking
Are common among middle and high school males, usually resulting in the victim shame, humiliation, and anger
Punking and bullying
Indicators of possible abuse or neglect are called
Red flags
With pregnant women as the uterus expands and moves upward the costal angle will widen. The Thoracic cage may widen also and place strain on the
Ribs
The anterior vertical landmarks are the
Ribs and their associated interspaces
Crackles
Rice crispy
Two pulmonary arteries carry deoxygenated blood from the _______ Side of the heart to each lung
Right
Bio graphical information
Risk factor assessment
Medications, Past medical history, and family history
Risk factor assessment
Aortic valve lies between
The left ventricle and aorta
The other two compartments of the thoracic cavity contain
The lungs
Refers to health as the patient's ability to adapt, compensate, manage, and it just to physiology Health setbacks. Assist patient to attain optimal level of physical health, self-concept, row function, inter-dependents.
Roy's adaptation model
A ____ maybe heard in airway obstruction
Rub
Harsh, scratching sound heard in either inspiration or expiration caused by inflamed pleural surfaces sliding over each other
Rub
Getting stuck on, Worrying, or thanking about an idea of repetitively
Ruminating
With general assessment of older adults you shouldn't
Rush patient with their answers anddint assume they have a deficit (hearing/vision)
State concisely why you are communicating
S in SBAR
Louder at Apex
S1
Louder in mitral and tricuspid areas
S1
S4 occurs beforehand ____ sounds like lub lub dub
S1
Louder at base
S2
Louder in aortic and pulmonic areas
S2
When S3 exists it follows ____ and sounds like lub dub dub
S2
The nurses auscultates an extra sound on a patient one week after a MI it is immediately after S2 and is heard best at the apex which of the following does the nurse suspect
S3 gallop
First developed by Kaiser Permanente Is a shared mental model for improving communication between and among clinicians
SBAR
90-120
SBP
Separates the left and right sides of the heart
SEPtum
Healthcare organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language
STandard 1
Healthcare organizations should ensure that data on the individual patients/consumers rice, ethnicity, and spoken and written language are collected and health records, integrated into the organizations management information systems, and periodically updated
STandard 10
Healthcare organization should develop implement and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services
STandard 8
Healthcare organization should conduct initial and ongoing organizational self assessments of CLAS related activities and are encouraged to integrate cultural and linguistIc competence related measurements into their initial audit, performance improvement programs, patient satisfaction assessments, and outcomes based evaluations
STandard 9
Prompt reporting an accurate recording a patient assessment data are essential to ensure
Safe and efficient delivery of care
It is important to ask _____ first and leave the presenting situation for last
Safety questions
Patients have focused assessmentafter treatments to monitor
Their effectiveness
Is a basic tool you use in a caring relationship with patients. The interaction focuses on the patient and the patient's concerns
Therapeutic communication
You in the patient work together to resolve problems by developing collaborative strategies and solutions. As you and the patient developed report with each other the patient feels respected and understood
Therapeutic communication
I nurses working with a patient doing a standard assessment. To establish report, the nurse would use which of the following statements
These are questions that I asked all my patients
Patients tend to think in their native language and translate thus delaying
They're response
Used in examinations of two anatomic regions with a neuromuscular assessment to determine vibration sensors and during assessment of hearing to tireman conductive versus sensorineural hearing loss
Tuning fork
What is an example of physical procedures
Turning the patient or assisting them with ambulation
Leave the heart with oxygenated blood
Two pulmonary arteries
Carry Deoxygenated blood back to the heart
Two pulmonary veins
The nurse assessing and older adult focus is the health history on
Sensory deficits, illness history, and lifestyle factors
Provide horizontal reference marks
Series of lines
S in SAD PERSONAS
Sex
Is never acceptable within therapeutic nurse patient relationship
Sexual contact
The comprehensive history includes sexual history and sexual orientation to establish a baseline for health behaviors and identify the need for education
Sexual history and orientation
Includes for sex and dating a marital relationships, gang rape, sexual harassment, inappropriate touching, Molestation, sex with a patient, forced prostitution, and forced exposure to sexual explicit behavior
Sexual violence
Spinal deformity
Shape
RIGHt main bronchus
Shorter, wider, and more vertical
Is among the most common type of violence that children experience
Sibling rivalry
The last S in SAD PERSONAS
Sickness
Purposefully allow patients time to gather thoughts and provide accurate answers
Silence
The SOAP format focuses on a
Single problem
In the right atrium generates the normal heartbeat
Sinoatrial node
Pacemaker
Sinoatrial node
Primarily to inform nurses about the patient's physical and mental health retaining to patients existing resources, constraints, and a man's
Social assessment of the individual
Second S in SAD PERSONAS
Social supports lacking
Assess over all psychosocial well-being as part of the screening of the functional health patterns including self perception/self concept, role/relationship, and coping/stress tolerance
Social, cultural, and spiritual assessment
Intensity or loudness refers to how
Soft or loud the sound is
Should be avoided in patients with your drainage, your pain, suspected ear infection, or care should be avoided in patients with ear drainage, your pain, suspected ear infection, or scarred tympanic membrane
Tympanic membrane thermometer
Use infrared Sensors to take the heat that the Tympanic membrane produces. Noninvasive, safe, efficient, and quick. Commonly used in emergency departments or hospitals
Tympanic thermometer
Violence against vulnerable adults such as those with physical and mental disabilities includes harmful affects of abuse or neglect
Violence against adults with disabilities
An integrated method of functioning which is oriented towards maximizing the potential of which the individual is capable
Wellness
Nurses collaborate to promote higher levels of
Wellness
ABCT
appearance, behavior, cognition, thought process
No emotional tone or reaction
flat affect
A palpable vibration
fremitus
A 90-year-old patient has a drooped body position appear sad and says that she has seasonal affective disorder. What would the nurse used to assess her
geriatric Depression scale
Left and right atria via
intraatrial pathways
Kyphosis
hunchback
Temperature greater than 100°F
hyperthermia
Three levels of social assessment
individual, community, societal
Innervates the intercostal muscles
intercostal nerves
POC or clinical pathway are a component of
medical record
Disheveled appearance is a change in
mental status
BMI 25-29.9
overweight
Primary data source
patient
Innervates the diaphragm
phrenic nerve
What are the four characteristics of respirations
rate, rhythm, depth, quality
Rhonchi
snoring sound
The purpose of health assessment is to obtain
subjective and objective data
Lordosis
swayback
Dorsal surface of hand
temperature
BMI <18.5
underweight
______ is Usually from your perspective and not the patients
unwanted advice
Lines the outer surface of the lungs
visceral pleura
THe top of the heart
Base
The very bottom of the lung
Base
The angle between the ribs at the costal margin's forms
Costal angle
Usually 90 degrees or less
Costal angle
Reduce the suicide rate
Health goals for patient to maintain and promote health
The clear long low pitch sound elicited over the normal lung
Resonance
Splinting
Rhythm
Intercostal spaces are named after the
Rib above it
Provide vertical reference points
Ribs
Patients with problems of the spinal cord especially ____ May require ventilator support
C3-C5
Value/belief
Category 11 of functional health patterns
Nutrition/metabolic
Category 2 of functional health patterns
Elimination
Category 3 of functional health patterns
Activity/exercise
Category 4 of functional health patterns
Coping/stress tolerance
Category Ten of functional health patterns
Role/relationship
Category eight of functional health patterns
Sleep/rest
Category five of functional health patterns
Sexuality/reproductive
Category nine of functional health patterns
Self perception/self-concept
Category seven of functional health patterns
Cognitive/perceptual
Category six of functional health patterns
Has largest chest size followed closely by African-Americans
Caucasians
PECTUS carinatum
Chest that protrudes
Breathing pattern characterized by alternating periods of apnea and hyperventilation
Cheyenne-strokes
Altered mood and affect
Common symptom of altered mental health
Auditory and visual hallucinations
Common symptom of altered mental health
Focused health history is related to
Common symptoms
Homicidal ideation and aggressive behavior
Common symptoms of altered mental health
Dress, grooming, speech, and nonverbal communication are examples of
Cultural influences
Turn the general survey of every patient note any
Cultural influences
The reporter is protected by the state if the report is done in
Good faith and without malice
Emphasizes personal role for filament, 11 functional health patterns
Gordon's functional health model
Some medications may reduce the ability of the brain to trigger breathing causing
Hypoventilation
Change in level of consciousness often is the first indication of
Hypoxia
Deficiency in the amount of oxygen reaching the tissues
Hypoxia
To prevent illness (levels of prevention)
(primary, secondary, tertiary)
Bodyweight greater than 20% less than idea
Imbalance nutrition less than body requirements
Bodyweight greater than 20% over idea
Imbalance nutrition more than body requirements
The spinous process of T1 usually correlates with the
1st rib
Left side of the heart has ___ main arteries instead of one
2
The left lung has _____ lobes
2
Normal strength
2+
For each 22 pounds of extra weight SBP elevates ____ and DBP elevates _____
2-3 mm Hg 1-3 mm Hg
Deep palpation
2-4 cm
Crossing of the patients legs may increase SBP by
2-8 mm Hg
Further assessment is required if the patient's oxygen saturation level is less than
92%
Normal pulse oximetry is
92-99%
Nonpalpable or absent
0
Sad personas suicide risk assessment total scores range from
0-10
Axillary temperatures are ______ lower than oral temperatures
0.5-1°F
Rectal and Temporel artery measurements are _____ higher than oral measurements
0.7- 1°F
Tympanic and core pulmonary artery temperatures ______ variation between
1 F
Full respiratory cycle
1 breath
With newborns and infants and children always count breath sounds for
1 full minute
Week, diminished, and barely palpable
1+
Moderate palpation
1-2 cm
Specific aim of cultural assessment is to provide an all inclusive picture of the patients cultural-based healthcare needs by
1. Gaining knowledge of the patients cultural beliefs and practices 2. Comparing cultural care needs of the specific person with the general theme of those who are of similar cultural background 3. Identify similarities and differences among the cultural beliefs 4. Generate a holistic picture
I normal respiratory rate is from _____ per minute
12-20
Normal respiratory rate for adults
12-20
National standards for culturally and linguistically appropriate services in healthcare has how many standrs
14
Light palpation _____ cm
1cm
In acute care facilities policy usually requires the completion and documentation of the initial complete nursing assessment within
24 hours of admission
Base of heart found at
2nd intercostal space
The sternal angle is continuous with the
2nd rib
Expiratory phase is ____ longer
2x
The right lung has _____ lobes
3
Full, increased
3+
Nursing has a focus comprising of how many main goals?
4
____ heart chambers
4
The sternal angle is
4 to 5 cm below sternal notch
Bounding
4+
After exercising it takes ____ minutes after stopping to return to baseline
5
I normal variation between blood pressure's in both arms is
5-10 mm
With chest expansion Thumbs should move a part
5-10cm
A mean of _____ mm Hg is needed to perfuse the vital organs
50
Apex of heart found at
5th intercostal space
Lack of back support increases DBP by as much as
6 mm Hg
A normal cardiac output is
6-8 L/min or 80bpm with 80 ml in each beat
Treatment of acute/chronic illness is for
65 and older
Lower tip of scapula
7th and 8th rib
Nursing assessment of trends in an Unconscious patients neurological status over time is best recorded on
A focused assessment flowsheet
A health assessment is made up of the following two parts
A healthy history and a physical assessment
Give objective and subjective data pertinent to the situation
A in SBAR
When assessing the child the nurse makes the following adaptation to the usual techniques
A pediatrics stethoscope is used for a better contact
Is thick to block environmental noises and short to increase transmission and reduce distortion of sound
Tubing
If the arm blood pressure is extremely high compared it with
A thigh blood pressure
Determine the level of urgency by considering assessments based on the mnemonic
A, B, C, D, E
With cervical spine protection if an injury is suspected
A-airway
Is audible when the artery is partially obstructed
BRUIT
APRN (Advanced Practice Registered Nurse) education
BSN MSN Doctorate
B in SBAR
Background
The ability to focus on patients and their perspectives. It requires that you constantly detailed messages, including thoughts, words, opinions, and emotions.
Active listening
Behavior such as eating, dressing, and grooming.
Activities of daily living
The most prominent and traditional model
Biomedical model
Social, cultural, and spiritual dimensions of health or not central to the ______ And are generally considered private matters
Biomedical perspective
Permits comparison of current findings with future data to detect changes in patient status
Accuracy
Involves assessment of violence and mental health conditions
Assessment of risk factors
A in DAR
Action
When organizing information with comprehensive mental health assessment you do it in the form of
ABCT
The nurse who asked about feeding, bathing, toileting, dressing, grooming, mobility, all maintenance, shopping, and cooking is assessing
ADL's. Activities of daily living
Whispered pectoriloquy isn't normal if it is muffled and abnormal if it can be heard
AS a clear whisper
Tympanum Is a percussion sound commonly located in the
Abdomen
Infants may have normal short periods 10 seconds of apnea Apnea> 20 seconds is
Abnormal
When 99 sounds clear with stethoscope
Abnormal
Commission
Abuse
Second A in SAD PERSONAS
Access to lethal means
When _______ findings are present the nurse begins interventions while continuing the assessment including vital signs assessment of pulse blood pressure and oxygen saturation
Acute or urgent findings
Psychological, socio-cultural, spiritual, economic, and lifestyle
Additional necessary factors assessed in a health assessment
Previous medical records
Additional sources of history
Care providers can refer to this initial assessment obtain important baseline information and to detect changes in status
Admission assessment
Provides all future care providers with comprehensive information about the patient's physical, psychological, functional, social, and spiritual abilities and forms the basis for an individualized POC.
Admission assessment
For which of the patients would the MMSE be most appropriate
Adults to assess for cognitive impairment
More likely to experience severe and long-term abuse, the victims of multiple violent episodes, and be abused by many perpetrators
Adults with disabilities
Nurses can enter data by checking boxes and adding free full text
Advantage of electronic medical record
are vibrations always resulting from some pathologic process and are not heard over healthy lung tissue. Not natural or hereditary
Adventitious sounds
A patient is having adverse effects resulting from a medication the nurse calls the primary care provider to request a change to the medication order the nurse is functioning as a
Advocate
In the professional role nurses are _____ for the patient in the profession. as _____ nurses take responsibility to protect the legal and ethical rights of patients
Advocates
No fever
Afebrile
Asthma a relatively common long disease is most common in
African Americans and American Indian adults
When are focused assessment conducted
After specific treatments are given
_____ is where the heart pumps against the high blood pressure in the arteries and arterioles
Afterload
The normal range of heart rate varies with
Age
first A in SAD PERSONAS
Age
respirations near death or during extreme suffering
Agonal
A in the ABCDE stands for
Airway
When the nurse assesses a 78-year-old patient with pneumonia what is the priority assessment
Airway patency
Motor restlessness, inability to remain steel, can also be subjective feeling
Akathisia
No movement or difficulty with movement
Akinesia
Are the various measurements of the human body, including height and weight
Anthropometric measurements
Subjective information is from the perspective of the patient secondary sources are
All the other sources of information
What are some strategies for effective handoffs during change of shift report
Allow an opportunity to ask and answer questions
CAM Therapy is used instead of conventional treatments to restore health are often termed
Alternative
Gas exchange occurs in The ____ of the lungs
Alveoli
Having two opposing feelings or emotions at the same time
Ambivalence
Hollow, metallic sound heard over a large cavity
Amphoric
Very private may not disclose personal information
Arab
A in SOAP
Analysis
A in SOAP
Analysis of the assessment data to identify a problem or indicate whether the problem is improving or worsening
When is a complete health history and physical assessment performed
Annually for outpatients Upon hospital/long-term care admission Every eight hours in critical care
A feeling of apprehension or worry especially about the future
Anxiety
Make sure that the patient has not had
Anything to drink or eat or smoked in the last 30 minutes
BOttom of the heart
Apex
Very top of the lung
Apex
Sternal angel Also marks the side of the
Apex of the heart
Partial or total loss of the ability to express sale of their language or to understand the verbal communication of another person
Aphasia
Listen to ___ of lungs moving side to side
Apices
Is the absence of spontaneous respirations for more than 10 seconds
Apnea
not breathing
Apneic
Overall appearance, posture, movement, hygiene, grooming, dress
Appearance
Abnormal heart rhythm with premature, delayed, or irregular beats
Arrhythmias
Comes from the thoracic aorta and from the subclavian, brachial, and axillary arteries
Arterial blood supply to the chest
Carry originated blocked blood
Arterial great vessels
Include the carotid artery's, aorta, and pulmonary veins
Arterial great vessels
_____ fill when the heart relaxes
Arteries
Asthma is least common Indian
Asian and Hispanic adults
Last name then first name
Asian cultures
Complete, accurate health data completion
Assess
______ the patient, analyzing data, and making nursing ______
Assessing Diagnoses
A in SBAR
Assessment
Asking patients about personal experiences of violence is a key aspect of
Assessment
Nursing Process
Assessment Diagnosis Outcome identification Planning Implementation Evaluation
Palpation is that assessment of the patient through touch. What is light palpation appropriate for
Assessment of inflamed areas of skin
Family history, age, and gender
Assessment risk factors
And example of a systematic community assessment framework is
Asset mapping
Unilateral wheezing is a common manifestation of
Asthma
Absence of pulse
Asystole
Collapsed section of alveoli from immobility, obstruction, compression, or decreased surfactant
Atelectasis
Shortness of breath Decreased breath sounds Decreased oxygen saturation Increased tactile fremitus
Atelectasis
Av junction and ventricles
Atria
Collate and pump blood into the ventricles.
Atria
The two atrioventricular valve separate the
Atria from the ventricles
Irregularly irregular heart rhythm
Atrial fibrillation
Tricuspid and mitral
Atrioventricular valves
The tricuspid valve separates the right
Atrium an ventricle
Listening to assess organ and tissue condition
Auscultation
Use of stethoscope to assess movement of air or fluid that are heard in the body over the lungs and abdomen
Auscultation
Using a stethoscope to assess movement of air or fluid within specific body systems
Auscultation
You will listen for sounds produced by the body usually from movement of organs and tissues
Auscultation
Identifies ventricular filling sounds
Auscultation of extra heart sounds S3 and S4
Enables the hearing of bruits
Auscultation of the carotid artery
A period in which there is no korotkoff sound during auscultation
Auscultatory gap
detects Assessment data indicating problems
Automated clinical surveillance tools
Sinoatrial node
Automaticity
Not consciously controlled, automatic, undirected motor activity
Automatism
It is important to identify similarities and differences among the cultural believes of the patient, healthcare agency, and the nurse to
Avoid making assumptions
Less commonly used then the oral route. It came to use with infants and young children and also with patients of other ages who cannot have oral temperature assessed. Electronic or disposable thermometers maybe used to measure this temperature
Axillary route
Describe the circumstances leading up to the current situation
B in SBAR
Rate and depth, use of accessory muscles
B-breathing
Health is restored by prompt diagnosis of illness, prevention of complications, and illumination of pathology
Biomedical standpoint
Is considered a more reliable indicator of healthy weight then weight measurement alone
BMI
Sphygmomanometer
BP
Accurate documentation provides a ______ so that changes are noted between assessments
Baseline
Vital signs are
Baseline
do you under, age, ethnicity, race, marital status, occupational class, shelter, employee status, and Educational level
Basic variables of social assessment
Contributes to many potential errors because if you wait to record you may forget important information or chart assessment data on the wrong patient
Batch charting
Waiting until the end of shift or until all patients have been assessed to document
Batch charting
The national standards for culturally and linguistically Appropriate services in healthcare mandate that the standards
Be upheld in every healthcare setting
Is the measurement of the force exerted by the flow of blood against arterial walls
Blood pressure
Common focus of auscultation
Blood pressure, lungs, heart, abdomen
Severe reduction in emotional expressiveness is _____ affect
Blunted affect
Introduction and state purpose for interview
Beginning phase
Level of consciousness, Eye contact, facial expressions, speech are _______
Behavior
Nurses should screen for an identified controlling and abusive
Behaviors
Carry judgment and lead patients to respond in a way that they think will be acceptable to you
Biased question
Is a heart rate less than 60 bpm
Bradycardia
Persistent respiratory rate less than 20 breaths per minute
Bradypnea
Use of accessory respiratory muscles signifies increased work of
Brazing and respiratory distress
B in ABCDE stands for
Breathing
Similar to tracheal breath sounds but are abnormal because they are heard over the Peripheral and we're only vasicular sound should be heard
Bronchial
Over the trachea and lyrics, loud, course high pitch
Bronchial BS
Are classically observed over the consolidated lobe of lobular pneumonia
Bronchial or tubular sounds
Smaller Branchi continue to separate like branches on a tree until they eventually become
Bronchioles
over major bronchi
Broncho vesicular BS
A change in the pitch of spoken word over an area of consolidation
Bronchophony
Less horse, easily, heart sounds of the airflow heard in central airways under sternum
Bronchovesicular
Swishing sound similar to the sound blood pressure makes. They result from turbulent blood flow related to atherosclerosis
Bruit
In the form of verbal violence is common among middle and high school girls
Bullying
Pulse rate and rhythm, skin color
C-circulation
And acute change in mental status
Call rapid response team
If a patient experiences Agitation or restlessness you need to
Call rapid response team
New onset of chest pain
Call rapid response team
Oxygen saturation less than 92%
Call rapid response team
Pulseless and 55 bpm or greater than 120 bpm
Call rapid response team
STridor
Call rapid response team
Systolic blood pressure less than Mandy or greater than 170
Call rapid response team
Temperature less than 95°F or greater than 103.1°F
Call rapid response team
what should you do when Respiration is less than 10 breaths per minute or greater than 32 breaths per minute
Call rapid response team
when a patient is showing increased effort to breathe you should
Call rapid response team
Antihypertensive agents, diuretics, narcotics, and general Anastasia
Can lower blood pressure
The continuous rhythmic movement of blood during contraction and relaxation of the heart is
Cardiac cycle
Rapid assessment plus intervention
Cardiac emergencies
Heart rate X stroke volume
Cardiac output
Increases heart rate, increases stroke volume,
Cardiac output
Reduce coronary heart disease deathS Increase proportions of patients who receive timely defibrillation and thrombolytic therapy Increase proportion of adults who control blood pressure levels
Cardiovascular health goals
The trachea bifurcated at the _____ into the right and left mainstream bronchi, and these in turn branch into smaller bronchi one for each love of the lung
Carina
Where does the trachea branch into the right and left main stem bronchi
Carina
Encompasses your empathy for and connection with the patient. It also includes the ability to demonstrate emotional characteristics such as compassion, sensitivity, and patient centered care
Caring
Temporary loss of muscle tone precipitated by strong emotions
Cataplexy
Health perception/health management
Category 1 of functional health patterns
To avoid potential areas the joint commission discourages the use of
Certain abbreviations
Pulse oximetry of 85% to 89% may be except a bowl for patients with
Certain chronic conditions such as emphysema
Lethargy
Change in mental status
Rapid speech
Change in mental status
Uses predetermined standards in the norms to record only significant assessment data
Charting by exception
A 45-year-old man has been admitted to the hospital with suspicion of pulmonary embolus him. Which of the following symptoms should the nurse report to the primary health practitioner immediately
Chest pain
Orientation, attention span, memory
Cognitive function
Are those that you are Monitoring that require the expertise of other healthcare providers for interventions
Collaborative problems
Registered nurse assessment
Common and specialty or advanced techniques
Dyspnea and orthopnea and cough
Common cardiovascular symptoms
Nocturia, palpitations Sorry
Common cardiovascular symptoms
Consultations
Component of medical record
Discharge or transfer summary
Component of medical record
Flow sheet documenting vital signs, intake and output, and routine assessments
Component of medical record
Laboratory and diagnostic test results
Component of medical record
Medication administration record
Component of medical record
Progress notes by different members of the healthcare team
Component of medical record
Focused assessment sheet
Component of medical records
History and physical examination by primary care giver
Component of medical records
Nursing admission assessment
Component of medical records
Primary care providers orders
Component of medical records
A patient is admitted to a hospital for surgery for colon cancer what type of assessment is the nurse most likely to perform upon admission
Comprehensive
Complete health history and physical assessment performed
Comprehensive
Cognitive development
Comprehensive assessment
Emotional development
Comprehensive assessment
Includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or a long-term care facility, or every 8 hours for patients in intensive care.
Comprehensive assessment
Physical growth is a _________
Comprehensive assessment
Are broad and wide ranging
Comprehensive assessments
How the patient communicates
Comprehensive mental health assessment
How the patient response to questions
Comprehensive mental health assessment
Physical presentation
Comprehensive mental health assessment
________ is an Ongoing process throughout the time that you are with the patient
Comprehensive mental health assessment
Observe and document any objective findings related to patients who have been victimized by violence
Comprehensive violence assessment
Unwanted repetitive actions
Compulsive
Allows healthcare providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing personnel
Computerized provider order entry
Good charting is complete yet
Concise
A stethoscope
Conducts sound does not amplify it
Making up answers to cover for not knowing. Demonstrates the ability to think and reason with only short-term memory present. Symptoms of Korsakoff syndrome
Confabulation
You are required to legally and ethically to keep all information in the patient record
Confidential
Manes keeping information private
Confidentiality
Fremitus is enhanced by
Consolidation
Vibration increases with
Consolidation
Your patient with a humerus fracture is stating pain of five and 10 point Scale his hand is pale, cool, and swollen his pain medication is ineffective and he is at risk for compartment syndrome what action will the nurse first take
Contact the primary care provider and document the findings now
Heart muscle fibers shortened leading to force of contraction
Contractility
Circulating blood volume contributes to
Contributes to blood pressure
Elasticity of the vessel walls contributes to
Contributes to blood pressure
Peripheral vascular resistance contributes to
Contributes to blood pressure
Viscosity of the vessel walls
Contributes to blood pressure
Gender, age, ethnicity, race, marital status, housing, employment status, and education of members
Core community assessment variables
Arise from the base and branch out to the apex of the heart
Coronary arteries
Cardiac veins empty deoxygenated blood into the
Coronary sinus at the base
Occurred during mid to late inspiration
Cracked or Rales
Indicate fibrosis of the lungs or fluid in alveoli And terminal airways
Crackles or rales
Chest hair can sound like
Crackles/rales
FEELS LIKe bubble wrap
Crepitus
Ensure that the disoriented or suicidal patient is safe
Critical intervention
Open the patient's airway Assist the patient breathing
Critical intervention
Protect the cervical spine if the patient is injured
Critical intervention
Provide assistance with circulation (CPR if needed)
Critical intervention
Provide pain management and sedation
Critical intervention
All of starting problems identified during the initial assessment require the initiation of
Critical interventions
Agency policy governance the process documentation of assessment data in the patient's record but as a nurse you continually use critical thinking and clinical judgment to determine the focus, dance, and frequency of assessment documentation.
Critical thinking
Entails Purposeful, outcome directed (result-oriented) thinking
Critical thinking
Is based on the nursing process, evidence-based thinking, in the scientific method
Critical thinking
Is constantly reevaluating, self correcting, and striving to improve
Critical thinking
Is driven by patient, family, and community needs
Critical thinking
Is guided by professional standards and codes of ethics
Critical thinking
Require specific knowledge, skills, and experience
Critical thinking
______ is used by the nurse to decide on the correct route of temperature measurement
Critical thinking
Is also noted in the radius of developing tuberculosis, and infection that primarily affects the respiratory system
Cultural and ethnic variability
People of different cultures have the right to receive
Cultural assessment
Nurses have an ethical, moral, and professional responsibility to conduct
Cultural assessment, create a safe, culturally congruent physical, and emotional environment
Are very powerful and cannot be in a word, many cultures have specific taboos relating to this
Cultural believes and practices surrounding pregnancy care and childbirth
The use of remedies, or consulting someone before the hospital
Cultural believes in expression of illness and pain
Refers to the complex combination of knowledge, attitudes, and skills that a healthcare provider uses to deliver care that considers the total context of the patient situation a cross cultural boundaries
Cultural competence
Cultural factors influence the believes of patients about their health status
Cultural considerations
Group or ethnicity Region Age Degree of acculturation Combination of factors
Cultural differences may relate to
Are known to promote health and healing
Cultural health Assessments and related care
Name of medication, dose, route, and frequency and identify the purpose of each medication because some drugs have more than one use
Current medications and indications
A bluish discoloration of the skin and mucous membranes.
Cyanosis
Level of consciousness, pupils, movement
D-disability
System of documentation organize history by data
DAR
60-80
DBP
D in DAR
Data
Place the extended fingers of the non-dominant hand over the dominant hand to use the pressure of both hands
Deep palpation
Generally has an underlying medical pause that, after being traded, results in the resolving of
Delirium
False belief kept despite non-supportive evidence
Delusion
Example of cognitive impairment
Dementia
Depending on the healthcare setting person at the front desk or in admissions department often collect
Demographic data
Environmental data about exposure to contagious diseases, travel to high-risk areas, and concerns about exposure to pollution, hazards, and allergens
Demographic data
Name, address, and billing information
Demographic data
Occupation and insurance
Demographic data
Percussion conducts sound through
Dense tissue, air, and fluid
Feeling that oneself or one's environment is unreal
Depersonalization
D in SAD PERSONAS
Depression
Feelings characterized by sadness, projection, helplessness, hopelessness, worthlessness, and gloom
Depression
The thoracic nerves H supply surrounding area of Skin horizontally following
Dermatome patterns
Church and religion play in important role is in sustaining peoples
Development, national identity, and survival
Sexual assault is exceptionally high in women with
Developmental disabilities
Based on a nurse's critical thinking
Diagnosis
Data clustering to determine patient's condition
Diagnosis
Is the clustering of data to make a judgment or statement about the patient's difficulty or condition
Diagnosis
North American nursing diagnosis association
Diagnosis
When breathing is triggered the _____ contracts and flattens, pulling the lungs down
Diaphragm
Chest piece
Diaphragm and bell
Relaxing of the heart During contraction is called
Diastole
Twice as long, ventricles fill
Diastole
The lowest pressure
Diastolic blood pressure
Tap fingers directly on the skin
Direct percussion
D in ABCDE stands for
Disability
Can be a computer generated form, a hand filled paper form, or narrative note in the progress notes
Discharge note
When a patient is discharged you enter a
Discharge note in the chart
A patient who visits the clinic has the controllable risk factors of smoking, high fat diet, overweight, decreased activity, and her blood pressure. What concepts should the nurse use when performing patient teaching
Discussed risk factors that the patient is interested in modifying
biomedical model Views health as the absence of
Disease
Sounds and symptoms that are red flags for violence include which of the following
Displaying mood and behavior changes
Can be used for oral and axillary temperatures. Reading are available within one minute. decreases the spread of infection but are less accurate than electronic thermometers
Disposable or Single use thermometer
Any pattern that occurs every 24 hours
Diurnal cycle
Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of
Divergent tactics
I double slash through the line indicates
Divorce
Reduce the annual rate of rape and attempted rape and other sexual assault
Health goals for patient to maintain and promote health
Is an important aspect of violence assessment
Documentation
_______ Of both subjective and objective findings is essential for legal purposes and also to communicate findings to others
Documentation
Involves entering patient information into the written or computer as patient record
Documenting
___ Is used in patients that are difficult to Ausculate or palpate pulse and blood pressure
Doppler
Senses and amplifies changes in sound frequency which is audible as wishing sounds similar to korotkoff sounds
Doppler transducer
In the written record you make corrections by
Drawing a line through the error and placing your initials above the correction
Pneumonia
Dullness
Sure, happiest, soft and putting sound which lacks the vibratory quality ever resident sound. Donis occurs when the air content of the underlying tissue is decreased and it's solidity is increased
Dullness
Difficulty breathing
Dyspnea
When the nurse assesses the client with respiratory symptoms which of the following complaint should be evaluated first
Dyspnea
Involuntary muscle contractions that cause low repetitive movements of abnormal posture can be painful or frightening
Dystonia
Records cardiac electrical changes as specific waves, intervals
ECG
P wave PR interval QRS complex T wave
ECG recordings
S1 and S2 are equal at
ERB point
Henna
East African
Ability to speak in full sentences, accessory muscle use, posture
Effort
The sound of a spoken E changes to A over an area of consolidation
Egophony
Is a technique that assist patients to more completely describe difficulties. You use the responses that encourage patients to say more and continue the conversation.
Elaboration (Facilitation)
The normal artery feel smooth, straight, and resilient this is known as _____ of the artery
Elasticity
High degree of confidence, boastfulness, and critical optimism, and joy accompanied by increased motor activity
Elation
Neglect, financial exploitation, or abandonment
Elder abuse
Permeates use of automated clinical surveillance tools
Electronic medical record
Interfaces medication orders with pharmacy dispensing and allows direct Computer charting of medication administration
Electronic medication administration record
Are fast, safe, and convenient they can accurately measure oral, rectal, and axillary temperatures
Electronic thermometers
Clinical agencies have computerized part or all of patient's medical record
Electronical medical record
Thin, Lines the inside of the heart chambers and valves
Endocardium
The wall of the heart consist of three layers
Endocardium, myocardium, epicardium
With older adults the left atrium _____ and the mitral valve closes more ____
Enlarges Slowly
Support system, housing, healthcare access, literacy
Environmental factors
Thin, Muscular layer on the outside of the heart
Epicardium
A 92-year-old woman with a history of COPD presents with increasing shortness of breath, decreased lung sounds in the bases, increased ankle Adema, and 5 pound weight gain in one week. What is the most likely problem
Excess fluid volume
A patient has dyspnea, Adema, weight gain, and liquid intake greater than output. They symptoms are consistent with which of the following nursing diagnosis
Excess fluid volume
Upper, middle, and lower lung fields are generally separated into approximately
Equal thirds
Validating the importance and difficulty of disclosure is
Essential
E in SAD PERSONAS
Ethanol abuse
Emphasizes the wholeness of the individual is essential to good health. Basic dimensions include biopsychosocial and Spiritual well-being
Eudaimonistic model of health
Excessive sense of emotional and physical well-being inappropriate to the actual situation or environment simulator
Euphoria
Normal respiration rate, rhythm, and effort
Eupnea
Normal respiratory rate, rhythm, and effort is called
Eupnea
Judgment of nursing care efficiency in meeting patient goals and outcomes based on patient responses to nursing interventions
Evaluate
Requires knowledge of care standards, expected patient responses, conceptual models and theories
Evaluate
E in PIE
Evaluation
E in SOAPIE
Evaluation of the problem
No single temperature is normal for
Every person
Helps you solve common problems through four steps
Evidence-based practice
Is an approach to patient care that minimizes intuition and personal experience and instead relies on research findings and high grade scientific support
Evidence-based practice
Appropriate equipment depends on the type of
Examination
Which of the following are components of a comprehensive health assessment
Examination of body systems
Immunizations, health teaching, safety precautions, and nutrition counseling
Examples of Primary prevention
Vision screening, Pap smears, blood pressure screening, hearing tests, scoliosis screening, tuberculin skin testing
Examples of Secondary prevention
Diet teaching for patients with diabetes, and inhaler teaching for patients with lung disease, and exercise programs for those who have had myocardial infarction
Examples of Tertiary prevention
Adult patients may have variations in pulse rate with
Exercise
With comprehensive assessment you should adentify
Expected growth Development patterns Expected variations Aberrations Deviations
Primarily a passive process
Expiration
The intercostal muscles and diaphragm relax decreasing the space in the pleural cavity and passively pushing air out of the lungs
Expiration
In a normal breath, the _____ phase takes more time
Expiratory
E in ABCDE stands for
Exposure
Occur from vibrations during rapid ventricular filling
Extra heart sounds like S3 and S4
Reaction extending beyond elation and accompanied by feelings of Gradeur
Exultation
Very short, and happy attached. Occurs when there is no air present in the underlying tissue
FLatness
Reporting to the primary care provider can occur
Face-to-face, by telephone, by text messaging, or even some settings by fax
True or false percussion is best assessed by simply listening
False
To minimize uncomfortable feelings.
False reassurance
The finger Palmar surface and finger joints Are best for assessing
Firmness, contour, position, size, pain, tenderness
Beginning of ventricular systole, lub
First heart sound
Closure of the tricuspid and mitral valves
First heart sound
There are four different percussion tones in the body
Flat, dull, resonant, and tympanic
Muscle of the Arm or thigh
Flatness
Rapid conversation with logically unconnected shifting of topics
Flight of ideas
You usually document routine scheduled assessment on
Flowsheets
Documentation may be in the form of
Flowsheets, case notes, or care planning
The social context influences the patterns of health and illness for individuals, communities, and societies. An example is assessment of
Focus groups in multiple locations
Occurs in our settings, small in scope but increased depth for specific issues
Focused
Is based on the patient's health issues. This type of assessment can occur in all settings, including the clinic, hospital, and home health setting.
Focused assessment
When patients are straying from a topic and need redirection. This helps when you need to address areas of concern related to current difficulties.
Focusing
Are an important part of cultural nursing assessment because they represent an expression of people's culture and, as such, their consumption may affect individuals physical
Food and nutrition
The nurse notes and irregular radio pulse in a patient further valuation includes assessing
For a pulse deficit
Is enhanced by consolidation and decreased by plural fluid or trapped air
Fremitus
Varies with the patient's needs, purpose of data collection, and healthcare setting. A patient in a long term care setting may need a comprehensive assessment once a month, where as a patient in an acute hospital setting may require an assessment once per shift
Frequency of assessment
Vital signs are checked
Frequently
Focuses on functional patterns all human share
Functional assessment
Health perception, health management, activity, exercise, nutrition, metabolism, sleep, rest, cognition, perception, self perception, rolls, relationships, coping, stress, sexuality, reproduction, and values and believes
Functional assessment
Three major health assessment frameworks
Functional assessment Head to toe assessment Body systems
The nurse conducts the health history based on the patient's responses to the medical diagnosis this type of framework is based on the
Functional framework
Paint can affect the ability to perform common movements and tasks
Functional goal
Are especially important to nursing because they focus on the Effects of health or illness on a patient's quality of life by using this approach you can assess the strengths of patients as well as areas needing improvement
Functional health patterns
S3 and S4 work or commonly called
Gallop
After deoxygenated blood is carried to each land _______ occurs
Gas exchange
Vital signs equipment, scale, flashlight, materials for recording findings
General assessment equipment
______ includes Weight gain or loss, fatigue, weakness, malaise, Pain, usual activity, fever, chills
General health state
Begins upon first meeting the patient and is ongoing
General survey
Begins with the first moment of the encounter with the patient and continues throughout the health history
General survey
Behavior
General survey
Body structure and development
General survey
Facial expression
General survey
Helps to form a global impression of the person
General survey
Hygiene and dress
General survey
Is the first component of the assessment
General survey
Level of consciousness
General survey
Mobility
General survey
No physical appearance, body structure, mobility, and behavior
General survey
Overall appearance
General survey
Skin color
General survey
Speech
General survey
Each type of health assessment begins with a
General survey of the patient, vital signs, and level of distress
Increase risks for respiratory disorders such as cystic fibrosis and alpha-1 antitrypsin deficiency
Genetic patterns of inheritance
This geographic representation allows you to Matt family structures and compile a large amount of information visually
Genograms
Patient outcomes are more specific than
Goals
The anterior to posterior is
Half the transverse
Which of the following interventions is most important to prevent Nosocomial infections
Hand hygiene
Precautions to prevent infection
Hand hygiene, glove use, standard precautions, check for latex allergy, minimize skin reactions
A car is any time one healthcare provider transfers the responsibility for the care of a patient to another
Handoff
Or transfer of care for a patient from one healthcare provider to another, significantly increases the risk of error
Handoff
A perpetrator chooses a victim because of a characteristics such as race, ethnicity, gender, sexuality, or religion and provides evidence that hate motivated to crime
Hate crimes
A history of high or low thyroid hormone level headaches, dizziness, sinus pain, Syncope
Head and neck
Most organized
Head to toe
Data in one functional area is collected from different parts of the body
Head to toe assessment
A seven step process for diagnostic reasoning can be used in the context of
Health assessment
Collect family and personal history for risk factors and past issues
Health assessment
Gathering information about the health status of the patient, analyzing and synthesizing the data, making judgments about nursing interventions based on the findings, and evaluating a patient care outcomes
Health assessment
Nursing process begins with a complete and accurate
Health assessment
The nurse provided teaching about smoking cessation to a 20-year-old man the nurse assesses the the patient is concerned because his father died from lung cancer which theory with the nurse most likely use when providing teaching to this patient
Health belief model
Systematic assessment of individuals, families, and communities regarding their
Health beliefs and values
Increased depression screening by providers
Health goals for patient to maintain and promote health
Reduce maltreatment And maltreatment facilities of children
Health goals for patient to maintain and promote health
Reduce physical assaults
Health goals for patient to maintain and promote health
A health assessment includes
Health history and Additional necessary factors assessed
Peoples cultural believes about health are important and often powerfully influence
Health practices
Facilitate wellness through
Health promotion Teaching
The US Department of health and human services has developed a national model for
Health promotion and risk reduction
The patient clinical record contains record information from all
Healthcare encounters
Focused assessment post treatment
Healthcare setting
Intensive care
Healthcare setting
Long-term care
Healthcare setting
Outpatient setting
Healthcare setting
To provide safe patient care nurse is continually communicate with all members of the
Healthcare team
Resonant
Healthy
The model for health promotion and risk reduction is called
Healthy people
The goal of this project is to increase the length and quality of life for the population of the United States and to illuminate health disparities among different segments of the population
Healthy people model
Data collected through society wide assessments are used to inform
Healthy public policy and broad health promotion initiatives
The pressure in the arteries changes with the contraction and relaxation of the
Heart
Sympathetic nervous system plus parasympathetic nervous system control
Heart rate
Which organs of the body areas does the nurse auscultate as part of the admitting assessment
Heart, lungs, and abdomen
The patient is crying after being given a diagnosis with a poor prognosis the best response from the nurse is
I'll stay with you
Using a cuff that is too small causes a falsely
High blood pressure
The diaphragm is used with firm skin contact to hear
High frequency sounds
Patient issues of top imports should be considered
High priority
Males show a ______ BP than females
Higher
Location Duration Intensity Quality Description Aggravating factors Alleviating factors Pain goal Functional goal
History of present illness
And accurate and complete nursing assessment is an essential foundation for
Holistic nursing care
Divides the right upper and middle lobes of the lungs
Horizontal minor fissure
Duration refers to
How long the sounds last once elicited
Identify the liver congestion with heart failure
How patient and inspection for hepato-jugular reflex
To assess self perception the nurse asks
How would you describe yourself
The recruitment, transportation, transfer, harboring and receipt of people through threats, force, coercion, or deception
Human trafficking
Suspecting possible abuse of patient
Human violence assessment
Resting respiration that is deeper and more rapid than normal
Hyperpnea
A more vibrant, low pH, louder and longer sound heard normally over lungs during maximum inspiration
Hyperresonance
Is not diagnosed and one blood pressure reading along but on average of two or more readings taken on subsequent visits
Hypertension
Body temperature exceeding 101.5°F orally
Hyperthermia
Deep, rapid respiration, which may result from hypoxia, anxiety, exercise, or metabolic acidosis
Hyperventilation
Morbid concern for one's health and feeling he'll without any actual medical basis
Hypochondriasis
SBP less than 90
Hypotension
The ______ is the body's thermostat. It functions to maintain a steady temperature throughout the day
Hypothalamus
Court temperature less than 95°F
Hypothermia
Temperature less than 95°F
Hypothermia
Is shallow, slow respiration that may be related to sedation or increased intracranial pressure
Hypoventilation
Seven step process used within context of health assessment (Diagnosis)
Identify abnormal data, strengths Cluster data Draw inferences Propose nursing diagnosis Check for presence of defining characteristics Confirm or rule out nursing diagnosis Document conclusions
Changes in papillary refill and respiratory rate, rhythm, and effort
Impaired gas exchange
Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes
Implement
Assist with ADLs promote optimal health and independence
Implement
Monitoring health status, prevent, resolve, control a problem
Implement
_______ and then ______ the patient status to determine whether interventions were effective
Implementing Evaluating
Examples of appropriate nursing interventions include
Implementing educational programs, coordinating community resources, and patient/family teaching
Outburst of unpredictable and sudden activity
Impulsiveness
Pulse and blood pressure are difficult to auscultate or palpate in some patients such as those
In shock or with poor peripheral circulation
Not making any sense
Incoherent
Use non-dominant hand as barrier on which to strongly tap
Indirect percussion
Nurses supply nursing process to the care of
Individuals, families, and communities
Changes in respiratory rhythm
Ineffective breathing pattern
Barrel chest is normal in
Infants
Do not park her chest of
Infants
Smaller airways, not fully developed
Infants and children
Computerization of the patient medical record has greatly increased the legibility of
Information
The patient record is not read like a book from beginning to end instead Healthcare providers become skilled at finding
Information quickly
Look, listen, and feel
Initial survey
When gathering the family history the nurse draws a genogram
Inserting lines between parents to show marriage
rapid, deep, labored
Kussmaul
Exaggerated posterior curvature of the thoracic spine associated with aging
Kyphosis
Consciously observing the patient for physical characteristics and behaviors, noting any odors. Initially, observe the patient for overall characteristics including age, gender, level of alertness, body size and shape, skin color, hygiene, Posture, and level of discomfort or anxiety
Inspection
Look the patient over for normal and irregular findings
Inspection
Observation of the patient for general appearance and specific details related to the body system, anatomical region, or condition under examination
Inspection
Observing patient visually for general appearance or specific details
Inspection
Only technique used for every body part/system
Inspection
Pink skin is an example of
Inspection
Provides objective physical data lading to accurate diagnosis and treatment
Inspection
Shape, configuration, symmetry, chest expansion, lesions, spinous process
Inspection
Visualization of general appearance
Inspection
IPPA
Inspection Palpation Percussion Auscultation
Helps determine jugular venous pressure
Inspection of the jugular vein's
Identifies abnormalities
Inspection of the precordium
For physical assessment techniques
Inspection, palpation, percussion, auscultation
Occurs when the intercostal muscles and the diaphragm contract and expand the pleural cavity creating a negative pressure for air to flow actively into the lungs
Inspiration
Limitations in English are not a reflection of
Intellectual functioning
Descriptors of auscultation
Intensity, pitch, Duration, quality, crackles
Violence against adults with disabilities may be
Intentional or unintentional
The center of an intended message belongs to my culture where as the receiver is from another
Intercultural communication
Satisfying interpersonal relationships
Interdependence
Gather all equipment needed for the physical assessment before entering the room to avoid
Interruption and to increase the patient's trust
I in PIE
Intervention
I in SOAPIE
Interventions to treat the problem
Female US immigrants and refugees particularly those who do not speak English or are here illegally are especially vulnerable to
Intimate partner violence
Has been defined as behaviors between spouses or nonmetal partners involving threatened or actual physical or sexual violence, psychological/emotional abuse, and/or coercive tactics when prior physical or sexual violence has took place
Intimate partner violence
In pregnancy is a serious and widespread problem
Intimate partner violence
Most women are comfortable being screened for
Intimate partner violence
Feeling of inpatients, annoyance, and easy provocation to anger
Irritability
Which of the following statements describe the cardiovascular system most accurately
It is a double pump with pulmonary and systemic elements
Slows pressure and right atria
Jugular pulsation
The Venus Neck vessels reflect the pressure in the right atrium because no valve exists between the right atrium and
Jugular vein's
The routine screening assessment includes the most important in common techniques
Kallman and specialty or advanced techniques
Two pulmonary veins return oxygenated blood to the ______ Side of the heart for circulation of the rest of the body
Left
The mitral valve separates the
Left atrium and ventricle
The medical record serves multiple purposes
Legal document, is used for communication among health team members, is used for care planning, quality assurance, financial reimbursement by insurers, education, and research
Note
Lesions, lamps, masses
Posterior thoracic landmarks are
Less important
With incrcreased thoracic size, pressure within the thorax is _____ than atomspheric pressure
Less than
Consensus model for APRN regulation:
Licensure, accreditation, certification, and education
A comprehensive assessment includes assessment of cognitive and emotional development in addition to physical growth this is looked at because of
Lifespan issues
Appropriate for surface characteristics
Light palpation
Finger pads are used with
Light palpation
The patient is complaining of abdominal pain what technique is used to form an overall impression
Light palpation
The temperature of older adults is at the
Lower end of the normal range
Oxygenation and ventilation occur
Lower portion
Occurs when the left ventricle relaxes between beats
Lowest pressure (diastolic)
The ventricles pump blood out into the
Lungs and body
Percussion is loudest over
Lungs and hollow stomach
Is used to assess for severity of alterations in orientation, registration, attention and calculation, recall, and language
MMSE
Assess cognitive function by using the
MMSE or Mini-Cog
Assess memory using
MMSE or Mini-Cog
Bronchophony i is norma/ negative if 99 is
MUffled
Identifies the relationship between cultural variables and hail and have lots the nursing behaviors and skills necessary to carry out effective cultural assessment
Madeleine leininger theory and the sunrise model
Proposes a sensual areas of assessment to better understand the relationship between one's culture and health
Madeleine leininger theory and the sunrise model
The joint national committee VII Dad wants to maintain control blood pressure
Maintain a healthy weight Limit alcohol Exercise regularly Limit sodium Quit smoking Reduce dietary saturated fat and cholesterol
Nurses are _______ when Child, Elder, or vulnerable adult abuse or neglect is disclosed, Assessed, or suspected
Mandated reporters
The heart and greater vessels are located in the
Mediastinum
Is exerted on the walls of the arteries with contraction of the left ventricle at the beginning of Systole
Maximum pressure
Seeking understanding of patients culturally based healthcare practices is essential to nursing because each culture has its own traditional values and believes about health and illness that
May affect patient adherence to treatment
Calculated by adding 1/3 of the SBP and 2/3 of the DBP
Mean arterial pressure
Contains the heart, great vessels, lymph nodes, nerves, and fat
Mediastinum
Membranous partition between the lungs
Mediastinum
The central compartment, located in the middle of the thoracic cavity
Mediastinum
After _____ females have higher BP than males
Menopause
There is no health without
Mental health
Is based on observation of the patient and the patient's responses to your questions
Mental health assessment
Mental health history, medications in use, alcohol use, and illegal drug use
Mental health assessment
Are integral to any full medical or nursing examination even in an examination of the patient without a history of mental illness
Mental health assessment questions
violence that can be assessed during patient's visit include depression, PTSD, panic disorder's, dissociative symptoms, relationship and marital problems, acting out violently, and sexual and substance abuse
Mental health effects associated with violence
You will collect objective data Barb serving the patient and the patient's behavior. This includes not only have a patient communicate and respond to questions but also physical presentation
Mental status examination
Parkinson, cancer, HIV/AIDS
Metabolic issues/psychological processes
May expect you to show warmth to patient and family
Mexican american
Anterior reference lines
Midsternal line, midclavicular line, anterior axillary line
Palmer surface of the fingers are used with
Moderate palpation
Use _______ to assess the size, shape, and consistency of abdominal organs
Moderate palpation
From birth to 10
Monitoring growth, development
When auscultating the patient should be instructed to breathe through
Mouth
When questioning a patient about violence, it is best to
Move from general to specific questions
In the SBAR Reporting format which of the following would be an example of data found in an assessment
Mr. Jones lung sounds or decreased
Thick, muscular, middle layer responsible for the pumping action of the heart
Myocardium
Sufficient innervation
Needed for effective breathing
Pace and extent of safety assessment should be geared to the patients
Needs
Omission
Neglect
Creating or using new words
Neologism
Words created by the patient that are either not easily understood by others or unintelligible
Neologisms
Develops as a potentially Lethal adverse effect of antipsychotic medications, with muscle rigidity, Tremors, altered consciousness, and incontinence, first warning signs are usually hyperthermia, hypertension, and tachycardia
Neuroleptic malignant syndrome
Designed to test neurological responses of the deep tendons to assess for abnormalities of the central and peripheral nervous system
Neurological reflex hammer
A tuning fork is used during what assessments
Neuromuscular assessment and assessment of hearing
Retractions are
Never normal
N in SAD PERSONAS
No spouse
Occurs when you cross the professional boundary relationship and establish social, personal, or economic ties with a patient
Non-professional involvement
False reassurance Sympathy unwanted advice Biased questions Changes of subject Distractions Technical or overwhelming language Interrupting
Non-therapeutic responses
Eyes scanning the room Jumping or easily startled Child is very clingy No Eye contact
Nonverbal behaviors
Is as important as if not more important than verbal communication
Nonverbal communication
Physical appearance, facial expression, Pastor, positioning, gestures, I contact, town of voice, and use of touch
Nonverbal communication
Historically violence between and among siblings has
Not been taken seriously
Return blood to the heart
Numerous veins
Build upon verbal and nonverbal communication within a specific setting differs from personal and social relationships because its foundation is the therapeutic use of self through verbal and nonverbal communication skills
Nurse patient relationship
Records information provider, notes discrepancies, identify as additional sources to confirm history
Nurses role
Sometimes referred to as the nursing history and physical, to obtain patient history and baseline data so that you can individualize care
Nursing admission assessment
Nursing scope and standards of practice ANA further describe ______
Nursing and its associated practice standards
A _________ Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
Nursing diagnosis
A clinical judgment about individual, family or community responses to actual or potential health difficulties/life processes
Nursing diagnosis
The nurse documents the following information in a patient's chart cough and deep breath every hour while awake this is example of
Nursing interventions
Advanced practice registered nurse roles include
Nursing practitioner Certified nurse midwife Certified registered nurse Anesthetist Clinical nurse specialist
A history of conditions that increase the risk of malnutrition or obesity. Nausea, vomiting. Normal daily intake, weight and weight change noting if changes were intentional or not, dehydration, Dryskin, fluid excess with shortness of breath, or Edema in the feet and legs. Diet practice is to promote health
Nutrition and hydration
Persistent, unwanted, reoccurring thoughts
Obsession
Dull
Obstruction/atelectasis
The nurse is caring for a patient with a sudden onset of chest pain which assessment is has priority
Obtain a blood pressure reading
Nurses must consider any potential effects of culturally based practices on Health when doing a social assessment
Of the individual
Also require specialized approach during the general survey and vital signs assessment
Older adults
Nurses belong to the American nurses Association as part of their
Ongoing professional responsibility
Allows patient a broad range of answers
Open ended questions
is a hand hailed system of lenses, lights, and mirrors that enables visualization of the interior structures of the eye
Ophthalmoscope
Hand hygiene is implemented as specific occurrences for
Optimal effectiveness
Is common and comfortable for many patients but it may be contra indicated for others the sub lingual pockets under the tongue are rich in blood supply that responds quickly to changes in the core temperature
Oral route
Not recommended for children younger than six years of age
Oral thermometer's
Cannot be used on patients who were unconscious, or really into baited, confused, or in those who have a history of seizures. I also cannot be used in cases of postoperative oral surgery or oral trauma
Oral thermometers
Five sheets and documentation system often cue you to a specific
Organizational structure
O in SAD PERSONAS
Organized plan
Why are posterior thoracic landmarks Less important
Organs are laying more anterior
Assess consolidation or obstruction/atelectasis
PERCUSSION
Begin with Apex and compare side to side
PERCussion
It's goal is to incorporate the plan of care into the progress note
PIE
Represents the time from the firing of the SA node to the beginning of ventricular depolarization
PR interval
Volume in the right atrium, indicates how much blood will be forwarded to the ventricles
PREload
Fifth vital sign
Pain
The fifth final sign is
Pain
What is an acceptable level of pain
Pain goal
Abdominal assessment Is done with the
Palm
Assessing condition throw sense of touch
Palpation
Clinical touching of specific body areas to assess characteristics
Palpation
Do use of your hands to feel the firmness of body parts such as the abdomen
Palpation
Is the best method for a valuation of the degree and symmetry of expansion with respiration, as well as for appreciation of the transmitted vibrations of a spoken voice
Palpation
Is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and Adema
Palpation
Start with fingertips above scapula, move side to side and compare sides
Palpation
Use of finger pads
Palpation
Assess for cardiac Enlargement
Palpation of PMI
Helps indicate the strength of the pulse
Palpation of the carotid artery's
Assess for masses and tenderness
Palpation of the precordium
Rest and digest reaction
Para sympathetic nervous system
Malformed, round, or invented words
Paraphasias
Lines the thoracic wall, diaphragm, And mediastinum
Parietal pleurae
An investigator who is an outsider to the community strive to address and evaluate intervention outcomes by actively engaging with community members and facilitating change and I culturally sensitive way
Participatory action research approach
Enclose an assessment of medical and surgical problems along with the treatment and course some problems are cute others resolve and others are chronic
Past health history
A primary source in subjective data collection is the
Patient
Use the _______ To implement new interventions, evaluate their effectiveness, and make a difference in the quality of patient care
Patient assessment
With health assessment you should maintain patient _______
Patient confidentiality
Interdisciplinary rounds allow members of different disciplines to share assessment data in an Effort to individualize and improve coordination of patient care
Patient rounds and conferences
Examples of independent nursing interventions include
Patient teaching, therapeutic communication, and physical procedures
Frequency of assessment varies due to
Patients needs, data collection purpose, nurses role, healthcare setting
You simple and clear language at a normal volume for
Patients with limited English
The nurse and the colleague well at the same time assess the Perineal and the apical pulse rates and compare measurements
Post deficit
A method of evaluating the consistency of tissues below the skin by the quality of reflected sounds impalpable vibrations generated by tapping on the body surface
Percussion
Produce sound or illicit tenderness
Percussion
Tapping technique with hands to determine condition of solid or airfilled body areas
Percussion
Tapping to assess condition of hollow or fluid filled space is
Percussion
The use of tapping motions with your hands to produce sound that indicates solid or airfilled spaces over the lungs and other areas
Percussion
Evaluates heart size
Percussion of the precordium
Important physical signs of acute pericarditis
Pericardial friction rub
THE TOUGH fibrous _______ ecloses and protects the heart
Pericardium
Focuses on the most common screening and prevention services for four age groups
Periodic health assessment
With post deficit what are the two pulses checked
Peripheral and apical pulse
Repetitive behavior such as lip licking, finger tapping, pacing, etc.
Perseveration phenomena
Social assessment is predominately by
Personal interviews
Strong, persistent, abnormal fear of an object or situation
Phobia
The 10 leading areas of focus for healthy people are.
Physical activity Overweight and obesity Tobacco use Substance abuse Responsible sexual behavior Mental health Injury and violence Environmental quality Immunization Access to healthcare
Involved in the proper functioning of a living organism
Physical health
The goal of nursing care Is to assist the patient to attain an optimal level of
Physical health, self-concept, well function, interdependence
Assessment includes
Physiological data, psychological data, socio-cultural, spiritual, economic, and lifestyle factors
In addition to intensity or loudness you will listen to
Pitch, duration, and quality of sound
P in SOAP
Plan
Determining resources, targeting nursing interventions, writing plan of care
Plan care
P in SOAP
Plan for treating or improving the problem
Formulation of measurable, realistic, patient centered goals
Plan goals/outcomes
And assessment of the patient allows for the development of a _______ That individualizes the patients goals, outcomes, and interventions
Plan of care POC
Which of the following represents the nurses documentation of a patient with normal mood
Pleasant or appropriate to situation
Two continuous membranes within thorax
Pleurae
Fremitus is decreased by
Pleural fluid and pneumothorax
Contains lubricating fluid, helps maintain negative pressure to enable full expansion
Pleural space
Bronchial breath sounds are heard on the side of the chest with the
Pneumothorax
Hyperresonance
Pneumothorax
You document assessment information as you gather it often using a portable computer
Point of care documentation
Can be found at the intersection of the fifth intercostal space in the left midclavicular line
Point of maximal impulse
Is used to describe the area where the apical Pulsation can be seen or palpated
Point of maximal impulse (PMI)
Respiration is initiated by brainstem
Pons and medulla
Program federally funded aimed at improving cardiovascular health
Potential building blocks
You learn effective interviewing skills through
Practice and repetition
Compiling existing data and preparing for patient interview from existing medical records
Pre-interaction phase
Your description should be as
Precise as possible
Breathing gets harder, diaphragm moves, weight gain
Pregnant women
Make sure the room is warm, comfortable, and relaxing. Ensure a quiet, well lit stating that provides privacy.
Preparation
Collect information about the ________ By beginning with open ended questions and having the patient explain symptoms. A complete description is essential to accurate diagnosis.
Present illness
The intention of standard precautions is to
Prevent disease transmission during contact with non-intact skin, mucous membranes, body substances, and blood-borne contacts
What is the second main goal of nurses
Prevent illness
P in SAD PERSONAS
Previous attempt
Schools, libraries, parks, fire stations
Primary
Major influences that shape worldview, and the extent to which people identify with their culture of origin, are called
Primary and secondary characteristics of culture
Age, gender, nationality, and ethnicity
Primary characteristics of culture
Subjective data
Primary data source
Is used to describe the percussion note found in the normal lung
Resonance
Involve strategies and at preventing problems.
Primary prevention
Data generated from community assessments are grouped into three categories
Primary, secondary, and potential building blocks
The three levels of interventions to promote healthy change are
Primary, secondary, tertiary
Hand hygiene is implemented at specific occurrences for optimal effectiveness occurrences are as follows
Prior to contact with the patient After contact with the patient/environmental equipment After removal of gloves Prior to invasive procedures
Acute assessment
Prioritize
Is an important skill and professional nursing practice. It's multi dimensional nature and need for solid judgment make it challenging to learn
Priority setting
Prioritize assessments and care upon the patient's health care situation
Priority setting
P in PIE
Problem
Advance practice registered nursing is governed and monitored by
Professional organizations, state law, and the consensus model for APRN regulation
Multiple health team members document in a _______ The patient's progress towards recovery
Progress note
The nurse should document the call to the
Protective services hotline
The purpose of comparing culture cares needs of the specific individual to the general theme of people from similar cultural backgrounds is to
Provide a picture of the individuals culture based healthcare needs
To determine if staff members are providing and documenting standards of care
Purpose of auditing charting
Emphysema
QRS complex
Subjective description of sound
Quality
The subjective description of the percussion sound such as a low pH third of short duration vs a drum like sound with high pitch and long duration
Quality
What does the pain/discomfort feel like
Quality/description
With decreased heart rate variability they don't recover as
Quickly
Pitch or frequency depends on how
Quickly the vibration oscillates
Dense tissue
Quiet tones
Make suggestions for what needs to be done to manage the difficulty
R in SBAR
circulates blood to the lower pressure pulmonary system
RIGht side of the heart
Extends from the 4th rib the sternal border to the 5th rib
RML
Of heartrate is greater than 100 May palpate ______ or _______ to identify s1
Radial pulse or visualize the carotid upstroke
Percussion of the heart was replaced by
Radiographs
The nurse may call _______ if they have an intuitive sense that something is going wrong with the patient or if the patient displays dangerous findings
Rapid response team
Palpitations
Rapid throbbing or flattering of the heart/arrhythmia
R in SAD PERSONAS
Rational thought loss
A brief statement usually in the patient's own words about why he or she is making the visit
Reason for seeking care
R in SBAR
Recommendation
Is contraindicated in newborns, infants, and young children, patients who are neutropenic, patients with rectal disease, and those who have undergone rectal surgery. Patient with Hemroids and diarrhea should not have rectal temperatures should also be avoided with patients who have cardiac conditions
Rectal temperature
Considered one of the most accurate methods, it is used one other routes are not practical or when an accurate core rating is necessary.
Rectal thermometer
Is similar to restatement however instead of simply restating the patients comments you summarize the main themes of communication.
Reflection
HIPAA Regulates all areas of information management including
Reimbursement, coding, and security of records
Occurs at handoffs, during patient rounds, during patient and family care conferences, and when calling or texting a provider to report a change in status or provide requested information
Reporting
Suspected violence and risk for harm is also a situation
Requiring urgent attention
Nurses advocate for underserved population's to reduce health disparities this promotes
Respect
What are the nursing values
Respect Unity Diversity Integrity Excellence
Primarily an automatic process
Respiration
Body language, inspection, and arterial blood gas is wise to determine if a patient is in
Respiratory distress
Another standard precautions is
Respiratory hygiene/cough etiquette
Is a count of each full inspiration and expiration cycle in one minute
Respiratory rate
R in DAR
Response
Experienced nurses will assist beginners in determining the level of
Response needed
Relates to the content of the communication. You make a simple statement, usually use in the patient's own words. The purpose is to ask the patient to elaborate.
Restatement
General health state Nutrition Hydration Skin, hair, and nails Head and neck As, ears, nose, mouth, and throat Thorax and lungs Heart, Nate vessels, peripheral vascular Breasts Abdominal gastrointestinal Abdominal urinary Musculoskeletal Neurological Genitalia Anus, rectum, and prostrate Endocrine, hematologic systems
Review of systems
Is a series of questions about all body systems that helps to reveal concerns as part of a comprehensive health assessment
Review of systems
Rattling, coarse sounds cost bad turbulence around mucus in larger airways
Rhonchi
Results from secretions moving around, make clear with coughing
Rhonchi
Agonal
Rhythm
Apneic
Rhythm
Cheyne-Stokes
Rhythm
Interval between beats
Rhythm
Kussmaul
Rhythm
Regular
Rhythm
Ability to adequately perform in roles occupied in society
Role function
Normal range of temperature depends on the
Route used for measurement
Teach patients to constantly weigh themselves at
Same time of day wearing clothing of similar weight
Today nurses perform ______ and ______ to provide care based on current evidence
Scholarship and research
End of systole beginning diastole dub
Second heart sound
Primary care clinic
Secondary
Cultural values, religious beliefs, Morals, occupation, Socio economic status, immigration status, raisins for migration, and believes about hail hailed as important to life and healthy living
Secondary characteristics of culture
Charts and information from family members are considered
Secondary data sources
Includes the early diagnosis of health problems and prompts treatment to prevent complications
Secondary prevention
To be aware of your own biasis, values, personality, cultural background, and communications style. You build such awareness through self reflection and through listening to an understanding feedback from others
Self concept
Mental health
Self-concept
Pulmonic And aortic
Semilunar valves
S in SBAR
Situation
AP diameter
Size
Minimize hand eczema by alcohol-based hand rubs
Skin reactions
Causes increased vasoconstriction blood pressure returns to normal in about 15 minutes after
Smoking
I normal artery feels
Smooth, straight, and resilient
To be effective that your tips must fit into the ear canal
Snugly but comfortably
Identifies the social context influencing the patterns of health and illness for individuals, communities, and societies
Social assessment
Integral to quality nursing care at every level
Social assessment
Diverse research methods
Social assessment at the societal level
Intended to generate information about suicidal trains and relationships among the societal variables and prevalent health concerns
Social assessment at the societal level
Used to identify the ecological risks, disaster preparedness, or post Trumatic stress
Social assessment at the societal level
Used to inform healthy public policy and Broadhale promotion initiatives
Social assessment at the societal level
Assessment involves gathering data to identify community resources, constraints, and high priority health concerns
Social assessment of the community
The scope of social assessment is broader and more complex
Social assessment of the community
Essential for planning long-term management of illness as well as health promotion
Social assessment of the individual
"Krun" Describes a variety of symptoms
Southeast asian
Patients interpret the message that reflects their cultural beliefs often changing the
Speakers intent
Hearing impairment Low level of consciousness Cognitive impairment Mental illness Anxiety/crying Anger Alcohol/drug use Personal questions Sexual aggression
Special situations in interviews
With Carmen and specialty or advanced techniques May add focused or advanced techniques if concerns exist over a
Specific finding
Moderate pace and volume with clear articulation
Speech patterns
Spiritual care within the healthcare contacts must be congruent with the patients
Spiritual beliefs
Even one daily prayers or other religious practices are not a part of the patients laugh routine, they often take a central position during life transitions, such as loss of a loved one, accident, or serious illness. I related nurse diagnosis might be
Spiritual distress
Pertains to matters of the human soul, be it a state of mind, a state of being in the world, a journey of self discovery, or a place outside the five senses
Spirituality
Assess importance of _____ and _____ on patients health
Spirituality and religion
Avoiding deep inspirations due to increased pain with breathing
Splinting
Healthcare organization should maintain a current demographic, cultural, and epidemiological profile of the community as well as needs assessment to accurately plan for an employment services that respond to the cultural and language stick characteristics of the service area
Standard 11
Healthcare organization should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal making isms to facilitate community and patient/consumer involvement in designing and implementing healthcare organization should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal make an isms to facilitate community and patient/consumer involvement in designing and implementing CLAS related activities
Standard 12
Healthcare organization should ensure that conflict and grievance resolution processes are culturally and linguistically Sensitive and capable of identifying, preventing, and resolving cross cultural conflicts or complaints about patient/consumers
Standard 13
Healthcare organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information
Standard 14
Evaluate the research evidence using establish criteria regarding scientific merit
Step 3 in evidence based practice
Choose interventions and justify the selection with the most valid evidence
Step for an evidence-based practice
Clearly identified the issue or difficulties based on an accurate analysis of current nursing knowledge and practice
Step one in evidence-based practice
Search the literature for relevant research
Step two in evidence-based practice
Repetitive imitation of movements
Stereotypy
Bony ridge that joins the sternum to the manubrium
Sternal angle
Conduct sound from the patient's body to the listener and also blocks environmental noise to more clearly pin point the patient's body sounds
Stethoscope
Indicates the volume of blood flowing through the vessel.
Strength
0-4+
Strength scale
Happiest crowing sounds from tracheal or laryngeal spasm is known as
Stridor
Amount of blood ejected with each beat
Stroke volume
S in SOAP stands for
Subjective
S in SOAP
Subjective assessment findings
Are based on patient experiences and perceptions
Subjective data
Based on the signs and symptoms that the patient reports they may not be perceived by observers
Subjective data
Paroxysmal nocturnal dyspnea
Suddenly waking up as fluid is re-distributed from the legs into the lungs
Happens at the end of the interview during the closure phase. You review and condense important information into two or three of the most important findings.
Summarizing
What is the nurses best response when I Amazon patient has a basin of water on his bedside stand that he does not want emptied
Support and accommodate his preferences
A good landmark to use when preparing to examine the patient's chest
Suprasternal notch
Located just above sternum between the clavicles
Suprasternal notch
Muscular and skeletal
Symmetry
Baroreceptors chemoreceptors
Sympathetic nervous system
Emotions increase blood pressure by stimulating the
Sympathetic nervous system
fight Vs flight
Sympathetic nervous system
Is feeling what the patient feels
Sympathy
Cough Sputum production Hemoptysis Dyspnea Wheezing
Symptoms of importance in pulmonary disease diagnosis
identifying and treating human responses to actual or potential health difficulties
Systematic problem solving approach
In a healthy patient the myocardial cells in the ventricle depolarize and contract during
Systole
Squeezing of the heart during contraction is referred to as
Systole
Ventricles contract, ejecta blood to the lungs and the body
Systole
Max pressure
Systolic blood pressure
Represents cellular repolarization, or the restoration of the ventricular resting state, caused by the return of intracellular sodium
T wave
Thoracic nerves
T1-T12
Feel for symmetry of intensity vibrations. Vibrations increase with consolidation as. Sounds move better through consolidation compared to air
TActile fremitis
Slow growing mycobacterium that may form lesions or cavities in the lung
TB
Is a heart rate greater than 100 bpm in an adult
Tachycardia
A rapid, persistent respiratory rate greater than 20 breaths per minute in an adult
Tachypnea
Base of palm or owner surface have patients say 99 and move side to side
Tactile fremitus
Deviation from the central theme of conversation
Tangential
Involuntary an abnormal movements of the mouth, tongue, face, and Jaw, may progress to the Limbs, irreversible condition, may occur in months after anti-psychotic medication use
Tardive dyskinesia
Using too many technical terms or providing too much information
Technical or overwhelming language
If a significant issue or problem with hers you may need to phone or take the primary care provider to report this information
Telephone communication
Factors such as age level of consciousness and presence of medical equipment influence the choice of route for assessing
Temp
Are especially useful and confused or unconscious patients as well as children. Measurement of either the right or left side of the four head is equally effective. Avoid moving the device to quickly across the four head or break in contact with the skin as it can cause inconsistency with the results
Temporal artery thermometer
Quick, safe, and convenient, and they do not require contact with mucous membranes. Measures body temperature by capturing the heat emitted from the skin over the Temporel artery
Temporel artery thermometer
Lesions, lamps, scars, piercings, tattoos
Tender areas
Focuses on preventing complications of an existing disease and promoting health to the highest level
Tertiary prevention
Requires an agency to make Reasonable effort to limit the use of, disclosure of, and requires for protected health information to the minimum necessary to accomplish the intended purpose
The HIPAA privacy rule
Right and depth of respiration change with the demands of
The body
The great vessels originate from the base of the heart and then turn in the direction of
The body part that they supply
What technique facilitates accurate auscultation
The chestpiece of the stethoscope is sealed against the skin
Social assessment of the community process begins with assessment of various social, economic, and environmental, and quality of life health and the caterers in their relationship with
The communities health concerns
The patient's family should not be present during interview with the patient about violence because
The family member may be the perpetrator of abuse and does the patient may be hesitant to honestly answer questions
An issue of top important to a patient should also be considered high priority for
The nurse
Mandatory reporting is the role of
The nurse
If abuse or neglect is disclosed, as a yes, or suspected the nurse must call
The protective services hotline
The pulmonic valve lies between
The right ventricle and pulmonary artery
With preparation
The room should be well it warm in the patient should see it at first and then lay down
The ____________ Describes nursing duties and work in tandem with the nursing process which consists of assessment, diagnosis, outcome identification, planning, implementation, and evaluation
The scope and standards of practice
The aortic and Pulmonic valve's close producing
The second heart sound
Enclose the sternum and clavicle anteriorly, scapulae, and 12 vertebrae posteriorly and 12 pairs of ribs
Thoracic cage
Subcostal
Thoracic muscle
Levator costarum
Thoracic muscles
Serratus posterior
Thoracic muscles
Transverse thoracic
Thoracic muscles
intercostals
Thoracic muscles
Sudden cessation of flow of thought and speech related to strong emotions
Thought blocking
Delusion that others can hear ones thoughts
Thought broadcasting
Admission assessment in skilled nursing facility is performed within
Three days
The thoracic cavity contains
Three main compartment's
At the base of the neck
Thyroid gland
Involuntary twitching and jerking of muscles, usually above the shoulders
Tics and spasms
You must enter assessment data into the record in a
Timely manner
What is the fourth main goal of nurses
To advocate for individuals, families, communities, and populations
(State of optimal functioning or well-being with physical, social, and mental components)
To promote health
What is the first Main goal nurses have
To promote health
Nurses should provide information about safety and resources
To the patient
What is the third main goal of nurses
To treat human responses to illness or health
Life-threatening situation is
Top priority
Loud, harsh, turbulent sound heard over the sternal notch
Tracheal
Should be in the midline. May deviate slightly to the right in older patients
Tracheal position
Abnormal movements from side effects of medications might be described as
Uncoordinated
Warms, moisturizer, and transport air to the lower portion
Upper portion
Responsible for moisturizing inhaled air and filtering noxious particles
Upper respiratory tract
Questions about violence and harm to self or others
Urgent mental health assessment
The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high fat/high calorie diet this critical thinking
Uses subjective data to analyze findings and intervene
Which of the following processes is the most important when providing nursing care to an I'll patient
Using critical thinking
Soft, low pH, found at distal airways,
VESicular BS
The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to
Values
Include the jugular vein's, superior vena cava, inferior vena cava, and pulmonary arteries
Venous great vessels
The two semi lunar valve separate the
Ventricles from the great vessels
With health assessment you should observe the patients
Verbal and nonverbal communication
Written information in the native language supports
Verbal communication
Effective interviewing skills Speech patterns Patients with limited English
Verbal communication skills
Differing communication styles of nurses/doctors
Verbal handoff potential communication barriers
Ethnic background differences
Verbal handoff potential communication barriers
Poor clinical decision making regarding patient data
Verbal handoff potential communication barriers
Relationship hierarchy questions
Verbal handoff potential communication barriers
Responsibility/contact ambiguity
Verbal handoff potential communication barriers
Posterior Reference Lines
Vertebral line Posterior axillary line Mid-axillary line
Normal quiet wishing noise of airflow through small airways
Vesicular
This sounds heard over normal lung parenchyma are called
Vesicular breath sounds
What would indicate that inhaled bronchiodilator's have been effected
Vesicular breath sounds, O2 saturation 96%, pink
Right of intimate partner violence or higher in
Veterans with posttraumatic stress disorder
Encompassing temperature, pulse, respiration, and blood pressure, or important indicators of the patients physiological status and response to the environment.
Vital signs
Have the patient rest for at least five minutes before taking
Vital signs
Reflex health status, cardio pulmonary function, and overall body function
Vital signs
Temperature, pulse, respiration, and blood pressure make up
Vital signs
Remove clothing constricting upper alarm for
Vital signs blood pressure
Portable device is usually on a stand that nurses can wheel from one room to another
Vital signs monitor
patients may confuse coughing up blood with
Vomiting blood
Happiest, indicates narrowing or partially obstructed airways
WHEEZES
Relatively common form of violence involves witnessing killing of friends and fellow service people, initially killing and injuring other humans, and being intentionally injured or potentially killed
War related violence
Holding body posture that is imposed by another person for a long time
Waxy flexibility
Arm BP Thigh BP Orthostatic BP
Ways to take BP
Ask patient to whisper 123
Whispered pectoriloquy
Happiest, intensified speech heard over area of consolidation when the patient is asked to whisper low pitched words
Whispered pectoriloquy
Do you have any thoughts of wanting to kill or harm yourself? Is a common question to assess for suicidal ideation because it
Will cover both suicidal and Parasuicidal thoughts
Disconnected and incoherent combination of phrases, words, and sentences
Word salad
Collect data about asking specific questions
Working phase
In what phase of the interview are open ended questions used
Working phase
The nurse is gathering the health history data before performing the physical assessment this phase of the interview process is the
Working phase
The complaint of dyspnea after walking up a flight of stairs is
Worrisome
The mother of an infant with severe asthma is extremely anxious the nurses treating the patient in the emergency room when collecting the history the best response of the nurse is
You seem worried but I need to ask if you questions
Many young people witness, participate, and are victimized by violence in and around their schools and neighborhoods
Youth and school valance
Suicidal idealization is a common symptom of
altered mental health
Automated clinical surveillance tools Requires timely input of
assessment data
Cardiac output contributes to
blood pressure
Diaphoresis, fatigue, Edema are common _______ symptoms
cardiovascular symptoms
Trance like state with loss of voluntary motion
catalepsy
Pneumothorax
collapsed lung
With transcultural assessment the nurse must
determine which questions to ask
orthopnea
difficulty breathing when lying down
BMI >40
extreme obesity
Most important transmission prevention strategy
hand Hygiene
Barrel chested
having a large rounded chest
BMI 18.5-24.9
normal
Vesicular
normal breath sounds
BMI >30
obese
Is the active breathing, which supplies oxygen to the body and vital organs and aluminates carbon dioxide
respirations
Abnormal curvature of the spine
scoliosis
Needed for effective breathing
strength