NUR 216 Exam 1 Study Guide PDF

NUR 216 Exam 1 Study Guide [General, Communication, & Health History] - Subjective vs. objective data - Subjective: anything reported by the patient or family - **ALL information obtained in the health history is [subjective]!** - Objective: anything you phys...

NUR 216 Exam 1 Study Guide [General, Communication, & Health History] - Subjective vs. objective data - Subjective: anything reported by the patient or family - **ALL information obtained in the health history is [subjective]!** - Objective: anything you physically see or measure - E.g., physical assessment findings, vital signs, lab/diagnostic results, etc. - Open-ended vs closed-ended questions - Open-ended: broad question that encourages patient to share information - E.g., "Tell me about..." - Used in the beginning of an interview to obtain thorough information - E.g., "what brings you into the clinic today?" - Closed-ended: direct question, usually a "yes or no" type of question - Only used to clarify a detail (use sparingly and intentionally for a purpose) - Not appropriate in the beginning of the interview as an opener - Therapeutic communication - Some strategies: - Making observations (e.g., "I heard you say..." or "I noticed that you...") - Restating, reflecting, or summarizing what the patient said - Conveying empathy (e.g., "this must be very frightening for you") - Rule of thumb: encourage expression (best done by asking open-ended questions) - What to avoid: - Asking "why" questions - Telling the patient what to do (e.g., "you should ask your family to take care of this so you don't have to worry about it") - Making assumptions before assessing (e.g., "I'll call the priest for you" -- the patient may not be religious or follow a different religion) - Giving false reassurance or making false promises (e.g., "everything will be fine", "you will get better", "I promise to check on you hourly", etc.) - Accusing the patient of something or implying the patient is lying - Switching the subject or shutting down the conversation - Comfort & therapeutic considerations - Before anything, wash your hands, introduce yourself, & provide privacy - Explain expectations & what you are going to be doing before you do it - E.g., "I will start by asking you some questions about your health history and taking your vital signs..." - Avoid asking about sensitive topics first (such as sexual activity) -- wait until you have built some rapport with the patient - Positioning and body language - Always maintain eye contact - Do not rush the interview - Sit down where the patient can see you at eye level - Encourage patient to ask questions - Do not have patient change into gown until necessary for physical assessment, and cover parts of body as soon as you are done assessing them - Patients can opt to have a support person accompany them - Patients 18 & older can make their own medical decisions -- may be seen without parent present (ask the patient what they want) - Address the patient, not the family or support person, when taking the health history (as long as the patient is competent & of age) - Inclusive care - Culturally competent care: ability to provide effective care to individuals with different cultural backgrounds - Ask each patient their preferred name and pronoun - Key principles: - Treat every health assessment as an act of humanity - Health assessments are not about sameness - Examine your own biases - Cultivate a safe environment of care - Patient interview & health history - Components: - Reason for seeking care/"chief complaint" - Brief reason why patient is presenting to healthcare setting today (typically just a few words) - History of Present Illness (HPI) - Paragraph containing a detailed assessment of the chief complaint - Use open-ended question to begin assessing - Use acronym such as OLDCARTS to obtain thorough assessment of a chief complaint to create HPI - O: Onset (when it started) - L: Location (where symptom is felt) - D: Duration (how long it lasts for) - C: Characteristics (what it feels like -- e.g., 'sharp' pain) - A: Aggravating & alleviating factors (what makes it better/worse) - R: Related symptoms (e.g., experiencing nausea with pain) - T: Treatments (what treatments have been tried) - S: Severity - Past medical, mental, surgical histories - Medications: prescription, over-the-counter, & herbal supplements - E.g., antihypertensives (blood pressure medication) - Functional assessment: assess whether patient can perform activities of daily living (ADLs) - ADLs: dressing, bathing, feeding one's self, etc. - Prioritize safety - Consider whether patient is reporting symptoms expected with aging or things that may promote safety - Any evidence of new sensory impairments (hearing, seeing, neuropathy, etc.) may indicate a serious safety issue - Family history - If multiple family members have history of cardiovascular disease, this is a significant risk factor for the patient & reason for concern - Review of Systems - Head, eyes, ears, nose, mouth, throat: double vision, difficulty hearing, nasal congestion, sinus pressure, sore throat, etc. - Respiratory: shortness of breath, wheezing, etc. - Cardiovascular: chest pain, palpitations, etc. - Gastrointestinal: nausea/vomiting, heartburn, etc. - Urinary: burning, difficulty urinating, urinary frequency, etc. - Neurological: vertigo, headaches, seizures, etc. - Musculoskeletal: joint pain, muscle pain, etc. - Emergency situations (e.g., car accident victim): do not delay history or physical assessment - Both contain information necessary to determine a safe treatment plan - May have to simultaneously take history & perform physical assessment while the patient is alert and able to provide the history - Biographical data: name, age, race, religion, marital status, etc. [General Survey, Pain, & Vitals] - General Survey: first part of physical assessment (**[objective]** data -- what you observe) - Used to obtain an overall first impression of the patient - Begins as soon as you lay eyes on the patient - Some components: - Hygiene/grooming - Affect - Overall appearance - Body structure: build/weight (e.g., obesity) - Behavior/activity: e.g., restlessness/pacing, abnormal speech, etc. - Mobility: movement/gait - Body posture (sitting up straight? hunched over? etc.) - Mental status (level of consciousness & orientation) - Normal: Alert & oriented x 4 (person, place, time, & situation) - Person: patient knows name and date of birth - Place: patient knows where he/she is at - Time: patient knows date, month, & year - Situation: patient knows why he/she is here - Pain - Advocate for adequate pain management - Pain is what the **[patient]** says it is -- patient's self-report of pain is the **gold standard** for pain assessment (as long as patient is A&Ox4 & able to rate) - If patient appears to be in pain but is denying pain, try asking open-ended question to assess discomfort further - Nonverbal pain indicators may include grimacing, abdominal guarding, moaning/groaning, elevated HR/RR/BP, etc. - Nonverbal indicators are objective (observed, not reported) - Reassure patients that pain management is our priority - If someone is having pain bad enough to interfere with daily activities and/or pain that is limiting mobility, notify provider & advocate for patient - Severe pain (7 or higher out of 10) pain is ALWAYS a concern/priority - Mild post-op pain may be expected/acceptable - Reassessment of pain - Use the same method you used to assess pain initially - Consider subjective report, nonverbal cues, and vital sign changes - Vital signs closer to normal range during reassessment = success - Nonpharmacological interventions (repositioning, ice, etc.) should help within 15 minutes (if not, patient needs a more appropriate intervention) - Pharmacological interventions: reassess within 30-60 minutes - Be very specific when documenting re-assessment (e.g., "pain decreased from 9/10 to 4/10" vs. "patient states pain improved") - Vitals - If any vital signs taken by UAP are abnormal, repeat them ASAP - Blood pressure - Normal range: SBP \< 120 & DBP \< 80 - HYPOtension: LOW blood pressure - HYPERtension: HIGH blood pressure - Appropriate techniques and procedure - Make sure cuff is appropriate size - Do not wrap cuff too tight around arm - Palpate brachial artery - Make sure patient's legs are not crossed - No smoking for 30 minutes prior - Orthostatic hypotension (\> 20 mm Hg drop or \> 20 bpm pulse increase when patient changes position from supine to sitting to standing) - Temperature - Normal ranges vary among individuals, route, and machine - Some patients run as low as 97.0 degrees -- compare to baseline, may be normal for patient - Core readings (most accurate) - Tympanic - Temporal - Rectal - When taking rectal temp on an adult patient, insert probe **no more than** **1-2 inches** - Although more accurate than oral, rectal temp is [invasive] -- not appropriate if alert & oriented - Avoid taking rectal temp if patient has any rectal problems or diarrhea - Oral route is a surface reading (less accurate) - Affected by smoking & hot or cold food/drink -- wait 30 minutes if patient just had a hot/cold beverage or cigarette - Avoid if patient is nauseas/vomiting or has facial trauma - Pulse - Normal range: 60-100 - Athletes may have HR of 40-60 (considered normal for them) - Bradycardia: HR \< 60 - Tachycardia: HR \> 100 - May be one of the first signs of distress (a priority vital sign if abnormal!) - Respiratory rate - Normal range: 12-18 breaths per minute - Bradypnea: \< 12 breaths/minute - Tachypnea: \> 20 breaths/minute - Pulse oximetry - Normal range: \> 94% [Nutrition & Anthropometric Measurements] - Body Mass Index (BMI) - Normal: 18.5-24.9 - Underweight: \< 18.5 - Overweight: 25-29.9 - Obese: 30.0-39.9 - Morbidly obese: \> 40 - Being overweight or obese increases risk of diabetes & cardiovascular disease - Assess knowledge & efforts related to weight loss - Provide education and encouragement for patients to maintain a healthy weight - Direct observation: observing a patient at mealtime to assess: - Percentage of food eaten, difficulty feeding self, or difficulty swallowing - Biggest safety concern: ability to swallow safely (aspiration may compromise the airway or "A" in "ABCs") - Malnutrition - Risk factors for undernutrition - Alcohol use, elderly, chronic illnesses, poverty, etc. - Cultural factors may impact nutritional status -- remember to use therapeutic communication when assessing - Use malnutrition screening tool if concerned about possible malnutrition - Weight Loss - Important to determine whether it was [intentional] or [unintentional] (unintentional weight loss can be a sign of serious illness such as cancer) [Physical Assessment Techniques] - Physical assessment sequence/order for most body systems: 1\. Inspection 2\. Palpation: using fingers/hands to feel for assess texture, temperature, etc. 3\. Percussion: tapping directly or indirectly on patient's body part 4\. Auscultation: listening (usually with stethoscope) - Inspection - What you see, smell, etc. - Palpation - Feeling for abnormalities in texture, temperature, moisture, etc. - Use finger pads to assess for textural details (e.g., mass/tumor) - Percussion - Tapping briskly on the skin to assess density of underlying structures - Assess pitch, intensity (loudness), duration, & quality (e.g., tympany, resonance, flatness, etc.) of sound produced - Auscultation - Listening to body sounds - Direct: listening with ears only (no amplification device used) - Must listen for one full minute - Indirect: listening with amplification device (e.g., stethoscope) - Equipment - Stethoscope - Hold firmly against the patient's skin (not on top of gown/clothing) - Diaphragm (bigger side): for high-pitched sounds - E.g., breath & bowel sounds - Bell (smaller side): for low-pitched sounds - E.g., murmurs and vascular sounds - Sphygmomanometer: blood pressure device - Patient Rights - Confidentiality (HIPAA) - Before beginning health history, get permission from patient if others are present in the room - Transparency - Share your assessment findings with patient once you are done assessing [Miscellaneous/Tips] - Prioritization: consider... - If you can ONLY do one thing right now, what would you do? - What is the most important safety concern or intervention right now? - Which patient has the most abnormal or concerning findings? - Does the finding significantly impact functioning? - Are the vital signs abnormal? If so, how abnormal? How many abnormal vital signs does this patient have? [Med math] - Calculating BMI: weight (kg)/height (m^2^) - E.g., "A patient is 1.65 meters tall and weighs 104 lbs. What is the patient's BMI?" - Dosage calculations: determining \# of mL to administer if you are given mg & strength in mg/mL - E.g., "Your patient has an order for furosemide 40mg IV. The drug is available in a vial that reads 20mg/mL. How many mLs will you administer?" - Dosage calculations: determining \# of tablets to administer if you are given dosage and concentration per tablet - E.g., "Your patient is to receive carvedilol 12.5mg PO. The pharmacy delivers carvedilol 25mg tablets. How many tablets will you administer? Round to the nearest tenth." - Pounds to kilograms (1 kg = 2.2 lbs) - E.g., "You are caring for a patient who weighs 166 lbs. How many kg does the patient weigh? Round to the nearest tenth."