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First level priority problems

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Are EMERGENT life threatening and immediate problems

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Second level priority problems

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require prompt intervention to forestall further deterioration mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk for infection, risk to safety or security.

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Third level priorities problems

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important to the patients health but can be addressed after more urgent health problems are addressed deficient knowledge, dysfunctional family processes, and chronic low self esteem, Interventions are more long term and response to treatment takes longer

question

collaborative problems

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Those which the approach to treatment involves muscle disciplines. Nurses have the primary responsibility is diagnose the onset and monitor changes in the status

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How do you set priorities?

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Problems with ABCV always go first A(airway problems) B(breathing problems) C(cardiac problems) V(vital sign concerns)

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What should you consider for culture?

answer

Certain cultures may not want to be touched, no eye contact. Some may not want to know their diagnosis and believes only the head of the household should know. They may need the hot/cold thing. Think about whether or not they speak english. Give your best care possible whether you agree with their views or not, but respect them.

question

What is a complete assessment?

answer

A complete health history and a full physical (head-toe) examination. It describes the current and past health state and forms a baseline. This yields the first diagnoses.

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What is a focused assessment?

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This is for a limited or short term problem. You collect info with a smaller scope and more targeted to the problem. It usually only concerns one problem or one body system.

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What is a follow up assessment?

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the status of any identified problems should be evaluated at regular and appropriate intervals

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What is an emergency database?

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rapid collection of data done at the same time as life saving measures. Diagnoses must be swift and sure.

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What is subjective data?

answer

what the patient says

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What is objective data?

answer

Stuff that you collect, vital signs, assessment.

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What type of data do you get from interviews?

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Subjective, because it's everything the patient says

question

How should you start an interview?

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Introduce yourself, state why you are there, how long it will take, have family leave or stay depending on situation, assure confidentiality, any costs of the interview.

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Body language

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be wary of how you present yourself, you could send the wrong meaning. sit at the same level as the patient. Don't dress too professionally, it may intimidate them.

question

What are some tips for giving an interview?

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Keep an open posture, don't take too much notes, make sure the environment is good, ask lots of open ended questions to make your answers better. Ask them more often when you are going to begin interview, To introduce a new section of questions, and Whenever the patient introduces a new topic There are different tricks for facilitating conversation, but just use them so that you can keep them talking.

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Things not to do during an interview

answer

Providing false assurance or reassurance Giving unwanted advice Using authority Using avoidance language Engaging in distancing Using professional jargon Using leading or biased questions Talking too much Interrupting Using "why" questions

question

What order should a complete health history exam be done in?

answer

Biographical data Source of history Reason for seeking care Present health or history of present illness Past health Family history Review of systems Functional assessment including ADLs

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Types of data- biographical data

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Name Address and phone number Age and birth date Birthplace Sex Marital status Race Ethnic origin Occupation

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Types of data--source of history

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Usually the person, may be relative or friend Reliability Note any special circumstances, such as use of interpreter

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Types of data-reason for seeking care

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Brief statement in person's own words Use quotation marks

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Types of data-present health or history of present illness

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Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient's perception

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Types of data-past health

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Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric history Immunizations Last exam date Allergies Current medications

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Types of data-family history

answer

Age and health or cause of death of relatives Health of close family members Family history such as heart disease, high blood pressure, stroke, diabetes, cancer, alcoholism, mental illness, etc

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Types of data-review of systems

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General overall health state, Skin, Hair, Head, Eyes, Ears, Nose and sinuses, Mouth and throat, Neck, Breast, Axilla, Respiratory system, Cardiovascular, Peripheral vascular, Gastrointestinal, Urinary system, Male genital system, Female genital system, Sexual health, Musculoskeletal system, Neurologic system, Hematologic system, Endocrine system

question

Types of data-functional assessment including ADL's

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Self-esteem, self-concept Activity and exercise Sleep and rest Nutrition and elimination Interpersonal relationships and resources Spiritual resources Coping and stress management Personal habits Illicit or street drugs Environment and work hazards Intimate partner violence Occupational health

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Perception of health

answer

How do you define health? What are your concerns? What are your health goals? What do you expect from us as health care providers?

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How to question kids

answer

Start with parents, then move to kids to make them more comforatable

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Psychosocial interview stuff

answer

Home Education and employment Eating Activities Drugs Sexuality Suicide and depression Safety HEEADSSS

question

Inspection

answer

Close, careful observation, first of individual as a whole and then of each body system Begins when you first meet person (general survey) Always comes first Requires Good lighting Adequate exposure Compare side to side

question

paplation

answer

Texture Temperature Moisture Organ location and size Swelling, vibration, or pulsation Rigidity or spasticity Crepitation Presence of lumps or masses Presence of tenderness or pain

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auscultation

answer

Listening to sounds with stethoscope Stethoscope does not magnify sound, but it blocks out extraneous sounds Once you can recognize normal sounds, you can distinguish abnormal and "extra" sounds

question

percussion

answer

Tapping person's skin with short, sharp strokes to assess underlying structures Used to assess: Location and size of organs Density of structure Detect superficial abnormal mass Percussion vibrations penetrate about 5 cm deep Deeper mass would give no change in percussion Elicit pain if underlying structure is inflamed Elicit deep tendon reflex using percussion hammer Resonant - lung Tympany - stomach Dull - organ Flat - bone

question

What are standard precautions?

answer

Wash your hands, wash your tools, wear gloves

question

What order should you assess?

answer

The appropriate sequence is inspection, auscultation, percussion, and palpation

question

How do you assess skin?

answer

ABCDE A= asymmetry B=border, it should be a regular circle C=color= it should be one solid color D=diameter= should be no greater than 6mm E=elevation or enlargement= it it has changed, new symptoms, changed color, itchy, burning, or bleeding

question

types of skin cancer

answer

malignant melanoma= the worst, come from old moles, irregular borders, may be scaly, flaky, or oozy basal cell carcinoma= round pearly borders, least bad squamous cell carcinoma= scaly patch with sharp margins, may have an actual ulcer on it

question

What is the normal range for vital signs?

answer

Heart rate- 60-100 should be +2 (on scale of +0(absent)- +3(full and bounding) Respiratory rate- 12-20 Blood pressure- 120/80- if the cuff is too big/small the reading will be wrong. Temperature- 96.4-99.1- changes at different times during the day.

question

Expected variations of vital signs

answer

If they are kids or elderly, hypertension, smoking, stress, meds, can all affect the vital signs

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Pain

answer

Pain is a subjective experience. Only the patient can tell you what their pain is. Children and elderly have trouble describing pain.

question

Questions to ask when assessing pain

answer

Where is your pain? When did your pain start? What does your pain feel like? How much pain do you have now? What makes your pain better or worse? Scale on 1-10

question

Different pain scales

answer

faces pain scale- children 1/2- 5 Regular- rate it 1-10 PAINAD- used for older adults with dementia CRIES- use for infants Wong-Baker Scale is one example; child is asked to choose face that shows "How much hurt do you have now?" Oucher Scale has six photographs of young boys' faces with different expressions of pain, ranked on a 0 to 5 scale of increasing intensity

question

Mental health assessment

answer

assess consciousness (test this one first), language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, perceptions The four main= ABCT A= appearence B=behavior C=cognition T=thought processes

question

Development considerations for mental status

answer

older adults may be a lot sadder, as things slow down it gets harder to think quickly Grief and despair surrounding loss can affect mental status and can result in disability, disorientation, or depression

question

When is a mental status assessment necessary?

answer

Anxiety disorder or depression Behavioral changes, such as memory loss, inappropriate social interaction Brain lesions: trauma, tumor, CVA or stroke Aphasia Psychiatric mental illness, especially with acute onset

question

Main components of mental status assessment= A

answer

Posture Erect, relaxed position Body movements Voluntary, deliberate, coordinated, smooth and even Dress Appropriate for setting, season, age, gender, and social group Grooming and hygiene Clean, well groomed; hair neat and clean Consider person's economic status or fashion trend, especially among adolescents Disheveled appearance in previously well-groomed person is significant

question

Main components of mental status assessment= B

answer

Level of consciousness Awake, alert, aware of stimuli, responds appropriately Facial expression Appropriate to situation; comfortable eye contact unless cultural norm says otherwise Speech Quality, effortless, conversation flows Pace is moderate, and stream is fluent Articulation is clear and understandable Word choice is effortless and appropriate to educational level; person completes sentences, occasionally pausing to think Mood and affect Body language, facial expression, ask directly, "How do you feel today?" or "How do you usually feel?" Person is willing to cooperate

question

Main components of mental status assessment= C

answer

Orientation Time: day of week, date, year, season Place: where person lives, address, phone number, present location, type of building, name of city and state Person: own name, age, who examiner is, type of worker Many hospitalized people normally have trouble with exact date but are fully oriented on remaining items Attention span Able to complete a thought without wandering Usually impaired in people who are anxious, fatigued, or intoxicated Recent memory 24-hour diet recall Ask time person arrived at agency Remote memory Verify past events; for example, past health, first job, birthday and anniversary dates, and historical events Lost in Alzheimer disease, dementia, or any disease that damages cerebral cortex FOUR UNRELATED WORDS TEST

question

Main components of mental status assessment= T

answer

Thought processes Logical, goal directed, coherent, and relevant; complete thoughts Thought content Consistent and logical Perceptions Aware of reality; should be congruent with yours

question

Things to screen for- mental health assessment

answer

Suicidal thoughts/tendencies, anxiety, depression, you can do a "mini-mental state test", it's only 11 questions

question

Tests for children- mental health assessment

answer

Denver II screening test gives a chance to interact directly with child to assess mental status From birth to 6 years of age, helps identify behavioral, language, cognitive, and psychosocial areas of concern "Behavioral Checklist" for school-age children, ages 7 to 11, is tool given to parent Covers five major areas: mood, play, school, friends, and family relations It is easy to administer and lasts about 5 minutes

question

Questions to ask about headaches

answer

Unusually frequent, severe? Onset? Had this type before? Location? Character? Mild, moderate, severe? Course and duration? Precipitating factors? Associated factors? Other illnesses? Taking meds? What makes it worse? Treatment? Coping strategies?

question

Extra about headaches

answer

A red flag is a severe headache in an adult or child that has never had one before.

question

Types of headaches

answer

Tension= tend to be occipital, frontal, or with band like tightness. Migraines= (vascular) then to be supraorbital, retroorbital, or frontotemporal, severe pain, N/V, photophobia, have to stay still to feel better Cluster headaches= (vascular) produce pain arounf the eye, temple, forehead, or cheek, pain is always unilateral and on the same side of the head, excruciating, alcohol ingestion and daytime napping can cause it , have to move to feel better

question

Vertigo vs. dizziness

answer

Vertigo= objective= room is spinning subjective= you are spinning Dizziness= light headed swimming sensation, feeling of falling

question

Hyperthyroidism

answer

Goiter= increase in the size of the thyroid gland. Symptoms= nervousness fatigue, weight loss muscle cramps heat intolerance tachycardia, SOB, excessive sweating, fine muscle tremor, thin silky hair and skin, infrequent bleeding, and a staring appearance

question

Bell's Palsy vs. a CVA

answer

Bell's palsy= a LOWER motor neuron problem (peripheral) in which cranial nerve VII causes unilateral paralysis, which can usually go away with treatment. It is complete paralysis. A CVA/stroke= an UPPER motor neuron (central) an acute neurologic deficit, caused by an obstruction of a brain vessel, this does NOT go away. the upper half of the face will still work because there is nothing wrong with the nerve

question

Pupils

answer

should be PERRLA

question

Visual reflexes

answer

Pupillary light reflex: normal constriction of pupils when bright light shines on retina When one eye is exposed to bright light, a direct light reflex occurs, constriction of that pupil; and a consensual light reflex, simultaneous constriction of other pupil Fixation: a reflex direction of eye toward an object attracting person's attention These ocular movements are impaired by drugs, alcohol, fatigue, and inattention Accommodation: adaptation of eye for near vision Convergence (motion toward) the axes of the eyeballs Pupillary constriction

question

developmental for eye things

answer

Cataract formation, or lens opacity, resulting from a clumping of proteins in lens Glaucoma, or increased intraocular pressure; chronic open-angle glaucoma is most common type Macular degeneration, or breakdown of cells in macula of retina Loss of central vision is most common cause of blindness; person is unable to read fine print, sew, or do fine work; loss of central vision may cause great distress

question

visual screening

answer

Preparation Position person standing for vision screening; then sitting with head at your eye level Equipment needed Snellen eye chart Handheld visual screener Opaque card or occluder Penlight

question

Snellen test

answer

Snellen alphabet chart is most commonly used and accurate measure of visual acuity Position person exactly 20 feet from chart; test one eye at a time If person wears glasses or contact lenses, leave them on; remove only reading glasses Ask person to read through chart to smallest line of letters possible

question

Sight related problems

answer

Myopia - nearsighted: difficulty viewing far objects Hyperopia - farsighted: difficulty viewing near objects Presbyopia - decrease in the power of accommodation with aging The person moves the card farther away

question

Age related concerns of Otits media

answer

Children are at a much higher risk for infections because their ear lobes are a lot more horizontal

question

Romberg test

answer

ask the person to stand up with feet together and arms at the sides. have them close eyes and hold the position. should be able to hold the position. positive result= loss of balance indicates a loss of vestibular function and prociception

question

Epistaxis

answer

Is just a bloody nose, from trauma, vigorous nose blowing, or a foreign body in there, nose picking, heavy exertion, or a coagulation disorder if it doesn't stop itself. lean forward and pinch nose.

question

TMJ= Temporomandibular Joint (TMJ)

answer

Articulation of mandible and temporal bone Can feel it in depression anterior to tragus of ear TMJ permits jaw function of speaking and chewing Allows three motions: Hinge action to open and close jaws Gliding action for protrusion and retraction Gliding for side-to-side movement of lower jaw

question

Test for TMJ

answer

With person seated, inspect area just anterior to ear Place tips of first two fingers in front of each ear and ask person to open and close mouth Drop fingers into depressed area over joint, and note smooth motion of mandible Audible and palpable snap or click occurs in many healthy people as mouth opens Palpate contracted temporalis and masseter muscles as person clenches teeth Compare right and left sides for size, firmness, and strength Ask person to move jaw forward and laterally against your resistance, and to open mouth against your resistance This tests integrity of cranial nerve V (trigeminal nerve)

question

Neuro exam

answer

Headache Head injury (LOC) Dizziness/Vertigo Seizures Tremors Weakness Incoordination (Falls) Numbness/Tingling Difficulty swallowing Difficulty speaking Significant History (CVA) Environment or occupational hazards Perform complete neuro exam on persons with neurologic concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction Perform neuro recheck on persons with demonstrated neurologic deficits who require periodic assessments, e.g., hospitalized persons or those in extended care

question

reflexes

answer

Reveals intactness of reflex arc at specific spinal levels Limb should be relaxed and muscle partially stretched Reflex hammer used Compare right and left sides: responses should be equal Reflex response graded on 4-point scale 4 = very brisk, hyperactive with clonus, indicative of disease 3 = brisker than average, may indicate disease 2 = Average, normal 1 = diminished, low normal, or occurs with reinforcement 0 = no response

question

What does a complete neuro exam test?

answer

Mental status Cranial nerves Motor function Sensory function Reflexes

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