Final Exam Study Guide
Final Exam Study Guide Nurs 20263
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This 5 page Study Guide was uploaded by Kiara Scheuer on Friday September 9, 2016. The Study Guide belongs to Nurs 20263 at Texas Christian University taught by Young in Fall 2016. Since its upload, it has received 3 views. For similar materials see Health assessment:concepts in NURSING at Texas Christian University.
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Date Created: 09/09/16
Final Exam Study Guide 1. Steps of the Nursing Process - Jarvis pg 3 a. Assessment b. Diagnosis c. Outcome identification d. Planning e. Implementation f. Evaluation 2. Holistic model of nursing - Jarvis pg 7 a. Consideration of the whole patient. Views the mind, body and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together. 3. Health Promotion - Jarvis pg 7 a. Now rounds out our concept of health. Emphasize the link between health and personal behavior. The great majority of deaths among Americans younger that 65 years are preventable. Prevention can be achieved through counseling from primary care providers designed to change people’s unhealthy behaviors related to smoking, alcohol and other drug use, lack of exercise, poor nutrition. Health promotion is a set of positive acts that we can take. 4. Religion versus Spirituality - Jarvis pg 15 a. Spirituality is borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. Religion refers to an organized system of beliefs concerning the cause, nature and purpose of the universe, especially belief in a superhuman power. Religion is s shared of experience of spirituality or the values, beliefs, and practices into which people either are born or which they may adopt. 5. Cultural Assessment - Jarvis pg 24 a. Five categories: Cultural identity, cultural explanation of the individual’s illness, cultural factors related to psychosocial environment and levels of functioning, and cultural elements of the relationship between the individual and the clinician. Provides an overall cultural assessment to promote culturally competent diagnosis. 6. Cultural competency - Jarvis pg 13 a. Is a set of congruent behaviors, attitudes and policies that come together in a system among professionals that enables work in cross cultural situations 7. Purpose of the health history- Jarvis pg 49 a. The purpose of the health history is to collect subjective data. 8. Mental Status Exam - Jarvis pg 68 a. The full mental status examination is a systemic check of emotional and cognitive functioning. b. A,B,C,T- appearance, behavior, cognition, thought process. c. It is necessary to perform a full mental status examination when you discover aany abnormality in affect or behavior and in the following situations i. Patient suggests anxiety disorder or depression ii. Family members concerned about a persons behavioral changes iii. Brain lesions iv. Aphasia v. Symptoms of psychiatric mental illness d. What could affect your interpretations i. Known illnesses, current medications, educational level, current stress, social interaction patterns, sleep habits. 9. Short-term cognitive ability - Jarvis pg 7 a. Recent memory. Assess recent memory in the interview by asking the 24-hour diet recall or by asking the time the person arrived. Ask questions you can corroborate. This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. 10. Dementia symptoms - Jarvis pg 71 a. Disorientation. Orientation is usually lost in this order: first to time, then to place, rarely to person. Easily distracted, confusion, negativism, Recent memory deficit,. Remote memory is lost, Score of zero or one on one word recall. Aphasia 11. Older adult priorities - Jarvis pg 76 a. Confusion common in aging people, easily diagnosed, acute delirium, delirium/dementia/alzhermiers common following cardiac surgery, noticeable as initial decline in cognitive ability, with prolonged impairment, check sensory status, vision and hearing, behavior (lvl of consciousness), cognitive fxns (orientation), new learning, supplemental mental status exam 12. Drug Addiction, dependency, withdrawal, tolerance, abuse – These are definitions, just know the meanings. 13. CAGE - Jarvis pg 5 a. Used to identify excessive or uncontrolled drinking(Cut down, Annoyed, Guilty, Eye- opener) i. Have you ever though..cut down drinking ii. Been annoyed by critiscism iii. Guilty about your drinking iv. Drink in the morning 14. Intimate Partner Violence (IPV) - Jarvis pg 103 a. Four types i. Physical Violence- using physical force ii. Sexual Violence- Physical force to engage in sexual activity iii. Threats of physical or sexual violence iv. Psychological/ emotional abuse and or coercive tactics- there has been prior physical and or sexual violence. 16. Risks associated with IPV (intimate partner violence) - Jarvis pg 74, 105 -suicidal thoughts, depression, alcoholism, firearms, family violence, incarceration, self mutilation, anorexia, death themes, saying goodbye -Low self-esteem, Low income, Low academic achievement, Young age, Aggressive or delinquent behavior as a youth, Heavy alcohol and drug use, Depression, Anger and hostility, Antisocial personality traits, Borderline personality traits, Prior history of being physically abusive, Having few friends and being isolated from other people, Unemployment, Emotional dependence and insecurity, Belief in strict gender roles (e.g., male dominance and aggression in relationships), Desire for power and control in relationships, Perpetrating psychological aggression, Being a victim of physical or psychological abuse (consistently one of the strongest predictors of perpetration), History of experiencing poor parenting as a child, History of experiencing physical discipline as a child 17. Purpura - Jarvis pg 108 -ecchymosis is related to purpura, petechia is related to purpura -can result from intimate partner violence 18. Skin turgor - Jarvis pg 211 Turgor: skin’s ability to return to place promptly when released, this reflect the elasticity of the skin, poor turgor evident in dehydration or extreme weight loss, the pinched skin will recedes slowly or tents and stand by itself 19. Inspection - Jarvis pg 115 -concentrated watching, close, careful, scrutiny, first of the indiv as a whole and then of each body system, begins the moment you first meet person and develop a general survey, start the assessment of each body system with inspection, always comes first, may feel embarrassed staring at the person without also doing something, a focused inspection takes time and yields a surprising amnt of data, train yourself not to rush thru inspection by holding hand behind your back, learn to use each person as their own control and compare right and left sides of the body, the 2 sides are symmetric, inspection requires good lighting, adequate exposure, occasional use of certain instruments to enlarge view 20. General survey - Jarvis pg 127 -physical appearance: age (person appears to be their stated age), sex sexual dvlp is appropriate for sex & age, if indiv is transgender, note their stage), level of consciousness (the person is alert and oriented person, place, time, and situation, attends to and responds appropriately to your questions), skin color (tone is even, pigmentation varying with genetic background, skin intact, no lesions, make note of tattoos/piercings), facial features (symmetric with movement), overall appearance (no signs of acute distress are present) -body structure: stature (height is in normal range for age), nutrition (weight is in normal range for height and body build, fat distribution is even), symmetry (body parts looks equal bilaterally and are in relative proportion to each other), posture (person stands comfortably erect as appropriate for age), position (person sits comfortably with arms relaxed at sides and head turned to examiner), obvious physical deformities (note) -mobility: gait (feet are shoulder width apart, foot placement accurate, walk is smooth and even, person maintains balance without assistance, symmetric arm swing is present), range of motion (full mobility for each joint and movement is deliberate, accurate, smooth, and coordinated) -behavior: facial expression (maintains eye contact, expressions are appropriate), mood and affect (person is comfortable and cooperative with the examiner and interacts pleasantly), speech (articulation is clear and understandable), speech pattern (stream of talking is fluent, with even pace, person conveys ideas clearly, word choice is appropriate), dress (clothing is appropriate to climate, clean, fits the body, appropriate to culture and age group), personal hygiene (person is clean and groomed for age, occupation, and socioeconomic group, hair is groomed, brushed, makeup is appropriate) 21. Mean arterial blood pressure, how is it determined - Jarvis pg 137 -pressure forcing blood into tissue averaged over the cardiac cycle, a value closer to diastolic pressure plus 1/3 of the pulse pressure 22. Neuropathic versus nociceptive - Jarvis pg 161 -neuropathic: pain caused by a lesion or disease of the somatosensory nervous system, implies abnormal processing of the pain message from an injury to the nerve fibers, most difficult to assess and treat, perceived long after the site of injury heals, evolves into chronic condition -nociceptive: pain dvlps when fxning and intact nerve fibers are stimulated, triggered by events outside of nervous system from actual or potential tissue damage, divided into transduction, transmission, perception, and modulation 23. Pain – subjective - Jarvis pg 166 -do you have pain, where is your pain, when did pain start, what does your pain fee like, how much pain do you have now, what makes your pain better or worse, how does pain limit your fxn or activities, how do you react when you are in pain, what does this pain mean to you -OLDCART Onset Location Duration Characteristics Aggravating Factors Relieving Factors Treatment 24. Rules for Skin Cancer (A, B, C, etc) - Jarvis pg 208 -A: asymmetric -B: border irregularity -C: color variation -D: diameter greater than 6mm -E: elevation or evolution 25. Clubbing - Jarvis pg 213 -clubbing of the nail occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases -angel is 180 degrees, nail base is spongy to palpation, nail becomes convex and finger grows 26. Symptoms of Bell’s palsy - Jarvis pg 278 -complete paralysis of ½ of face, person cant wrinkle forehead, raise eyebrow, close eyelid, whistle, or show teeth of left side, smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, pain behind ear 27. Consensual light reflex - Jarvis pg 285 -simultaneous constriction of the other pupil -constricts pupil of the opposite eye -occurs bc optic nerve carries the sensory afferent message in and then synapses with both sides of the brain 28. cranial nerves (again) -I: olfactory (smell) -II: optic (vision) -III: oculomotor (motor: EOM movement, opening of eyelids, parasympathetic: pupil constriction, lens shape) -IV: trochlear (down & inward eye movement) -V: trigeminal (motor: muscles of mastication, sensory: sensation of face and scalp, cornea, mucous membranes of mouth & nose) -VI: abducens (lateral movement of eye) -VII: facial (motor: facial muscles, close eye, labial speech, close mouth, sensory taste— sweet, salty sour bitter, parasympathetic: saliva and tear secretion) -VIII: vestibulcochlear (hearing & equilibrium) -IX: glossopharyngeal (motor: pharynx phonation & swallowing, sensory—taste , pharynx gag reflex, parasympathetic: parotid gland, carotid reflex) -X: vagus (motor: pharynx and larynx talking/swallowing, sensory general sensation from carotid body, carotid sinus, parasympathetic carotid reflex) -XI: spinal accessory: movement of trapezius and sternomastoid muscles -XII: hypogolossal: movement of tongue
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