NUR235 Exam 1 Study Guide
Know IASP and McCaffery's definitions of pain. ALWAYS use McCaffery's.
-The International Association for the Study of Pain (IASP) has defined pain as "an unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage" -McCaffery's: "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.
What factors contribute to a client's blood pressure?
-cardiac output -distensibility of the arteries -blood volume -blood velocity -blood viscosity (thickness)
Know the "key points" to remember during a PE for pain.
-choose an assessment tool that is reliable and valid to the client's culture. -explain to the client the purpose of rating the intensity of pain. -ensure the client's privacy and confidentiality. -respect the client's behavior toward pain and the terms used to express it. -understand that different cultures express pain differently and maintain different pain thresholds and expectations.
Appearance & Movement: Normal
-posture: relaxed, with shoulders back and both feet stable -gait: smooth, coordinated movements; client alters position occasionally -motor movements: same as above -dress: clothes fit and are appropriate for occasion and weather -hygiene: skin clean, nails clean and trimmed -facial expression: good eye contact, smiles/frowns appropriately -speech: clear with moderate pace
Summary & Closure Phase
-summarize the information obtained during the working phase and validate the problems and goals with the client -you may begin to discuss possible plans to resolve the problems (nursing diagnoses and collaborative problems) -allow the client time to express feelings, concerns, and questions
Know what measurements are included when we discuss "Vital Signs".
-temperature -pulse -respirations -blood pressure -pain
What does the nursing health assessment comprise?
A nursing health assessment can be defined as the *systematic collection of subjective data stated by the client and objective data observed by the nurse used to make nursing judgments* (nursing diagnoses, collaborative problems, and referrals).
When does the collection of the health history occur?
A nursing health history usually *precedes the physical assessment and guides the nurse as to which body systems must be assessed*. It also assists the nurse in establishing a nurse-client relationship and allows client participation in identifying problems and goals
LOC: Normal
Alert and awake with eyes open and looking at examiner; client responds appropriately
What else should the nurse do to facilitate data collection?
Accept the client; display a nonjudgmental attitude. Use silence to help the client and yourself reflect and reorganize thoughts. Provide the client with information during the interview as questions and concerns arise. Note that not all clients can read. Basic care terms can be communicated best by using pictures
Know how to assess temperature. Study temporal arterial, tympanic, oral, and axillary. How does the nurse choose how to assess temperature? How is each measured, what are pros and cons? What does it mean clinically if temperature is higher than 99.9 or lower than 96? When is temperature naturally on higher end of normal and lower end of normal and what causes this?
Know that "normal" body temperature is *96 to 99.9 degrees Fahrenheit* (we will use 96-99.9 regardless of how it was measured).
How will the nurse alter exam techniques in the geriatric client?
To avoid fatiguing the older client, *allow rest periods* between parts of the physical assessment. Provide a room with a *comfortable temperature* setting and no drafts, close to the restroom. Allow *sufficient time for the client to respond* to directions and to change positions. *Use silence* to provide more time for the client to process thoughts and respond. If possible, assess geriatric clients in a setting where they have an opportunity to perform normal activities of daily living to determine their optimum potential. Conduct the examination in an area with ample space to accommodate wheelchairs and other supportive devices.
How does the nurse collect subjective data from a patient who is angry, anxious, manipulative, depressed?
*Angry client:* Approach in a calm, reassuring, in-control manner. Allow ventilation of client's feelings. Avoid arguing and provide personal space. *Anxious client*: Approach with simple, organized information. Explain your role and purpose. *Manipulative client:* Provide structure and set limits. *Depressed client*: Express interest and understanding in a neutral manner.
Pack Year
# of packs smoked a day *x* number of years they have smoked
Define acute versus chronic pain. What is cancer pain?
*Acute pain:* usually associated with an injury with a *recent onset* and duration of *less than 6 months* and usually *lasts less than a month* *Chronic nonmalignant pain*: usually associated with a specific cause or injury and is described as a *constant pain that persists for more than 6 months* *Cancer pain*: often due to the *compression of peripheral nerves or meninges* or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration
How do the affective and cognitive dimensions affect pain?
*Affective dimension*: influence of negative and positive emotions; affective consequences of pain, including suffering; and impact of pain on mood, sleep, socialization *Cognitive dimension*: personal beliefs, attitudes, and meanings attached to pain experience and/or the disease condition associated with the pain; spiritual beliefs, community, culture, family, and social networks related to cognitive responses to pain
Review the Present Health Concerns chart, Questions and Rationale for asking them (7)
*Are you experiencing pain now or have you in the past 24 hours?* This helps to establish the presence or absence of perceived pain. *Where is the pain located?* The location of pain helps to identify the underlying cause. *Does it radiate or spread?* Radiating or spreading pain helps to identify the source. For example, chest pain radiating to the left arm is most probably of cardiac origin, while pain that is pricking and spreading in the chest muscle area is probably musculoskeletal in origin. *Are there any other concurrent symptoms accompanying the pain?* Accompanying symptoms also help to identify the possible source. For example, right lower quadrant pain associated with nausea, vomiting, and the inability to stand up straight is possibly associated with appendicitis. *When did the pain start?* The onset of pain is an essential indicator for the severity of the situation and suggests a source. *What were you doing when the pain first started?* This helps to identify the precipitating factors and what might have exacerbated the pain. *Is the pain continuous or intermittent?* The pain pattern helps to identify the nature of the pain and may assist in identifying the source. *If intermittent pain, how often do the episodes occur and for how long do they last?* Understanding the course of the pain provides a pattern that may help to determine the source. *Describe the pain in your own words.* Clients are quoted so that terms used to describe their pain may indicate the type and source. The most common terms used are throbbing, shooting, stabbing, sharp, cramping, gnawing, hot/burning, aching, heavy, tender, splitting, tiring/exhausting, sickening, fearful, and punishing. *What factors relieve your pain?* Relieving factors help to determine the source and the plan of care. *What factors increase your pain?* Identifying factors that increase pain helps to determine the source and helps in planning to avoid aggravating factors. *Are you on any therapy to manage your pain?* This question establishes any current treatment modalities and their effect on the pain. This helps in planning the future plan of care. *Is there anything you would like to add?* An open-ended question allows the client to mention anything that has been missed or the issues that were not fully addressed by the above questions.
Define cutaneious, visceral, deep somatic, radiating, referred, phantom, neuropathic, and intractable pain.
*Cutaneous pain*: skin or subcutaneous tissue *Visceral pain:* abdominal cavity, thorax, cranium *Deep somatic pain*: ligaments, tendons, bones, blood vessels, nerves *Radiating*: perceived both at the source and extending to other tissues *Referred:* perceived in body areas away from the pain source *Phantom pain*: perceived in nerves left by a missing, amputated, or paralyzed body part *Neuropathic pain* causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels *Intractable pain* is defined by its high resistance to pain relief
How will the nurse alter exam techniques in a pediatric client age 1 month to 18 years?
*Establishing rapport with the child and caregiver* is the most essential step in obtaining meaningful physical assessment data. Allowing time for interaction with the child before beginning the examination helps to reduce fears. Allowing the child to use play medical instruments and/or allowing the child to touch and see instruments used, such as the stethoscope, otoscope, and ophthalmoscope may reduce anxiety and fear, making use of instruments more accepting by the child. In certain age groups, portions of the assessment will require physical restraint of the pediatric client with the help of another adult. Intermingling distraction and play throughout the examination assists in maintaining rapport with the pediatric client. Involving assistance from the child's parent or guardian may facilitate a more meaningful examination of the younger child. Based on the child's responses, prepare to alter the order of the assessment and your approach to the child. For infants and small children, the examiner should use a pediatric stethoscope to auscultate the heart and the lungs. If a pediatric stethoscope is not available, use of the bell of the adult scope. Protest or an uncooperative attitude toward the examiner is a normal finding in children from birth to early adolescence, throughout parts or even all of the assessment process. If another member of the health care team is needed to help restrain the child, allow the parent to comfort the child after the procedure.
Know the guidelines Weber (2018) recommends for documenting data. Be able to apply.
*Make notes* as you perform the assessments, and document as concisely as possible. *Avoid documenting with general nondescriptive or nonmeasurable terms* such as normal, abnormal, good, fair, satisfactory, or poor. Instead, use specific descriptive and measurable terms (e.g., 3 in in diameter, red excoriated edges, with purulent yellow drainage) about what you inspected, palpated, percussed, and auscultated. *Keep confidential all documented information in the client record*. Most agencies require nurses to complete the Health Insurance Portability and Accountability Act (HIPAA, 1996) training to ensure that the use, disclosure of, and requests for protected information are used only for intended purposes and kept to a minimum. Clients must also be educated on their rights in relation to HIPAA. *Document legibly or print neatly in nonerasable ink*. Errors in documentation are usually corrected by drawing one line through the entry, writing "error," and initialing the entry. Never obliterate the error with white paint or tape, an eraser, or a marking pen. Keep in mind that the health record is a legal document. *Use correct grammar and spelling*. Use only abbreviations that are acceptable and approved by the institution. Avoid slang, jargon, or labels unless they are direct quotes. *Avoid wordiness that creates redundancy*. Record: "Bowel sounds present in all quadrants at 36 per minute." *Use phrases instead of sentences to record data*. Record: "Bilateral lung sounds clear." *Record data findings, not how they were obtained*. Record: "has 3-year history of hypertension treated with medication. BP sitting right arm 140/86, left arm 136/86." *Write entries objectively without making premature judgments or diagnoses*. Use quotation marks to identify clearly the client's responses. For example, record: "Client crying in room, refuses to talk, husband has gone home" instead of "Client depressed due to fear of breast biopsy report and not getting along well with husband." Avoid making inferences and diagnostic statements until you have collected and validated all data with client and family. *Record the client's understanding and perception of problems.* For example, record: "client expresses concern regarding being discharged soon after gallbladder surgery because of inability to rest at home with six children." *Avoid recording the word "normal" for normal findings*. For example, do not record: "liver palpation normal." Instead record: "liver span 10 cm in right MCL and 4 cm in MSL. No tenderness on palpation." Also avoid using the terms good, fair, poor, sometimes, occasional, frequently, recently, or some. Instead use specific quantitative or qualitative descriptive terms. *Record complete information and details for all client symptoms or experiences*. Record: "client reports aching-burning pain in lower back for 2 weeks. Pain worsens after standing for several hours. Rest and ibuprofen used to take edge off pain. No radiation of pain. Rates pain as 7 on scale of 1 to 10." *Include additional assessment content when applicable*. For example, include information about the caregiver or last physician contact. *Support objective data with specific observations obtained during the physical examination.* For example, when describing the emotional status of the client as depressed, follow it with a description of the ways depression is demonstrated such as "dressed in dirty clothing, avoids eye contact, unkempt appearance, and slumped shoulders."
Know cultural variations for pain: Meaning, Expression, and Treatment.
*Meaning*: Asians may associate pain with atoning for sins. Many Westerners believe pain is a sign of physical illness. Some Westerners of traditional religions believe pain can enhance spiritual well-being. *Expression*: Some cultures, such as Asian, Irish, and others, assume a stoic approach and avoid expressing pain. Latin cultures and others express pain openly and loudly with moaning, crying, etc. *Treatment:* Many cultures promote folk, alternative, or complimentary therapies as pain treatment, or use them in addition to pain medications.
How are objective data collected?
*Objective data are:* -data that are directly observed by the nurse -measurements reported by other health care professionals -observations noted by the family or significant others about the client:* -Data directly or indirectly observed through measurement -Observations and physical assessment findings of the nurse or other health care professionals Documentation of assessments made in client record Observations made by the client's family or significant others -Observation and physical examination -Inspection -Palpation -Percussion -Auscultation -Respirations 16 per minute -BP 180/100, apical pulse 80 and irregular -X-ray film reveals fractured pelvis
How does the nurse adjust subjective data collection for pediatric clients & older adults?
*Pediatric:* -Use language that is familiar for the appropriate age. -Involve the parent and/or significant other when interviewing the child to achieve accurate information. -Allow the child to sit with parent, or in parent's lap, if desired *Older:* -Use a gentle, genuine approach. -Use simple, straightforward questions in lay terms. -Let the client set the pace of the conversation. Be patient and listen well. -Allow ample time. -Introduce yourself, but remember that an older client may forget your name; you may have to write it for the client later in the interview. -Use direct eye contact and sit at client's eye level; establish and maintain privacy (especially important). -Assess hearing acuity; with loss, speak slowly, face the client, and speak on the side on which hearing is more adequate. Speak louder only if you confirm the client has a hearing deficit. Turn off any background noises. -Wear a nametag and provide written notes for the client to refer to in the future
How does the nurse collect data from a patient who is experiencing sensitive issues (sexuality, dying, spirituality)?
*Sensitive issues (e.g., sexuality, dying, spirituality):* Be aware of your own thoughts and feelings. These factors may affect the client's health and need to be discussed with someone. Such personal, sensitive topics may be referred when you do not feel comfortable discussing these topics
Know what SBAR stands for and what is involved in each. See Box 3-1.
*Situation:* State concisely why you need to communicate the client data that you have assessed. (e.g., Mary Lorno, age 18, is experiencing a sudden onset of periumbilical pain.) *Background:* Describe the events that led up to the current situation. (e.g., client first noticed periumbilical pain at 10:30 am. She denies any precipitating factors.) *Assessment:* State the subjective and objective data you have collected. (e.g., Subjective: Client rated pain as 7-8 on a scale of 0 to 10 at onset and now rates the pain as 3-4 on a scale of 0 to 10. She denies nausea, vomiting, and diarrhea. She voices anorexia. Eating and drinking exacerbates the pain and lying in a knee-chest position diminishes pain. Describes the pain as "stabbing." Objective: Client is awake, alert, and oriented. She makes and maintains conversation. Does not appear to be in acute distress. T—98.7, P—72, R—16, BP—112/64. Color pink. Skin warm and dry. Mucous membranes moist. Abdomen flat without visible pulsations. Bowel sounds present and hypoactive. Abdomen tympanic upon percussion. Abdomen is soft. Light palpation reveals minimal tenderness in RLQ. Deep palpation reveals minimal tenderness in RLQ. Rovsing sign is negative. Obturator sign is negative. No rebound tenderness noted.) *Recommendation*: Suggest what you believe needs to be done for the client based on your assessment findings. (Example: Suggest that the primary care provider come to further assess the client and intervene.)
How does the nurse auscultate and what is he/she listening for?
-*Auscultation is listening for various breath, heart, vasculature, and bowel sounds using a stethoscope.* Use a good stethoscope that has the following: -snug-fitting earplugs -tubing not longer than 38.1 cm (15 in) and internal diameter not greater than 2.5 cm (1 in) -diaphragm and bell
nurse MUST use a light source.
-*Inspection is using the senses of vision, smell, and hearing to observe the condition of various body parts, including any deviations from normal* -expose body parts being observed while keeping the rest of the client properly draped. -always look before touching. -use good lighting; tangential sunlight is best; be alert for the effect of bluish red-tinted or fluorescent lighting that interferes with observing bruises, cyanosis, and erythema -provide a warm room for examination of the client -observe for color, size, location, texture, symmetry, odors, and sounds
How does the nurse palpate and what is he/she feeling for? Which parts of hands are used to feel pulsations, vibrations, and temperature? Study "light" palpation only.
-*Palpation is touching and feeling body parts with your hands to determine the following characteristics:* Texture (roughness/smoothness) Temperature (warm/hot/cold) Moisture (dry/wet/moist) Motion (stillness/vibration) Consistency of structures (solid/fluid filled)* Keep your fingernails short. Use the most sensitive part of the hand to detect various sensations Perform light palpation before deep palpation. Palpate tender areas last. Use four different types of palpation, depending on the purpose of the exam
How does the nurse percuss and what data does it elicit? NOTE: In this course, we will ONLY use percussion to determine whether the client is experiencing costovertebral angle (flank) pain.
-*Percussion is tapping a portion of the body to elicit evidence of tenderness or sounds that vary with the density of underlying structures. The reliability of this technique is often questioned due to variations in the specificity and sensitivity of percussion* -to detect tenderness over organs (e.g., kidneys) -place one hand flat on the body surface and use the fist of the other hand to strike the back of the hand flat on the body surface
Working Phase
-*facilitate the client's comments about:* major biographical data reason for seeking health care history of present health concern past health history family history review of body systems for current health problems lifestyle and health practices developmental level functional health pattern responses -use critical thinking skills to listen for and observe cues and to interpret and validate the information received from the client -collaborate with the client to identify problems and goals -the approach used for facilitation may be either free-flowing or more structured with specific questions, depending on available time and type of data needed
General Survey: Normal
-*physical development for age*: appears to be stated chronologic age -*dress*: dressed for occasion -*posture & gait*: erect posture. Gait is rhythmic, smooth, steady, and coordinated with arms swinging at side -*body build:* a wide variety of body types fall within a normal range: from small amounts of fat and muscle to larger amounts of fat and developed muscle Body proportions are normal. Arm span (distance between finger tips with arms extended) is approximately equal. The distance from the head crown to the symphysis pubis is approximately equal to the distance from the symphysis pubis to the sole of the client's foot -*gender & sexual development*: appropriate for age and gender -*skin color & condition:* varies from light to dark skinned. Color is even without obvious lesions: light to dark beige pink in light-skinned client; light tan to dark brown or olive in dark-skinned clients. Underlying red tones from good circulation give a liveliness or healthy glow to all shades of skin color
How does the nurse assess orthostatic (postural) hypotension? Know that a drop of 20 mmHg or more from sitting BP may indicate orthostatic (postural) hypotension.
-If the client takes antihypertensive medications or has a history of fainting or dizziness, assess for possible orthostatic hypotension by measuring the blood pressure and pulse with the client in a standing or sitting position after measuring the blood pressure with the client in a supine position -A drop of less than 20 mm Hg from recorded sitting position -A drop of 20 mm Hg or more from the recorded sitting blood pressure may indicate *orthostatic (postural) hypotension*. Pulse will increase to accommodate the drop in blood pressure. Orthostatic hypotension may be related to a decreased baroreceptor sensitivity, fluid volume deficit (e.g., dehydration), or certain medications (i.e., diuretics, antihypertensives) Symptoms of orthostatic hypotension include dizziness, lightheadedness, and falling Further evaluation and referral to the client's primary care provider are necessary HOW TO: 1. place cuff on/leave on 2. measure the BP with client in supine position 3. measure the BP with client in a sitting position 4. measure the BP with client in standing *cannot delegate*
Oral route
-PROs: cost effective, not as long -CONs: cant talk
Tympanic route
-PROs: quick, easy, accessible -CONs: expensive
Temporal route
-PROs: quick, effecient, noninvasive -CONs: expensive, learning curve
What questions are appropriate to use to elicit subjective data regarding cognitive issues?
-Past mental health diagnoses? -Counseling services? injury, meningitis, encephalitis, stroke? Headaches? -Served active duty in armed forces? -Difficulty breathing, dizziness, nausea and vomiting, heart palpitations? -Eating and bowel habits, family history of mental health disease, Alzheimer's disease? -Coping patterns? -Pattern activities of daily living (energy level, sleep patterns, eating habits)? -Use of over-the-counter and prescribed drugs? Use of alcohol? Use of drugs?
Know types of respirations "apnea", "bradypnea", "tachypnea".
-apnea: absence of respiration -bradypnea: slower than 12/min (dont really worry until 8), shallow respiration -tachypnea: more than 20 breaths/min and regular
Know BP is a measurement of pressure in arteries during contraction (systole) and relaxation (diastole).
-blood pressure reflects the *pressure exerted on the walls of the arteries* -this pressure varies with the cardiac cycle, reaching a high point with systole and a low point with diastole. Therefore, blood pressure is a *measurement of the pressure of the blood in the arteries when the ventricles are contracted* (systolic blood pressure) and *when the ventricles are relaxed* (diastolic blood pressure) -blood pressure is expressed as the ratio of the systolic pressure over the diastolic pressure
Thoughts process & perceptions: Abnormal
-clarity & content: expressed thoughts are jumbled, confusing, and not reality oriented ---repetition and expression of illogical thoughts are seen with schizophrenia ---rapid flight of ideas with manic phases ---irrational fears with phobias ---delusions seen with psychotic disorders, delirium, and dementia ---illusions seen with acute grief, stress reactions, schizophrenia, and delirium ---hallucinations with organic brain disease or psychotic illness -perceptions: is unable to follow through with directives; perceptions unrealistic and inconsistent with yours and others -judgment: impaired judgment may be seen in organic brain syndrome, emotional disturbances, mental retardation, or schizophrenia -suicidal tendencies: clients who are suicidal may share past attempts of suicide, give plan for suicide, verbalize feelings of worthlessness about self, joke about death frequently. Clients who are depressed or feel hopeless are at higher risk for suicide. Clients who have depression early in life have an increased risk for dementia
Thought process & perceptions: Normal
-clarity & content: expresses full and free-flowing thoughts during interview -perceptions: follows directions accurately; perceptions realistic and consistent with yours and others -judgment: answers to questions are based on sound rationale -suicidal tendencies: verbalizes positive, healthy thoughts about the future and self
Know how to assess respiratory rate.
-do NOT let patient know you are counting this -place client's arm across the chest and continuing to count after HR and counting for 30 seconds and multiply by 2 -know rate is "normally" 12 to 20 breaths/min and regular.
Which agency(ies) oversee documentation?
-documentation of assessment data is crucial as evidenced by state nurse practice acts, accreditation and/or reimbursement agencies (e.g., *The Joint Commission on Accreditation of Healthcare Organizations [TJC], Medicare, Medicaid*), professional organizations (local, state, and national), and institutional agencies (acute, transitional, long term, and home care)
How does the nurse approach a client from another culture?
-cultural variations in communication and self-disclosure styles may seriously affect the information obtained -be aware of possible variations in the communication styles of yourself and client -if misunderstanding or difficulty in communicating is evident, seek help from a "culture broker" who is skilled at cross-cultural communication
Mood: Abnormal
-feelings: Expresses feelings inappropriate to the situation (e.g., extreme anger or euphoria) -expressions: Expresses dissatisfaction with self, others, and life in general; verbalizes negative coping mechanisms (use of alcohol, drugs, etc.) ---prolonged negative feelings seen with depression ---elation, and high energy seen with manic phases ---excessive worry seen in obsessive-compulsive disorders ---eccentric moods not relevant to situation are seen in schizophrenia
Mood: Normal
-feelings: responds appropriately to the topic discussed; expresses feelings appropriate to the situation -expressions: expresses good feelings about self, others, and life; verbalizes positive coping mechanisms (talking, support systems, counseling, exercise, etc)
Introductory Phase
-introduce yourself and describe your role (e.g., RN, student) -address the client by surname -next, explain the purpose of the interview to the client (i.e., to collect data, to understand the client's needs, and to plan nursing care) -discuss the types of questions that will be asked, reason for taking notes, electronic documentation, and assure client that confidential information will remain confidential using HIPAA -ensure client comfort and privacy, and conduct the interview at eye level to show respect -convey a sense of priority and interest in the client
How does the nurse protect privacy?
-maintain privacy and proper draping; make sure the examination area has adequate lighting and a comfortable temperature (provide blanket if necessary) -explain the procedure and purpose of each part of the examination to the client
Know the assessments and "abnormal" findings which may indicate pain.
-observe posture: client appears to be slumped with the shoulders not straight (indicates being disturbed/uncomfortable). Client is inattentive and agitated. Client might be guarding affected area and have breathing patterns reflecting distress -observe facial expressions: client's facial expressions indicate distress and discomfort, including frowning, moans, cries, and grimacing. Eye contact is not maintained, indicating discomfort. -inspect joints & muscles: edema of a joint may indicate injury or arthritis. Pain may result in muscle tension. -observe skin for scars, lesions, rashes, changes, or discoloration: bruising, wounds, or edema may be the result of injuries or infections, which may cause pain.
Know components of general survey, how to assess general survey, whether findings are "normal" or "abnormal".
-physical development for age -dress -posture & gait -body build -gender & sexual development -skin color & condition
General Survey: Abnormal
-physical development for age: appears older than age with evidence of hard manual labor, chronic illness, or alcoholism/smoking -dress: dress bizarre and inappropriate for occasion ----seen in mentally ill, grieving, depressed, or poor clients -posture & gait: curvatures of the spine (lordosis, scoliosis, or kyphosis) may indicate a musculoskeletal disorder ---stiff, rigid movements are common in *arthritis or Parkinson disease* ---slumped shoulders may signify *depression* ---clients with chronic pulmonary obstructive disease tend to lean forward and brace themselves with their arms -body build: ---lack of subcutaneous fat with prominent bones seen in the malnourished ---abdominal ascites seen in starvation ---abundant fatty tissue seen in obesity ---extreme weight loss is seen in anorexia nervosa Decreased height and delayed puberty, with chubbiness, are seen in *hypopituitary dwarfism* Skeletal malformations with a decrease in height are seen in *achondroplastic dwarfism*. In *gigantism*, there is increased height and weight with delayed sexual development Overgrowth of bones in the face, head, hands, and feet with normal height is seen in *hyperpituitarism* Arm span is greater than height, and pubis to sole measurement exceeds pubis to crown measurement in *Marfan syndrome* Excessive body fat that is evenly distributed is referred to as *exogenous obesity*. Central body weight gain with excessive cervical obesity (Buffalo hump), also referred to as endogenous obesity, is seen in *Cushing syndrome* -gender & sexual development: delayed or advanced puberty for stated age; male client with female characteristics, and female client with male characteristics -skin color & condition: extreme pallor, flushed, yellow skin in light-skinned client; loss of red tones and ashen gray cyanosis in dark-skinned client
Appearance & Movement: Abnormal
-posture: tense, rigid, slumped, asymmetrical posture ---slumped posture is seen with depression or organic brain disease -gait: uncoordinated—staggering, shuffling, and stumbling -motor movements: jerky, uncoordinated; tremors, tics, fast or slow movements ---bizarre movements are seen with schizophrenia ---tense, fidgety, and restless behavior in anxious patients -dress: clothes extra large or small and inappropriate for occasion ---inappropriate dress is seen with depression, dementia, Alzheimer disease, and schizophrenia -hygiene: dirty, unshaven; dirty nails; foul odors ---poor hygiene is seen with depression, dementia, Alzheimer disease, and schizophrenia ---meticulous, finicky grooming in obsessive-compulsive disorder -facial expression: ---poor eye contact is seen in apathy or depression ---mask-like expression in Parkinson disease ---extreme anger or happiness in anxious clients -speech: high pitched; monotonal; hoarse; very soft or weak ---slow, repetitive speech is present in depression or Parkinson disease ---loud and rapid in manic phases ---irregular, uncoordinated speech in multiple sclerosis ---dysphonia in impairment of CN X ---dysarthria in Parkinson or cerebellar disease ---aphasia in lesions of dominant hemisphere
What are the purposes of documentation?
-primary reason for documentation of assessment data is to *promote effective communication among multidisciplinary health team members* -the use of electronic health records (EHRs) has improved diagnostic and clinical outcomes, reduced errors, and improved patient safety
How does the nurse validate data?
-recheck your own data through a *repeat assessment*, such as taking the client's temperature again with a different thermometer -clarify data with the client by *asking additional questions* ---Example: A client is holding his abdomen; the nurse may assume he is having abdominal pain, when actually the client is feeling nauseated -verify the data with *another HCP* ---Example: Ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard. -*compare* your objective findings with your subjective findings to uncover discrepancies ---Example: A client states "I never get any time in the sun," yet has dark, wrinkled, suntanned skin. Validate the client's perception of never getting any time in the sun by asking exactly how much time is spent working, sitting, or doing other activities outdoors. Also, ask what the client wears when engaging in outdoor activities
Why does the nurse complete a health assessment?
-to help the nurse make decisions with the best interest of the patient in mind -help to determine nursing diagnoses, what systems to assess further during the physical examination
What are standard precautions? Know when the nurse must perform hand hygiene and wear gloves.
-wash hands before beginning the examination; after completing the physical examination; or after removing gloves -wear gloves if you will have direct contact with blood or other body fluids, if you have an open wound, when collecting body fluids (e.g., blood, sputum, wound drainage, urine, or stools) for a specimen, when handling contaminated surfaces (e.g., linen, tongue blades, vaginal speculum), and when performing an examination of the mouth, an open wound, genitalia, vagina, or rectum
Know the seven factors that may cause an inaccurate blood pressure reading.
1. The patient has a full bladder 2. The patient's back is unsupported 3. The patient's feet are unsupported 4. The patient's legs are crossed 5. The sphygmomanometer cuff is over clothing 6. The patient's arm is unsupported 7. The patient is talking or hasn't had at least three minutes of quiet time prior to the measurement
Know what the nurse "does" for pain. Study the nursing diagnosis Acute Pain so you know what the nurse DOES (look at defining characteristics, goals/outcomes, and nursing interventions).
Acute Pain: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe and with a duration of less than 3 months. *Related Factors:* -biological injury agent [e.g., infection, ischemia, neoplasm] -chemical injury agent -physical injury agent [e.g., trauma, operative procedure, burn, heavy lifting, overtraining] *Subjective:* Appetite change; hopelessness Self-report of intensity using standardized pain scale Self-report of pain characteristics using standardized pain instrument Proxy report of pain behavior activity changes [e.g., family member, caregiver] *Objective:* Change in physiological parameter [e.g., vital signs] Diaphoresis Distraction behavior; expressive behavior Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally Facial expression of pain; pupil dilation Guarding behavior; protective behavior; positioning to ease pain Self-focused; narrowed focus *Desired Outcome/Evaluation Criteria:* Report pain is relieved or controlled. Follow prescribed pharmacological regimen. Verbalize nonpharmacological methods that provide relief. Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation. Verbalize sense of control of response to acute situation and positive outlook for the future. Nursing Priority No. 1. *To assess etiology/precipitating contributory factors:* 1. determine and document presence of possible pathophysiological and psychological causes of pain (e.g., inflammation; tissue trauma, fractures; surgery; infections; heart attack or angina; abdominal conditions [e.g., appendicitis, cholecystitis]; burns; grief; fear, anxiety; depression; and personality disorders). Acute pain is that which follows an injury, trauma, or procedure such as surgery, or occurs suddenly with the onset of a painful condition (e.g., herniated disk, migraine headache, pancreatitis). 2. assess for potential types of pain that may be affecting client (i.e., nociceptive pain or neuropathic pain) to aid in understanding reason for severity of pain associated with client's condition, and point toward needed interventions for pain management. P #2: To evaluate client's response to pain: Obtain client's/significant other's (SO) assessment of pain to include location, characteristics, onset, duration, frequency, quality, and intensity. Identify precipitating or aggravating and relieving factors in order to fully understand client's pain symptoms. P #3: To assist client to explore methods for alleviation/control of pain P#4: To promote wellness (Teaching/Discharge Considerations)
What data are included & how are they documented under "Family Health History"?
Age of parents (Living? Deceased date?) Parents' illnesses and longevity Grandparents' illnesses and longevity Aunts' and uncles' age and illnesses and longevity Children's ages and illnesses or handicaps and longevity
What are physiologic responses to pain?
Anxiety, fear, hopelessness, sleeplessness, and thoughts of suicide Focus on pain, reports of pain, cries and moans, and frowns and facial grimaces Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilated pupils Increased heart rate, peripheral, systemic, and coronary vascular resistance Increased respiratory rate and sputum retention resulting in infection and atelectasis Decreased gastric and intestinal motility Decreased urinary output, resulting in urinary retention, fluid overload, and depression of all immune responses Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, and glucagon; decreased insulin and testosterone Hyperglycemia, glucose intolerance, insulin resistance, and protein catabolism Muscle spasm resulting in impaired muscle function and immobility and perspiration
What causes pulses, how does the nurse assess pulses, and where on the body are they able to be assessed?
Arterial or peripheral pulses are shock waves produced when the heart contracts and forcefully pumps blood out of the ventricles into the aorta. The body has many arterial pulse sites.
Know how to assess for decorticate and decerebrate posturing and what these mean clinically.
Client with lesions of the corticospinal tract draws hands up to chest (decorticate or abnormal flexor posture) when stimulated Client with lesions of the diencephalon, midbrain, or pons extends arms and legs, arches neck, and rotates hands and arms internally (decerebrate or abnormal extensor posture) when stimulated
What data are included & how are they documented under "Lifestyle & Health Practices"?
Description of a typical day (am to pm) Nutrition and weight management 24-hour dietary intake (foods and fluids) Who purchases and prepares meals Activities on a typical day Exercise habits and patterns Sleep and rest habits and patterns Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs) Self-concept Self-care responsibilities Social activities for fun and relaxation Social activities contributing to society Relationships with family, significant others, and pets Values, religious affiliation, spirituality Past, current, and future plans for education Type of work, level of job satisfaction, work stressors Finances Stressors in life, coping strategies used Residency, type of environment, neighborhood, environmental risks
How does the nurse use the stethoscope, the diaphragm and the bell, and which is each side of the head for?
Diaphragm: To detect high-pitched sounds (e.g., breath sounds, normal heart sounds, bowel sounds) Press firmly on body part Bell: To detect low-pitched sounds (e.g., abnormal extra heart sounds, heart murmurs, carotid bruits) Press lightly over body part
What data should be validated?
Discrepancies between the subjective and objective data. For example, a male client tells you that he is very happy despite learning that he has terminal cancer. Discrepancies between what the client says at one time versus another time. Findings that are highly abnormal and/or inconsistent with other findings. For example, a client has a temperature of 104°F, but is comfortable, and skin is warm to touch and not flushed.
Know geriatric variations:
Dress may be heavier because of a decrease in body metabolism and a loss of subcutaneous fat *Osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis* In older men, gait may be wider based with arms held outward Older women tend to have a narrow base and may waddle to compensate for a decreased sense of balance Mobility may be decreased, and gait may be rigid Steps in gait may shorten with decreased speed and arm swing Temperature may range from 35 to 36.3°C *(95 to 97.5°F)*. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 35.5°C (96°F). Normal body temperature values for all routes in older adults are consistently lower than values reported in younger populations Arteries are more rigid, hard, and bent More rigid, arteriosclerotic arteries account for higher systolic blood pressure Systolic pressure over 140 mm Hg but diastolic pressure under 90 mm Hg is called *isolated systolic hypertension* Systolic murmurs may be present Widening of the pulse pressure is seen with aging due to less-elastic peripheral arteries
What should the nurse avoid in communication with patients?
Excessive or insufficient eye contact (varies with cultures). Doing other things while taking the history, and being mentally distant or physically far away from the client Biased or leading questions—for example, "You don't feel bad, do you?" Relying on memory to recall all the information or recording all the details. Rushing the client. Reading questions from the history form, distracting attention from the client
What does the nurse "do" with data that deviate from normal?
Explore all data that deviate from normal with the following questions: "What alleviates or aggravates the problem?" "How long has it occurred?" "How severe is it?" "Does it radiate?" "When does it occur?" "Is its onset gradual or sudden?" The mnemonic COLDSPA may be used to further explore the client's symptoms
Know order of exam techniques in every system.
Follow a planned examination order for each body system, using the four techniques described earlier. Specific history questions related to each body part being examined may be integrated with the physical examination (e.g., when examining vision, ask the date of the client's last eye examination, if he or she has a history of blurring or double vision) First *inspect, palpate, percuss, and then auscultate*, except in the abdominal examination. To avoid alterations in bowel sounds: First auscultate and then percuss the abdomen, before palpating the abdomen. Use each technique to compare symmetrical sides of the body and organs. Assess both structure and function of each body part and organ (e.g., the appearance and condition of the ear, as well as its hearing function). When you identify an abnormality, assess for further data on the extent of the abnormality and the client's responses to the abnormality -Is there radiation of pain to other areas? -Is there an effect on eating? Bowels? Activities of daily living? (e.g., with left upper quadrant abdominal pain: Is there radiation of the pain?)
What are the phases of the interview & what happens in each?
Introductory phase Working phase Summary & Closure phase
Define and recognize Lethargic, Obtunded, Stupor, and Coma and know that clinically, these progress from Lethargy to Coma in this order.
Lethargy: Opens eyes, answers questions, and falls back asleep; slow to answer quesitons & follow commands; inattentive Obtunded: Opens eyes to loud voice, responds slowly with confusion, seems unaware of environment; difficult to arouse; needs contant stimulation to follow simple commands; may respond with 1-2 words then go back to sleep Stupor: Awakens to vigorous shake or painful stimuli, but returns to unresponsive sleep; doesnt follow commands; withdraws from painful stimulus; returns to unresponsive sleep Coma: Remains unresponsive to all stimuli; eyes stay closed.
Know that the nurse must ask the following questions before measuring vital signs:
Name, address, current age, birthdate, reason for seeking health care? Gender association? Major concern about current health? Current age, height, and weight? Recent weight change? High fevers? Change in pulse or heart rate? Usual blood pressure? Blood pressure last checked? Problem with hypertension or hypotension? Difficulty breathing? At rest? With mild or strenuous exercise? Any pain? How does it feel (dull, sharp, aching, throbbing)? How does the area of pain look (shiny, bumpy, red, swollen, bruised)? Onset: when did it begin? Location: where is it? Does it radiate? Duration: how long does it last? Does it recur? Severity: how bad is it? Associated factors: what makes it better? What makes it worse? What other symptoms occur with it? See Chapter 7 for further assessment of pain. Over-the-counter and prescribed medications? Allergies? Family history of heart disease, diabetes, thyroid disease, lung disease, high blood pressure, cancer, or others? Educational background, employment? Disabilities, satisfaction with current life, frequency for seeking health care, use of tobacco products including cigarettes, chewing tobacco, snuff, or dip? Consumption of alcohol (amount, frequency, and type)? Use of illicit drugs (type and frequency)? Usual diet? Exercise (type and frequency)?
Know "normal" BP is less than 120 over less than 80, prehypertension is 120-139/80-89, Stage 1 HTN is 140-159/90-99, Stage 2 HTN is 160 and above/100 and above.
Normal <120 | <80 Prehypertension 120,139 | 80-89 Stage 1 hypertension 140-159 | 90-99 Stage 2 hypertension ≥160 | ≥100
Know how to assess Level of Consciousness (LOC). Know "normal" and "abnormal" findings for LOC and how to document.
Note response to calling the client's name. If the client does not respond, call the name louder. If necessary, shake the client gently. If the client still does not respond, apply a painful stimulus
Know how to assess mood, "normal" and "abnormal" findings, and what findings mean clinically.
Observe mood by asking, "How are you feeling?" or "What are your plans for the future?" -Feelings (vary from joy to anger) -Expressions
Know how to assess thought processes and perceptions, "normal" and "abnormal" findings, and what findings mean clinically.
Observe thought process and perceptions by stating, "Tell me your understanding of your current health situation"
Know how to assess pulse for rhythm and rate. What is tachy and what may cause it? What is brady and what may cause it?
Palpate radial pulse, count number of beats for 30 seconds and multiply by 2 if HR is regular or a full 60 seconds if HR is irregular. If irregular, assess apical pulse with stethoscope AND assess for pulse deficit in addition. Know "normal" heart rate is *60 to 100 beats/min* and regular. *Tachycardia (>100 beats/min)* may occur with fever, certain medications, stress, and other abnormal states, such as cardiac dysrhythmias *Bradycardia (<60 beats/min)* may be seen with sitting or standing for long periods causing blood to pool, decreasing pulse rate, with heart block or dropped beats may be caused by: -fevers -exercise -dehydration -bleeding -caffeine -alcohol -nicotine -stimulant drugs -thyrotoxicosis
What data are included & how are the documented under "Past Health History"?
Problems at birth Childhood illnesses Immunizations to date Adult illnesses (physical, emotional, mental) Surgeries Accidents Prolonged pain or pain patterns Allergies Physical, emotional, social, or spiritual weaknesses Physical, emotional, social, or spiritual strengths
What data are included & how are the documented under "Reason for Seeking Care/Chief Complaint"?
Reason for seeking health care (major health problem or concern) Feelings about seeking health care (fears and past experiences) W/ COLDSPA: Character (How does it feel, look, smell, sound, etc.?) Onset (When did it begin; is it better, worse, or the same since it began?) Location (Where is it? Does it radiate?) Duration (How long does it last? Does it recur?) Severity (How bad is it on a scale of 1 [barely noticeable] to 10 [worst pain ever experienced]?) Pattern (What makes it better? What makes it worse?) Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities [leisure or exercise]?
What types of statements should nurse use?
Rephrase or repeat your perception of the client's response to reflect or clarify the information shared. For example, "You feel you have a serious illness?" Encourage verbalization of client by saying "Um hum," "Yes," or "I agree," or nodding. Describe what you observe in the client. For example, "It seems you have difficulty on the right side."
What data are included & how are they documented under "Review of Systems"?
Skin, hair, and nails: Color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff Head and neck: Headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat Ears: Pain, ringing, buzzing, drainage, difficulty hearing, exposure to loud noises, dizziness, drainage Eyes: Pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double vision Mouth, throat, nose, and sinuses: Mouth pain, sore throat, lesions, hoarseness, nasal obstruction, sneezing, coughing, snoring, nosebleeds Thorax and lungs: Pain, difficulty breathing, shortness of breath with activities, orthopnea, cough, sputum, hemoptysis, respiratory infections Breasts and regional lymphatics: Pain, lumps, discharge from nipples, dimpling or changes in breast size, swollen and tender lymph nodes in axilla Heart and neck vessels: Chest pain or pressure, palpitations, edema, last blood pressure, last electrocardiogram (ECG) Peripheral vascular: Leg or feet pain, swelling of feet or legs, sores on feet or legs, color of feet and legs Abdomen: Pain, indigestion, difficulty swallowing, nausea and vomiting, gas, jaundice, hernias Male genitalia: Painful urination, frequency or difficulty starting or maintaining urinary system, blood in urine, sexual problems, penile lesions, penile pain, scrotal swelling, difficulty with erection or ejaculation, exposure to STIs Female genitalia: Pelvic pain, voiding pain, sexual pain, voiding problems (dribbling, incontinence), age of menarche or menopause (date of last menstrual period), pregnancies and types of problems, abortions, STIs, HRT, birth control methods Anus, rectum, and prostate: Pain with defecation, hemorrhoids, bowel habits, constipation, diarrhea, blood in stool Musculoskeletal: Painful, swollen, red, stiff joints; strength of extremities; ability to care for self, ability to work Neurologic: Mood, behavior, depression, anger, headaches, concussions, loss of strength or sensation, coordination, difficulty with speech, memory problems, strange thoughts or actions, difficulty reading or learning
Describe ANA Standards 1&2.
Standard 1 in the Nursing: Scope and Standards of Nursing Practice states *"The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation":* Collects pertinent data, including but not limited to demographics, social determinants of health, health disparities, and physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic, ongoing process with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Recognizes the importance of the assessment parameters identified by WHO (World Health Organization), Healthy People 2020, or other organizations that influence nursing practice. Integrates knowledge from global and environmental factors into the assessment process. Elicits the health care consumer's values, preferences, expressed and unexpressed needs, and knowledge of the health care situation. Recognizes the impact of one's own personal attitudes, values, and beliefs on the assessment process. Identifies barriers to effective communication based on psychosocial, literacy, financial, and cultural considerations. Assesses the impact of family dynamics on health care, consumer health, and wellness. Engages the health care consumer and other interprofessional team members in holistic, culturally sensitive data collection. Prioritizes data collection based on the health care consumer's immediate condition or the anticipated needs of the health care consumer or situation. Uses evidence-based assessment techniques, instruments, tools, available data, information, and knowledge relevant to the situation to identify patterns and variances. Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information. Recognizes the health care consumer as the authority on their own health by honoring their care preferences. Documents relevant data accurately and in a manner accessible to the interprofessional team Standard 2 states: *"The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues":* Identifies actual or potential risks to the health care consumer's health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural, or environmental circumstances. Uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential diagnoses, problems, and issues. Verifies the diagnoses, problems, and issues with the individual, family, group, community, population, and interprofessional colleagues. Prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health-illness continuum. Documents diagnoses, problems, and issues in a manner that facilitates the determination of the expected outcomes and plans.
Study pathophysiology of pain-nociceptors
The pathophysiologic phenomena of pain are associated with the central and the peripheral nervous systems. The *source of pain stimulates the peripheral nerve endings (nociceptors)*, which *transmit the sensations to the central nervous system*. They are sensory receptors that *detect signals from damaged tissue and to chemicals released* from the damaged tissue. Nociceptors are sensitive to intense mechanical stimulation, temperature, or noxious stimuli (chemical, thermal, or mechanical). Nociceptors are distributed in the body, in the skin, subcutaneous tissue, skeletal muscle, joints, peritoneal surfaces, pleural membranes, dura mater, and blood vessel walls. Note that they are not located in the parenchyma of visceral organs. Physiologic processes involved in pain perception (or nociception) include transduction, transmission, perception, and modulation. These processes serve as means for the stimuli to be sent to various parts of the spinal cord and to the brain, where they are perceived and can be responded to. The modulation process, which changes or inhibits transmission, is poorly understood but affects the level of pain perceived.
What are open ended and closed ended questions useful for?
Use open-ended questions to elicit the client's feelings and perceptions. These questions begin with "What," "How," or "Which," and require more than a one-word response. Use closed-ended questions to obtain facts and zero in on specific information. The client can respond with one or two words. These questions begin with "Is," "Are," "Will," "When," or "Did," and help avoid rambling by the client
What types of questions should the nurse use?
Use open-ended questions to elicit the client's feelings and perceptions. These questions begin with "What," "How," or "Which," and require more than a one-word response. Use closed-ended questions to obtain facts and zero in on specific information. The client can respond with one or two words. These questions begin with "Is," "Are," "Will," "When," or "Did," and help avoid rambling by the client. Use a laundry list (scrambled words) approach to obtain specific answers. For example, "Is the pain severe, dull, sharp, mild, cutting, or piercing?" "Does the pain occur once every year, day, month, or hour?" This reduces the likelihood of the client's perceiving and providing an expected answer. Explore all data that deviate from normal with the following questions: "What alleviates or aggravates the problem?" "How long has it occurred?" "How severe is it?" "Does it radiate?" "When does it occur?" "Is its onset gradual or sudden?" The mnemonic COLDSPA may be used to further explore the client's symptoms
Be able to assign a score on the Glasgow Coma Scale. Know that the higher the number, the "better" the person is clinically. Know there are scores that range from 3 to 15
Use the Glasgow Coma Scale (GCS) for clients who are at high risk for rapid deterioration of the nervous system GCS score of 15 indicates an optimal level of consciousness GCS score of less than 15 indicates some impairment of consciousness. A score of 3, the lowest possible score, indicates deep coma
Know pediatric variations for VS measurement: Change order of measurement from least to most invasive.
When taking vital signs in infants, *measure the respiratory and pulse rates first*, as taking a temperature (especially a rectal temperature) may cause the infant to cry, which will alter the pulse and respiratory rates. Monitor temperature In infants <6 months old use: axillary tympanic rectal measurements In infants and children >6 months old use: temporal tympanic axillary rectal oral measurements
What are subjective data?
sensations or symptoms (e.g., pain, hunger) feelings (e.g., happiness, sadness) perceptions desires, preferences beliefs, ideas, values personal information that can be elicited and verified only by the client
Why collect a health history?
used to make nursing judgments (nursing diagnoses, collaborative problems, and referrals)
