261 Study Guide Midterm PDF

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261 Study Guide Midterm If it’s not on this list it’s not on the midterm!! Multiple choice test-60 questions; 90 mins Taking the midterm in class, bring pencil and V-# Hey guys! I thought it would be helpful for us to combine study guides/ work on this stuff together. I’ve already started, so please feel free to add stuff/ make notes anywhere and everywhere! -Rachel

1. What are the different types of health assessments, and when would each be performed? o Comprehensive health assessment: mainly done in the community by nurses; doctors/residents in a hospital setting (head to toe; typically at admission) o Problem-based or focused health assessment: example is cardiac; focuses on an any urgent change in status or a particular risk related to the hospitalized pts situation o Episodic assessment: follow-up exam o Shift assessment: first encounter – hospital when you come on shift; an abbreviated exam with emphasis on critical body systems and areas of risk ● Ten minute assessment is a good example of a shift assessment ○ ABC: Airway, Breathing, Circulation o Screening assessment: person is basically well, but looking for an opportunity to promote health and wellness; short exam focused on disease detection (ex:BP, physical etc…)

2. What are the purposes of a nursing health assessment? ● To conduct a health history and perform a physical exam while taking in the pts age, gender, physical and psychological status ● Correct problem identification: first assessment gives you a baseline. ● Detecting changes in patient’s condition: reassessment is needed after a change such as giving a new medication or giving blood. ● Ongoing process for evaluating effectiveness (or not) of care plan ● Developing a therapeutic relationship: Touch is therapeutic. Have effective communication (Be courteous, provide comfort, establish a connection, confirm what the patient says and feels). As a nurse, your appearance, demeanor, and comfort level serve as nonverbal communication that the patient can pick up on. You will have to tailor how you communicate to each patient. Never use “honey” or “sweetie.” ● Understanding patient’s experience of illness: Patients may have tremendous fear that their symptoms are the result of cancer or another debilitating disease. They may be embarrassed or they may not understand their condition or medical terminology that you use. Always communicate vitals and information – this reassures the patient and provides them the opportunity to tell you if what you observe and the objective data you gather is

normal for them; i.e. blood pressure. Always find out their health literacy. This can serve as a good teaching area. ● Basis for planning nursing care – to restore, maintain, or improve the patient’s health ● Maintaining a safe patient care situation

3. What are the steps in clinical decision making? ● Problem formation, data input, data interpretation also known as noticing, interpreting, responding, reflecting ● Clinical decision making requires careful reasoning (i.e., choosing the options for the best patient outcomes on the basis of a patient’s condition and the priority of the problem.) ● Assessment, nursing diagnosis, planning, implementation ● You must know your patient so that you can recognize changes that are abnormal for them. ● Steps of Evidence Based Clinical Decision making according to Fundamentals of Nursing Textbook: ○ Ask a Clinical question - what makes sense to you and what needs to be clarified? ○ Search for the most relevant and best evidence - using all of the most reliable resources around you ○ Critically appraise the evidence you gather - evaluate everything you find and determine its value, feasibility, and usefulness regarding your clinical question. ○ Integrate all evidence with your clinical expertise and patient preferences/values. once you decide the evidence you found is strong enough to use how can you integrate it into a way to use with your patients? ○ Evaluate the outcomes of practice decisions or changes using evidence. ○ Share the outcomes of Evidence based practice with others

4. What are the factors in symptom analysis? ● (OLDCARTS) -used to assess pain; ○ Onset- When did this first happen? ○ Location- Where exactly in the body is this problem? ○ Duration- How has the symptom changed over time? Has it gotten better? Worse? Is it in intervals or constant? How has the symptom behaved since the onset? ○ Character- characteristics. Example - what type of pain? What type of cough? ○ Alleviated/Aggravating factors- What makes it better? What makes it worse? ○ Related Symptoms- What happens at the same time this symptom occurs? ○ Treatment- what are some prescribed treatments that the patient is currently on or has previously tried? Example could be taking nitroglycerin for sudden onset of chest pain ○ Severity- usually a 0-10 pain scale; 0 being no pain and 10 being the worst pain you have ever felt

5. How does the nurse assess pain?

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Nature of pain – “Describe your pain,” “Place your hand over the area that hurts or is uncomfortable.” During physical assessment, observe the patient’s nonverbal cues. And, observe where patient points to pain; note if it radiates or is localized. Precipitating factors – “Do you notice if pain worsens during any activities or specific time of day,” “Is pain associated with movement?” During assessment, observe if the patient demonstrates nonverbal signs of pain during movement, positioning, swallowing. Severity – “Rate your pain on a scale of 0 to 10.” During assessment, inspect the area of discomfort; palpate for tenderness.

6. Know the difference between biological sex, gender identity, gender expression, and sexual orientation. ● Biological sex- are you male or female → Male = XY → Female = XX ○ Ovaries & testes: some people have both, some have one of each, some have other variations. ○ Some people can be born with genitalia that is very difficult to distinguish. ○ Criteria: chromosomal configuration, gonads, internal reproductive structures, external genitalia, hormonal secretions, sex assigned at birth, gender identity ● Gender identity- who you consider yourself to be ● Gender expression- how you choose to portray yourself to the world (He, She, They). How they express gender (clothing, appearance, behavior) ● Sexual orientation- to whom you are attracted to in an erotic way

7. Differentiate between culturally-sensitive and culturally-insensitive methods for asking about gender identity and sexual orientation. Your assessment needs to match how the patient would assess themselves when it comes to sexuality, gender identity, biological sex, and sexual orientation. ● Ask your patient what they would like to be called. Don’t automatically assume they are a woman or a man. ●

8. Compare health promotion and health protection. ● Health promotion- behavior motivated by desire to increase well-being and actualize health potential. A person is relatively healthy already, trying to increase wellbeing. Already healthy – ex: suggest 30 minutes of exercise each day if they don’t already get it. ● Health protection- behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill. Trying to avoid, delay, or prevent a health problem. You would help them to avoid a health problem, such as early blood pressure screening if they have a family history of hypertension. ○ Four levels of health literacy: Below Basic, Basic, Intermediate, & Proficient. One in seven adults is below basic, ex: can’t read directions on medication bottle.

9. Describe the differences between a screening assessment and a monitoring assessment. ● Screening- no obvious sign of disease. Disease or problem may exist but it is not symptomatic. May be a stand-alone assessment. May be part of a comprehensive health assessment. Goal is disease detection. May lead to health promotion and disease avoidance. Ex: child in school to have a vision screening. ● Monitoring- condition is present, is likely to develop, or is suspected. May be part of a comprehensive, problem-focused, episodic, or 10 minute assessment. Goal is determining disease trajectory and/or treatment effectiveness. May lead to nursing intervention or self care. Not looking to promote health, but what do I need to do to stop what’s happening.

10. Identify infection control procedures to be used when conducting a health assessment. (i.e. when do you wear gloves, and when don’t you) ● Gloves are used when nurses touch blood, body fluids, secretions, excretions, and contaminated items. Clean gloves are donned before touching the mucous membranes or nonintact skin of patients or when a nurse anticipates general contact with any wet body secretion. ○ Whenever you wear gloves you must wear goggles. ● Standard precautions- help reduce transmission of pathogens. Their intention is to prevent disease transmission when health care providers are in contact with the nonintact skin, mucous membranes, body substances, and blood-borne contacts of patients. ● Airborne precautions and droplet precautions

11. What are the differences between subjective and objective data? ● Subjective data- your patient’s verbal descriptions of their health problems. EX: Mr. Lawson’s self-report of pain at the area of his incision. ● Objective data- observations or measurements of a patient’s health status. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring BP

12. What assessment techniques are used to evaluate vital signs? ● Inspection - respirations. ● Palpation - palpate the patient’s arterial pulse points (usually the radial) noting the rate, rhythm, and strength of the pulse ● Auscultation - BP ● Vitals: ○ Temperature - under the tongue probe, tympanic (ear), forehead, rectal, axillary (under the arm). ○ Heart rate – pulse is an indicator of heart rate and rhythm (heart rate is # of times pulsation is felt in 1 minute. rhythm is regularity of pulsations or time between each beat). Radial pulse à inside of wrist. Apical à at heart itself (5th intercostal space).

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Respiratory rate – is the most sensitive indicator to deteriorating status in a patient. Men breathe more with abdomen, women more with chest. Always count when patient is not aware. ○ Blood pressure: measured in millimeters of mercury (mm Hg). Sphygmomanometer bladder should encircle about 80% of arm. Too small = false high reading. Too large = false low reading. Cuff should cover about 2/3 of upper arm. Korotkoff sounds are heard when blood is pulsating through partially occluded artery. ○ Oxygen saturation: light technology to determine oxygen in blood. Blue, black, green nail polish directly affect pulse ox sensor. ○ Pain - on a scale of 0-10 with 0 being no pain and 10 being the worst pain. Pictures of faces are used as the pain scale for children and those who are unable to communicate (oucher scale).

13. Define orthostatic hypotension, and describe how to assess for it. ● Orthostatic hypotension- also referred to as postural hypotension, occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm HG within 3 minutes of rising to an upright position. When a healthy individual changes from a lying to sitting to standing position, the peripheral blood vessels in the legs constrict. When standing, the lower extremity vessels constrict, preventing the pooling of blood in the legs caused by gravity. An individual normally doesn’t feel any symptoms ● Patient should rest supine for 2 minutes before assessment of baseline reading à assess BP and heart rate à have patient sit up for 1-2 minutes à assess BP and heart rate à have patient stand for 1-2 minutes à assess BP and heart rate. ● A drop in SBP (systolic blood pressure) of less than 15 mm Hg may occur and is normal. Ex: 120/72 supine, 115/70 sitting, 110/68 standing = normal.

14. State the rationale and technique for the two step blood pressure measurement. ● Two-step blood pressure allows for double checking. BP is first measured by palpating the brachial artery and then measured again by auscultating the brachial artery. ● Arrow on cuff goes above brachial artery → palpate brachial artery → pump up cuff until pulse is no longer palpable (systolic pressure) → let all air out of cuff & wait 30 seconds → repeat, but instead of palpating you will auscultate → pump to 20 mm Hg over systolic you received first time → release valve and note when you hear heart beat (or look at arrow jumping on manometer) – this is systolic → slowly continuing to release valve until you no longer hear a sound (this is diastolic)

15. Give an example of how each physical assessment technique is used: inspection, palpation, percussion, and auscultation. ● Inspection- a conscious observation of the patient for general appearance; physical characteristics and behavior; odors; and any specific details related to the body system,

region, or condition under examination. Use of a systematic process, proceeding from head to toe, will help to ensure a thorough inspection. ● Palpation- palpation- involves use of the hands and utilizes the sense of touch to assess specific characteristics. ● Percussion- involves use of specific, tapping motions with the hands to produce sounds that indicate solid or air-filled spaces over the lungs and abdomen. ● Auscultation- involves use of a stethoscope to hear movements of air or fluid in the body over the thorax and abdomen.

16. Identify the use of the bell and diaphragm of a stethoscope. ●

The bell is used with light skin contact to hear low-frequency sounds, while the diaphragm is used with firm skin contact to hear high-frequency sounds.

17. What is meant by “general survey”, and what are the elements included? ● The general survey begins with the first moment of the encounter with the patient and continues throughout the health history, during the physical examination, and with each subsequent interaction. Helps to form a global impression of the person based upon observations of overall behavior, physical appearance, mental status, and mobility. Must look, listen, and note any unexpected findings. Note the pts overall physical appearance, body structure, behavior, and mobility. ● Elements: overall physical appearance, hygiene and dress, skin color, body structure and development, behavior/mood, facial expressions, level of consciousness, speech, mobility/posture, range of motion, gait, height, weight ● Does patient make eye contact? Do they smile? Do you hear anything or smell anything? Are there any outstanding features? Does the patient respond to their name? Is their hand moist? Is their skin warm or smooth? Look for edema, clubbing (could be indication of chronic hypoxia; i.e. deprived of oxygen), malformations, or enlarged joints. Do they participate in conversation?

18. What is the usual order of physical assessment techniques? ● Inspection, palpation, percussion, auscultation ● Inspection is a conscious observation of the patient for general appearance; physical characteristics & behavior; odors; and any specific details related to the body system, region, or condition under examination. Go from head to toe. Focus on age, gender, level of alertness, body size and shape, skin color, hygiene, posture, and level of discomfort or anxiety. Inspection is the only technique performed for every body system! ● Palpation involves use of the hands and utilizes sense of touch to assess specific characteristics. Touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus (grating sound produced by friction between bone and cartilage), tenderness, pain, & edema. Feel for firmness, contour, position, size, pain, & tenderness using fingers. Back of hand for temperature. Outside surface of hand for feeling for tremors on patient’s chest. Always use a gentle circular motion when palpating, although there are times when moderate to deep palpation is necessary.

● Percussion involves use of specific, tapping motions with the hands to produce sounds that indicate solid or air-filled spaces over the lungs and abdomen. Loudest tones are over lungs and stomach. Quietest are over bone. Direct palpation is directly on skin, whereas indirect palpation is placing nondominant hand on patient and tapping on that hand. ○ Stomach is high pitched. Lungs are low pitched. ● Auscultation involves use of stethoscope to hear movements of air or fluid in the body over thorax & abdomen. The sounds are usually from movement of organs & tissues, including blow flow.

19. What are the four domains of mental status that are assessed by a nurse? These are things we are constantly assessing as we interact with patients. ● –Appearance - How do they overall look? Are they dressed appropriately for the occasion. ● –Behavior - how is this patient acting? Are their actions appropriate for the situation? ● –Cognition - can determine patients short and long term memory using series of tests. ● –Thought Processes - Does the patient’s thought processes seem to be “normal” within society?

20. What are the components of a health history? Be able to give an example of each element. ● Demographical data- name, address, billing info, employment, and insurance details ● Reason for seeking care- this brief statement in the patient's words establishes why he or she is making the visit. Ask “Tell me why you came to the clinic today” ● History of present illness- Begin with open-ended questions and ask patients to explain symptoms related to the reason for the visit. Questions about symptoms in 6-8 categories assist patients to be more specific and complete: location, duration, intensity, description, aggravating factors, alleviating factors, pain goal, and functional impairment. OLDCARTS, PQRSTU (Provocative/palliative, quality, region, severity, timing, understanding patient perception), COLDSPA (character, onset, location, duration, severity, pattern, associated factors/ how it affects the patient) ● Past health history- includes pt history of medical and surgical problems along with treatments and outcomes. Acute and chronic problems. ● Current medications and indications- ask about current medicines including names, doses, and routes; purposes of each, and any over-the-counter medications, supplements, or herbal remedies used ● Family history- Questions about the health of parents, grandparents, siblings, and children help identify those diseases for which patients may be at risk and enable nurses to provide health teaching

21. What is symptom analysis (OLDCARTS) and how is it performed?

● Onset, Location, Duration, Character, Associated/Aggravating factors, Relieving factors, Timing, Severity. - By interviewing patient, or if patient is unable to communicate ask a family member (ex: child under 7, mentally incapacitated person).

22. Describe the seven major assessments to be completed of the integumentary system. • • • • • • •

Color *consistent with their racial background Moisture *Feeling whether it is dry or clammy etc. Temperature *use backs of your hand to feel temp. Texture *can be smooth, rugged, textured Turgor *usually best place is skin in sternum or clavicle Vascularity *how many blood vessels Lesions *anything on skin that is not skin

23. Know the difference between a macule, papule, vesicle and pustule. ● ● ● ●

Macule- flat, circumscribed, discolored;...