NUR314StudyGuideExam1Fall20141.doc NUR 314
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This 11 page Study Guide was uploaded by Danielle Schlazer on Thursday September 25, 2014. The Study Guide belongs to NUR 314 at a university taught by a professor in Fall. Since its upload, it has received 337 views.
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Date Created: 09/25/14
NUR314 Exam 1 Study Guide FALL 2014 Please note this study guide is intended to assist you in your studies It is NOT meant to replace the required reading review of class notes videos etc Describe the interview setting environment Distractions Seating Privacy Space and distance open vs closed positions 0 Distractions remove distracting objects or equipment 0 Seating equal status seating comfortably seated at eye level don39t sit across a desk or table barrier 90 degree chair angle do not stand demonstrates superiority 0 Privacy geographic privacy a private room asking someone to leave or psychological privacy closing a curtain 0 Space amp distance distance between you and patients should be 45 feet too close anxiety invade space too far distant aloof 0 Open positions leaning slightly toward person equal seating status close proximity 0 Closed positions tense posture slouched back far away standing Phases of the interview process and the purpose Interview allows us to build rapport with our patient you can t just walk in and start asking questions You need to set the tone How do you set the tone Working Phase Understand that data gathering isn t only the questions you ask but also your responses to the answers and to the questions the individual may ask of you Openended use them to open the interview to introduce a new topic or when patient introduces a new topic These questions ask for a narrative response They get the patient talking EXAMPLE A What brought you in today B How have you been feeling Close or direct questions ask for specific information Elicit short one or two word answers or yes no responses Use them to narrow the information Use them to fill in the details when you need specific facts and to move the interview along EXAMPLE A Where does it hurt B Have you been checking your blood pressure C When was the last time you were seen by a doctor Closing the Interview Ask the patient if he she was any more questions or would like to tell you anything else EXAMPLES Is there anything else you would like to mention Are there any questions you would like to ask Are there any other areas I should have asked about What are objective ndings subjective ndings symptoms signs Symptoms subjective Subjective the patient tells us in their own words why they are here Sign Objective Detectable on physical exam or in laboratory reports Communication techniques Re ection Confrontation Silence Empathy etc 1 Facilitation Verbal cues to say more go on uh huh continue 2 Silence Particularly important after openended questions 3 Re ection Repeating part of the patient s statement 4 Empathy Naming a patient s feeling and encouraging him or her to discuss it put yourself in their position to see what they re going through 0 I cant imagine what you re going through must be very hard 5 Clari cation Summarizing the patient s statement and confirming that you have understood them correctly why are they there 6 Confrontation Focusing the patient s attention on an inconsistency or observation of yours 7 Interpretation Making associations or implying cause and effect body language nonverbal 8 Explanation Sharing information with the patient 9 Summary Final review of the patient s statements by the interviewer summarize why they are there recap 1o Traps of interviewing 1 providing false assurance or reassurance a everything will be fine 2 Giving unwanted advice a if it was me I d b should provide specific facts instead 3 Using authority a I m the nurse and what I say is right 4 Using avoidance a He s passed on to a better place i have to say the fact that he she DIED 5 Engaging in distancing a Don t back away b Have to think about cultural sensitivity 6 Using professional jargon a Don t use medical acronyms terms i Depends on the patient 7 Using leading or biased questions a you don t smoke right 8 Talking too much 9 Interrupting 10 Using why questions Purpose of the Health History and Review of Systems Purpose 0 Evaluate past and present health state of each system 0 Validate significant data was not missed in health history 0 Evaluate health promotion practices Review of Systems Functional Assessment including ADL s Selfesteemselfconcept Education financial status religious spiritual practices perception of personal strengths Activity exercise Tell me how you spend a typical day 0 Includes ability to perform ADLs leisure exercise patterns Sleep rest Naps sleep aids Nutrition elimination 24hour diet recall 0 who buys prepares food adequate finances who is present for meals allergy or intolerance caffeine intake bowel and bladder patterns and aids used Interpersonal relationships resources Family friends work and home 0 To whom would you go with a problem Spiritual resources FICA faith in uence community address Coping and stress management Recent changes in lifestyle 0 methods of coping that have been successful in the past 0 What are the eight critical characteristics in assessing any symptom 1 0 quotF Location Quality Quantity Severity Timing onset duration frequency Setting whenwhere did it start Aggravating or Relieving Factors Associated Factors Patient s Perception PQR TU P provocative what makes it worse palliative what makes it better Q quality stabbing constant dull sharp R radiate pain go to any other part of the body S scale of 110 10 being unbearable pain 0 being no pain T timing when did it start and how long did it last U understanding what do they think is causing the pain Assessment for Domestic violence and suicide Domestic Violence 0 Evidence or threat of physical sexual violence 0 Psychological emotional abuse and or coercive tactics after physical violence 0 Between spouses non marital partners or former spouses or partners CDC Abuse Assessment Screen AAS 1 Begin with the following How are things at home and Do you feel safe 2 Progress to the following Have you ever been emotionally or physically abused by your partner or someone important to you 3 Within the last year have you been hit slapped kicked pushed or shoved or otherwise physically hurt by your partner or expartner 4 Does your partner ever force you into having sex 5 Are you afraid of your partner or expartner History prior abuse including child abuse history of traumatic injuries do mental status exam Screening Frequency Protocol 0 All women over the age of 14 years 0 Primary care every visit Emergencyurgent care all women all visits OB GYN each prenatal family planning visit all visits in STD and abortion clinics Mental health every assessment 0 Inpatient all admissionsdischarges Documentation 0 Detailed nonbiased notes Use of injury maps Photographic documentation Cultural Aspects of care Available resources What is CAGE assessment tool Other aspects of a social history Cage assessment tool Substance abuse screening tool C Have you ever felt you should cut down on your drinking A Have people annoyed you by criticizing your drinking G Have you ever felt bad or guilty about your drinking E Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover eye opener Concepts of culture assimilation Norms acculturation biculturalism Concepts of culuture Who are you meeting for the first time 0 Where does the patient come from 0 What is his or her heritage 0 What is his or her cultural background ethnicity and religion Provide culturally competent care Heritage The thoughts communications actions beliefs values and institutions of racial ethnic religious or social groups Four Basic Characteristics 1 Learned handed down through the processes of language acquisition and socialization 2 Shared by all members of the same cultural group 3 Adapted to specific conditions related to environmental and technical factors and to the availability of natural resources 4 Dynamic ever changing Acculturation the process of adapting to acquiring another culture Assimilation the process by which a person develops a new cultural identity and becomes like the members of the dominant culture Biculturalism dual pattern of identification and often of divided loyalty Cultural Competence RESPECT Realize Must know your own heritage cultural values bias health beliefs and practices Examine Within patient s own cultural context Select Appropriate questions Pace questions Encourage discussion Check understanding Touch within appropriate cultural boundaries Communication related to developmental considerations Adolescence Elderly Children Adapted to include specific age appropriate information such as prenatal labordelivery developmental milestones nutritional history activities of daily living Adolescent HEEADSSS Home Suicide Education Employment Safety Eating Activities Drugs Depression Sexuality Older Adult Ask about ADL s and how they are affected by the normal aging process effects of chronic illness or disability Want to recognize what the older adult is doing to help themselves stay well Communication with nonEnglish speaking patients Title VI of the Civil Rights Act of 1964 Services cannot be denied to people of limited English proficiency You cannot turn people away even if they do not speak English Need to use an interpreter Cultural considerations as related to eye contact and touch beliefs about illness 0 Culturally Sensitive Possessing basic knowledge of and constructive attitudes toward diverse cultural populations 0 Culturally Appropriate Applying underlying background knowledge necessary to provide the best possible health care Mental Status Examination Level of consciousness and orientation Mini Mental Exam 0 Main components ABCT I Appearance I Behavior I Coginition I Thought processes 0 Research indicates perception of recent life events determines person s emotional or psychological reactions to it our perception affects mental health 0 When to perform a FULL I behavior changes I brain lesions trauma tumor brain attack I aphasia caused by brain damage I symptoms of psychiatric mental illness 0 Mini Mental State concentrates on cognitive functioning not moodthought process 11 q s detect dementia delirium normal 27 impairment below 24 Orientation Registration Attention and calculation Recall Language Describe the different types of Aphasia s signi cance o Aphasia True language disturbance defect in word choice and grammar or defect in comprehension defect is in the higher integrative language processing 0 Global aphasia Most common and most severe Individual can t speak or comprehend o Wernicke or Receptive Cannot comprehend what is being said but they can express themselves The person hears sounds and words but cannot relate them to previous experiences Speech is uent effortless and well articulated but has many made up words and paraphasias do higgy thingy Speech can be totally incomprehensible Often there is a great urge to speak Repetition reading and writing are also impaired I Lost ability to identify things 0 Broca or expressive Can comprehend but cannot express themselves The speech is mostly nouns and verbs telegraphic speech Repetition and reading aloud are severely impaired Auditory and reading comprehensions are intact broken What can nurses do to prevent health care associated nosocomial infections Wash your hands 0 Before and after physical contact with each patient 0 After inadvertent contact with uids 0 After contact with any equipment with body lfuids 0 After removing gloves Wear gloves 0 Wear gown mask and protective eyewear when potential exists for any blood or body uid spattering Assessment techniques Inspection palpation Percussion and Auscultation how to Perform each what you are assessing with each technique normal ndings percussion Order of physical examination Inspection compare LR use person as own control I Visual exam of body including movement and posture I Data obtained by smell I Client is draped appropriately to maintain modesty while allowing sufficient exposure to exam adequate lighting is essential Palpatation 1 State purpose manner and location of touching 2 Wear gloves when palpating mucous membranes or other areas where contact with body uids is possible I Light palpation press approximately 1cm used to assess skin pulsations and tenderness I Deep Palpation press to depth of 4cm determine organ size and contour I Parts of the hand I Dorsal temperature I Fingertips swelling pulsation lumps fine tactile discrimination I Finger and thumb grasp position shape consistency of organ or mass I Palmar Base of fingers vibrations I Crepitation I When air seeps into subcut tissue crunching effect subcut ephesema from lung into subcut I When joints grind against each other tissue paper or rice crispies Percussion Evaluate size borders and consistency of internal organs detects 5cm deep I Direct or immediate direct strike I Direct percussion involves striking finger or hand directly against client s body I Evaluate adult sinus by tapping a finger over sinus I Indirect or mediate striking other hand I Indirect requires both hands methods can vary by system being assessed I Place nondominant hand palm down with fingers together and gently strike fingers with lateral aspect of fist of dominant hand I Indirect percussion of thorax or abdomen performed by placing distal aspect of middle finger of nondominant hand against skin over organ being percussed or between ribs when percussing thorax o This finger is sometimes referred to as pleximeter o Other fingers are spread apart and slightly elevated off client s skin so as not to dampen vibration o Stronger percussion is needed for obese or very muscular clients because thickness of tissue can impair vibrations Auscultation listen to sounds produced by body I Stethoscope I Diaphragm highpitched sounds bowel sounds I Bell lower pitched sounds murmurs I Production of Sound I Tympanic high pitch abdomen I Resonance lung I Hyperresonance in ated lung stomach w gastric bubbles I Dullness liver distended bladder I Flatness bone muscle I Bruits turbulent blood ow through a vessel wooshing I GI listen THEN touch Use of stethoscope and Doppler I Doppler I uses ultrasonic waves to detect and amplify difficulttohear vascular sounds such as fetal heart tones or peripheral pulses I Coupling gel applied to client s skin then transducer is slid over skin surface until blood ow is heard I As blood in vessels ebbs and ows Doppler picks up and amplifies subtle changes in pitch the resulting sound that nurse hears is a swishing pulsating sound I Volume control may further amplify sound I Stethescope I Eliminate noise in room I Never listen THROUGH the gown always place stethoscope on skin I Maintain at contact with skin and stethoscope head Pain acute vs chronic characteristics to assess use of scale for severity types of pain considerations in elderly and pediatric patients I Acute pain Short term Selflimiting Follows a predictable trajectory Dissipates after injury heals 0 Chronic pain Continues for 6 months or longer Types are malignant cancer related and nonmalignant Does not stop when injury heals I Nociceptive pain arises from stimulation of somatic or visceral structures I Neuropathic pain occurs due to abnormal processing of sensory input by central or peripheral nervous systems I Sources of Pain 0 OOOO Visceral pain Originates from large interior organs Deep somatic pain Blood vessel joints tendons muscles and bones Cutaneous pain Skin and SQ Referred pain Pain is felt in a particular site but originates elsewhere Phantom pain is felt in an amputated extremity after residual limb has healed I It commonly occurs in a person who experienced pain in that limb before amputation I Phantom pain also is in uenced by emotions and sympathetic stimulation I Considerations in elderly and pediatric patients 0 Neonate responses to pain are global evidenced by increased heart rate hypertension pallor sweating decreased oxygenation saturation Young children have difficulty understanding pain but have a basic ability to describe pain and location Schoolage children better understand pain and are able to describe pain location Although transmission and perception of pain may be slowed in older person pain is felt no differently from that of any other adult Many older adults have a lifetime of experience in coping with pain but pain is not an expected part of aging Blood pressure measurement correct cuff size what does the results mean How to perform orthostatic hypotension O O O 0 First korotkoff intial sound clear rhythmic thumping systolic Fifth korotkoff marks cessation indicates artery completely open diastolic Physiological factors affecting bp I Diurnal variations pressuretemp is lower in early morning and peaks in late afternoon 6pm or early evening Bp measurements I lt12o80 is normal I Prehypertension12o1398089 I Stage I 14o 1599o 99 I Stage 2 gt16o1oo Pulse qualities to assess O O 0 Can only feel pulse at body sites where the artery lies close to the skin amp over a bone Temporal artery is palpated in front of ear Carotid artery is palpated in groove between sternomastoid muscle and trachea only do 1 at a time Radial artery is palpated on the thumb side of patient s hand I Palpate both radial pulses noting rate rhythm elasticity of vessel wall and equal force I o absent I 1 weak thready pulse I 2 normal press gently and feel it I 3 bounding full barely press it and feel it I 4 woooah excessive uid Cranial nerve assessment 0 CNI olfactory I Sensory CNII optic visual acuity field snellen confrontation I Seonsory CNIII oculmotor pupil constriction accommodation EOM extraocular muscle I Motor CNIV Trochlear EOM I Motor CNV Trigeminal mastication muscles facial corneal re ex I Both CNVI Abducens EOM I Motor CNVII Facial facial symmetry sweet sour taste I Both CNVIII Acoustic whisper Weber Rinne I Sensory CNIX glosspharyngeal tongue uvula gag posterior tongue taste I Both CNX Vagus gag I Both CNXI Spinal Accessory sternomastoid and traps I Motor CNXII hypoglossal move tongue I Motor Glascow Coma Scale High score 15 Dead 3 Under 8 intubate 0 Eyes I 4 open eyes spontaneously I 3 call name to open eyes I 2 call name sternal rub trap squeeze roll pen on cuticle nail bed painful stimuli I 1 NO RESPONSE after quot o Verbal I 5 Talk I 4 slightly confuseddisoriented I 3 inappropriate speech I 2 incomprehensible sounds I 1 no response 0 Motor I 6 obey all commands 5 localize pain 4 exion withdrawal 3 Decorticate pull legs up ex protect something worthy in core I 2 Decerebrate Extension abnormal sternal rub and turn into exorcist heel and head on bed I 1 no response Deep tendon re ex how to test and signi cance of ndings Needs an intact sensory nerve afferent functional synapse in cord intact motor nerve fiber efferent neuromusc junction competent muscle 0 o no response 0 2 normal 0 4 brisk hyperactive with clonus Types Biceps triceps brachioradialis quadriceps knee jerk Achilles Describe dizziness vertigo nystagmus aura and nursing considerations 0 Dizziness is a lightheaded swimming sensation feeling of falling o Vertigo is true rotational spinning from neurological disease objective vertigo person feels like the room is spinning subjective person feels like they are spinning I When have you noticed this How often does it occur Does it occur with activity change in position I Do you ever feel a sensation called vertigo a rotational spinning sensation Do you feel as of the room spins Do you feel that you are spinning Did this come on suddenly or gradually o Nystagmus is back and forth oscillation of the eyes eye twitch assess movement amplitude frequency and plane of movement I Occurs with disease of vestibular system cerebellum or brainstem o Aura is a subjective sensation that precedes a seizure it could be auditory visual or motor Describe the following Romberg Babinski re ex Romberg have patient stand with feet together and arms at sides then close eyes and hold position 0 note any swaying or falls Babinkski toes fan out and only should occur in an infant Determine this doing plantar re ex o Toes should curl in Describe the RinneWeber and signi cance of results Weber Done for bone conduction place vibrating tuning for in midline of skill and ask if heard equally in both ears if they are not equal then hearing loss has occurred Rinne Done for comparing air conduction and bone conduction Place vibrating tuning fork on mastoid process and ask patient to tell you when he stops hearing the sound Then place the fork immediately by his ear and ask if he hears the sound Air conduction should be 2X as long as bone conduction How to assess pupillary response EOM accommodation visual acuity Snellen chart 1 Eye 2 Ear 2500 O O Opthalmoscope normal to have the red re ex Ocular fundus Inspect Optic disc bright circle on nasal side I Color creamy yellow orange with distinct edges I Shape round or oval I Veins and arteries come from disk thin out moving away from disk Retinal vessels I Color arteries are a brighter red I AltV ratio I Caliber thin out moving away form disk General background of the fundus I Pink to dark brown to red congruent with patient s ethnicity I Follow v a to make sure no micsnics mic piece oating out as artry or vein continues split end Macula darker red area keenest vision one optic disk diameter in size two disc diameters from optic disk on temporal side Infection acute otitis media AOM is infection of middle ear Clinical findings I Major symptom with AOM is ear pain otalgia I May include fever vomiting infants and decreased hearing older children and adults I In early stages tympanic membrane TM appears in amed red and may be bulging and immobile I Later stages may reveal discoloration white or yellow drainage and opacification to the TM I Purulent drainage from the ear canal with a sudden relief of pain suggests perforation Sound waves reach cochlea by middle ear causing movement of hair cells I Sensory hair cells transmit impulses through nerve receptors and vestibular nerve branch of acoustic nerve CN VIII air conduction 2x as long as bone conduction I Transmit to temporal lobe of the brain where sound is interpreted Ataxia uncoordinated Stereognesis familiar object identification 0 Ability to perceive and recognize the form of an object by touch no sight or hear I Ex nurse puts a penny in your hand and you say it s a key 5 Graphesthesia ability to recognize writing on the skin only by the sensation of touch 6 Kinesthesia position of your own body parts and strength of effort to move Delirium vs Dementia l Delirium disturbance of consciousness and rapid change in cognition O 0 short manifestations 1 weeks reversible with treatment dehydrations infection electrolyte imbalance 2 Dementia not reversible O O progressive intellectual compromise of memorylanguagevisualspatial emotion personality short term goes first
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