EAQ’s Chapter 8, 9, 10 Health Assessment – Flashcards

The nurse should be keenly observant while inspecting a patient. The use of sight can reveal many facts about a patient and the nurse should watch for various signs that are indicative of a disease condition. The sense of smell helps the nurse to gather vital information about the patient's health status, such as body odor, which can provide clues about the patient's hygiene. The nurse cannot use the sense of taste during physical examination to gather data. The nurse is not supposed to touch or auscultate the patient, because inspection refers to the visual examination. The nurse uses touch as a tool to gather specific information about the patient during palpation and percussion. The nurse uses the sense of hearing to gather data during auscultation. Abnormal body sounds help in detecting the presence of organ pathology.

The nurse should be slow, systematic, calm, and gentle while palpating the body parts of the patient. The nurse should wash his or her hands under warm water because cold hands can increase the muscle tension of the patient. Placing the patient in a supine position ensures the comfort of the patient during palpation. The nurse should use the pads of the fingertips first during palpation of a skin surface because it is important to start with light palpation to detect the surface characteristics. Then the nurse should use the palmar surfaces of the fingers to perform deep palpation, which helps in identifying the position, shape, and consistency of the organs. Finally, the nurse should document the findings accurately in the patient's medical record with his or her initials, the date, and the time.

forward toward the nose. This matches the natural slope of the ear canal and efficiently blocks out environmental sound.

Emphysema is a lung disorder caused by the accumulation of air in the alveolar spaces. While performing chest percussion on a patient with emphysema, the nurse would obtain a hyperresonant note. This characteristic of the percussion note would help the nurse to differentiate the emphysematous lung from the normal lung.

The nurse should take protective measures to ensure self-safety while caring a patient with Clostridium difficile. The nurse should wear gloves and a gown, because this prevents physical contact with the patient. The nurse should also perform regular hand washing with soap and water, because this minimizes the microorganisms.

extra heart sounds and murmurs

room warmer and tangetial lighting

avoid the chandelier sign-Chandelier sign can occur when a cold stethoscope endpiece is placed on a warm chest. Therefore, the nurse cleans the stethoscope endpiece with an alcohol wipe and warms it with his or her palm to avoid chandelier sign during the assessment

The nurse should take protective measures to ensure self-safety while caring a patient with Clostridium difficile. The nurse should wear gloves and a gown, because this prevents physical contact with the patient. The nurse should also perform regular hand washing with soap and water, because this minimizes the microorganisms. Hand washing should be with soap and water because the Clostridium difficile spores are not killed by alcohol. The nurse should maintain a distance of more than 3 feet while caring for a patient with respiratory disorders.

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The pregnant woman has increased cardiac output because of the greater peripheral vasodilatation during pregnancy. The nurse documents both phase IV and phase V readings when a difference greater than 10 mm Hg exists between them. Therefore, the nurse documents the reading as 140/96/80, which indicates 140 mm Hg is the systolic pressure and 96/80 mm Hg indicate the phase IV and phase V diastolic pressures. The nurse should document the phase IV diastolic reading only if the pressure difference between phases IV and V is greater than 10 mm Hg. Because the difference in the reading is 5 mm Hg, the nurse need not document the observation. Both phases IV and V represent diastolic pressure, not systolic pressure. Therefore, the systolic pressure difference of 10 mm Hg or 5 mm Hg does not exist.

Infection causes the release of pyrogens from the bacteria and results in hyperthermia. Cerebral trauma may alter the functioning of the hypothalamus, resulting in hyperthermia. A myocardial infarction may decrease the blood supply to the brain, resulting in an increased body temperature.

Many people by their 80s and 90s show postural changes of kyphosis, a condition in which a convex curvature of the thoracic and sacral regions of the spine occurs. There is also a slight flexion in the knees and shortening of the individual vertebrae. Therefore, many older adults may become shorter than they were in their 70s

I + IV

Stature or height is an important criterion for body structure assessment. An anomaly in patient height may indicate the presence of a growth-related disease. Symmetry is another important factor in body structure assessment. Body parts should look equal bilaterally and must be in relative proportion to each other. Any discrepancy may lead to conditions like unilateral atrophy or hypertrophy. Body build or contour is also an important aspect of body structure assessment. For a normal person, the body length from crown to pubis should be approximately of the same length as that of pubis to sole.

While measuring the temperature with a glass thermometer, the nurse should instruct the patient to close the lips to prevent a false reading on the thermometer. The anterior portion of the tongue has a lower blood supply than the posterior end so it is not as sensitive to shifts in core temperature. For this reason, the nurse measures the oral temperature at the base of the patient's tongue at either of the posterior sublingual pockets rather than in front of the patient's tongue. The nurse measures body temperature for at least 8 minutes in a febrile patient, because a reading of 3 to 4 minutes may not be accurate.

The electronic thermometer with a blue-tipped probe measures oral temperature within 20 to 30 seconds.

The Korotkoff sounds are classified into five phases for the assessment of blood pressure. The crisp and high-pitched sounds occur during phase III because of an abnormally longer duration of blood flow through the artery. Phase I is characterized by the appearance of soft, clear tapping sounds with increased intensity caused by the turbulent flow of blood through the artery. Phase II is characterized by a soft murmur that occurs because of the turbulent flow of the blood through a partially occluded artery. Phase IV involves low-pitched, cushioned murmuring sounds with a blowing quality due to a decrease in the velocity of blood flow through the artery.

When a patient experiences pain for months and years, he or she becomes adapted to the pain and may avoid mentioning the pain to the health care provider. This is why the nurse should be observant and mindful of the patient's behavior to identify whether the patient has pain. The patient with chronic pain may subconsciously rub the knee for pain relief. The pain may increase during a change of position from sitting to standing. The patient may support the knee when changing positions to help minimize the pain. The patient may also subconsciously respond to the pain by sighing constantly during the assessment. A patient with acute pain has increased autonomic functioning and will thus exhibit stillness, diaphoresis, restlessness, and facial grimacing.

The patient who has pain due to damage in blood vessels, joints, and tendons experiences deep somatic pain. Tendonitis is the inflammation of tendons.

During the interview, the nurse uses a variety of words such as discomfort or soreness to identify severity of pain. These types of questions help to assess pain in patients who report pain only when it is severe. To identify the quality of pain, the interviewer can ask the patient what the pain feels like to him or her. To identify the onset and duration of the pain, the interviewer can ask the patient when the pain started. To identify the intensity of the pain, the interviewer can ask the patient how much pain he or she feels.

The patient states that he or she has episodic pain that usually occurs within half an hour of eating fatty foods and that it lessens after bringing the knees to the chest and not moving for a period of 1 hour. In addition to these statements, severe tenderness in the left upper quadrant of the abdomen indicates acute episodic pain in the patient.

Antidepressants are required for the management of chronic pain conditions. Fibromyalgia involves chronic widespread pain and allodynia, a heightened and painful response to pressure. Antidepressants will help to alleviate the pain, depression, fatigue, and anxiety associated with the disease. A patient with trigeminal neuralgia has chronic pain manifested in the form of severe stabbing pain in the facial muscles. A patient with diabetic neuropathy, who has chronic pain symptoms such as burning pain in the feet bilaterally, also benefits from this therapy. A patient with osteoarthritis may not require antidepressant medications because the damage is due to tissue degeneration, not nerve degeneration. Cancer pain generally worsens with disease progression, and the antidepressants may not be of help.

PQRST is a pain assessment scale; it stands for Provocation/Palliation, Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the patient is describing methods that provide comfort and relieve the pain, it indicates that the patient is addressing Provocation/Palliation. If the patient reports about severity of pain on a scale of 0 to 10, then it indicates that the patient is addressing Severity. When addressing the Quality/Quantity of the pain, the patient describes the pain felt. If the patient reports about the site of pain, then the patient is addressing Region/Radiation.

Diabetic neuropathy is a neuropathic disorder that is associated with burning, electric shock-like pain in the lower extremities. Opioids alleviate neuropathic pain by activating the opioid receptors located in the spinal cord. These medications block the transmission of the pain impulses from the brain to the thalamus. Antidepressants and anticonvulsant medications decrease the serotonin levels and increases gamma-aminobutyric acid (GABA), so these medications alleviate pain by blocking the transmission of pain impulses from the damaged nerves and reducing their sensitivity. Corticosteroids are prescribed for the treatment of nociceptive pain, which is associated with redness and inflammation at the site of injury. These medications reduce prostaglandin levels, but do not repair the damaged nerve fibers and so do not alleviate neuropathic pain. Muscle relaxants are effective in preventing muscle spasm and can alleviate the pain associated with musculoskeletal injuries. These medications do not alter neurotransmitter levels, however, nor do they prevent neuropathic pain.

The patient may experience severe back pain due to a sudden fall. If the pain shoots down to the legs and the patient is unable to perform hip extension and flexion, it indicates that the patient has herniation of the lumbar disc. If the patient has an irregular pattern of pain and swelling in the back and frequently rubs the lower back, it indicates that the patient has chronic pain with increased intensity. The patient does not have pain due to damage of the large internal organs. Therefore, the patient is not experiencing visceral pain. When pain is short-term and is associated with an acute event such as a lumbar disc herniation, it is acute pain, not chronic.

Nociceptive pain develops when intact nerve fibers in the central nervous system are stimulated. There are four phases of nociceptive response: transduction, transmission, perception, and modulation. In the transduction phase, the injury stimulus releases prostaglandins, which travel to the spinal cord through afferent nerves. During the transmission phase, if the opioid receptors are not activated, then the stimulus travels from the spinal cord to the thalamus. During the third phase, perception, cortical structures interpret the emotional response to the pain. The fourth phase is the modulation phase, in which an inbuilt mechanism slows the process of the stimulus by releasing analgesic neurotransmitters like serotonin.

The presence of pale, dry skin, brittle nails, joint pain, edema, and discoloration of the affected extremity indicates that the patient has complex regional pain syndrome (CRPN). Damaged nerves result in impaired functioning of the sensory, motor, and autonomic nerves. Due to nerve damage, the patient feels severe pain even with the contact of a cotton swab. Pregabalin, prednisone, and amitriptyline block the pain impulses from the damaged nerves and help to alleviate pain and inflammation. Therefore, the primary health care provider would prescribe these medications to the patient. Aspirin and acetaminophen reduce prostaglandin levels and alleviate nociceptive pain. These drugs do not repair damaged nerve fibers and do not alleviate neuropathic pain.

The presence of constant irritation and inflammation in the lower limbs indicates that the patient has neuropathic pain, which is chronic pain caused by nerve damage. In this situation, the patient experiences severe pain long after the injury is completely healed. Due to the constant irritation caused by the pain, the opioid receptors are damaged and make the patient unresponsive to opioid therapy. Referred pain is pain that is felt at a particular site but that originates from another location. Nociceptive pain does not cause damage to the opioid receptors and can be alleviated by administering opioid analgesics to the patient. Pain that starts again or escalates before the next scheduled analgesic dose is called breakthrough pain.