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Relationship based health care focuses on what?
emotional, physical, spiritual, and holistic health
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What questions would the nurse ask to determine the patients ADL?
- What foods do you like to eat?
- Do you have any allergies to medications?
- Do you have any pain in your abdomen?
- Do you need any assistance bathing?
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All health care workers protect themselves by wearing a surgical mask, and googles or face shield when?
there is a reasonable chance that splash or spray of blood or body fluids may occur to the eyes, mouth or nose
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All healthcare workers protect themselves by wearing gloves when?
touching blood, body fluid, non- intact skin, mucous membranes, contaminated items
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All healthcare workers protect themselves by wearing gowns when?
there maybe risk of skin or clothing being exposed to blood or body fluids.
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Diseases that would use airborne precautions would be?
tuberculosis, varicella (chickenpox), measles
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Equipment need for airborne precautions include?
N95 respirator, negative air pressure isolation room
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Diseases associated with droplet precautions include?
- bordetella pertussis
- mycoplasma pneumonia
- group a streptococcus
- Neisseria meningitidis
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Equipment needed for droplet precautions include?
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Diseases associated with contact precautions includes?
- (MRSA) Methicillin-resistant Staphylococcus Aureus
- (VRE) Vancomycin-resistant Enterococci
- (c. diff) Clostridium difficile
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Equipment needed for contact precautions include?
gown and gloves
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What precaution is needed for MRSA?
contact precautions
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What precaution is needed for tuberculosis?
airborne precautions
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What precaution is need for a patient with the measles?
airborne precautions
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What precautions is needed for a patient with group a streptococcus?
droplet precautions
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What precaution is need for a patient with neisseria meingintidis?
droplet precautions.
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What precaution is need with a patient who has Vancomycin resistant enterococci?
contact precautions
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A patient receiving a vaccine is utilizing what level of prevention?
Primary prevention
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The nurse is caring for a paitent with an infectious drainage from an abdominal wound. The nurse would wear gloves and: a) gown b) n 95 respirator c) eye wear d) mask?
gown
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What website would you access to determine the status of an ecoli outbreak in Mexico? a) www.CDC.org b)www.WHO.int c)www.healthypeople.gov d) www.FDA.gov?
www.WHO.int
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What happens to the skin of an aging adult?
loss of elastin, collagen, subcutaneous fat, reduction of muscle tone, wrinkling occurs, sweat glands decrease in number, senile purpura
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Some abnormalities with the skin include?
Seborrheic kerotosis, and senile lentigines
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Dermatitis is? cause by?
irritation of the skin which can be caused by allergies, insect bites, eczema
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What is subjective data?
what the person says about himself or herself during history taking
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What is objective data?
what you as the health professional observe by inspecting, percussing, palpating, and aucultating during the physical examination
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There are two method of percussion. Which method is the immediate striking hand that contacts the body wall?
Direct percussion
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What method of percussion is used more often and involves both hands in which the striking hand is on contacts the stationary hand on the persons skin
indirect percussion
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A loud or soft sound? (percussion) *loudness depends on the force of the blow and the structures ability to vibrate.
amplitude
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The number of vibrations per second, written as cps or cycles per second. More rapid vibrations produce a high pitched tone; slower vibrations yield a lower pitched tone. This is what type of percussion?
pitch
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a subjective difference due to a sounds distinctive overtones. a pure tone is a sound of one frequency. Viariations within a sound wave produce overtones which allow you to distinguish a C on a piano from a C on a violin. Which percussion is this?
quality
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the length of time the note lingers. What type of percussion is this?
duration
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Identify the note. The pitch is medium-loud, and the quality is low.
resonant
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Identify the note. The pitch is louder, and the quality is lower.
Hyperresonant
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Identify the note. The pitch is loud and the quality is high.
tympany
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Identify the note. The pitch is soft the quality is high.
dull
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Identify the note. The pitch is very soft and the quality is high
flat
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When completing a physical exam and finding objective data for the hair, you are looking to inspect and palpate what?
color, texture, distribution, lesions
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When completing a physical exam to find objective data for the nails, you are inspecting and palpating for?
shape and contour, consistency, color (capillary refill)
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When completing a physical exam to find objective data for a the skin and you notice a lesion, you are inspecting and palpating for?
color, elevation, pattern or shape, size, location and distribution, exudate
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When completing a physical exam to find objective data for the skin, you are inspecting and palpating?
texture, thickness, edema, mobility and turgor, vascularity or brusing
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During a physical exam objective data is found when assessing temperature when their are noted temperature changes to the patient by the nurse. An increased temperature which is a temp over 100.4 degrees F is called?
hyperthermia
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A temperature below 98.6 degrees F is called?
hypothermia
*When a patient notes this, it is objective data
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When assessing the skin, you want to look for moisture. What are abnormal finding to moisture?
- diaphoresis: profuse sweating
- dehydration: dry thirsty skin
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When inspecting the mouth you check for?
lip color, symmetry, moisture, cracking, or lesions. inspect teech for clor, number, straightness, spacing and cleanliness (debris or decay)
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When you are palpating the mouth you check for?
symmetry, edema, cracking and lesions
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When patient clenches her teeth and smiles, she is using cranial nerve?
7
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When patient extends the tongue, he/she is using cranial nerve?
twelve
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The uvula position is?
midline
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When in inspecting the bucal mucosa check for?
color, smoothness,moisture, ulcerations, lesions
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When inspecting the throat, check tonsils using the tongue blade and note?
color, size, exudate
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The gag reflex activates what cranial nerves?
9 and 10
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When assessing the nose, you are checking for?
discharge, frequent colds, sinus pain, trauma, epistaxis (nose bleeds), allergies, altered smell
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Inspect the nose for?
shape, size, color, discharge, nasal flaring or narrowing lesions.
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When palpating rideg and soft tissues of the nose, note any?
displacement of bone and cartilage, tenderness or mass and evaluate patency of the nares.
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When inspecting for sinuses, inspect?
frontal and maxillary sinuses for swelling
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Percuss sinus areas using what type of percussion
direct percussion (lightly tap over each area with index finger)
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What sort of symptoms may indicate pain?
swelling, tenderness, pain
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What is performed is sinuses tender or infection is suspected?
transilumination in which a light source is positioned lateral to the nose, just beneath medial aspect of the eye.
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Dysphagia is?
difficulty swallowing
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In older adults, the oral muscosa is often
drier and more fragile due to degeneration of epithelial lining of salivary glands. ability to smell and taste decreases with age.
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Abnormal findings include
- black hairy tongue
- candidiasis
- atrophic glossitis
- aphtous ulcers (canker sore)
- gingivitis
- herpes simplex 1
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early signs of oral cancer include
a sore that doesn't heal, smooth or leathery white patch or lump, a prolonged sore throat or feeling that something is in the throat, difficulty chewing, restricted movement of the tongue or jaw
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effects of slt use include
- gum recession
- tooth discoloration
- bad breath
- nicotine dependence
- unhealthy eating
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Periodontal means? What is periodontal disease?
around the tooth. the disease is a chronic bacterial infection taht affects the gums and bone supporting the teeth. bacteria in plaque causes the gums to become inflamed.
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If the presence of tearing occurs after inspecting lacrimal duct, this may be an indication of a?
blockage of the nasolacrimal duct.
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How far should patient stand away from the chart?
20 feet
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With the corneal light reflex, you must?
shine light toward the person eyes. have them stare straight ahead as light is held about 12 inches away.
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The six cardinal fields of gaze include cranial nerves?
3 4 and 6
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What is red reflex?
a red glow filing the person pupil caused by reflection of the ophthalmoscope light off inner retina.
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When inspecting the ocular fundus, what color should the general background be?
light red to dark brown red
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What inspecting the optic dis located on nasal side of the retina, what should the color and shape be?
creamy yellow-orange to pink, round or oval
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What does aging cause in connection with the eyes?
- problems with lacrimal duct
- decreased tear production
- dryness and burning of eyes
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What are normal changes of aging in connection with the eyes?
- pupils are smaller in size, arcus senilis (gray white arc or circle around limbus.
- lens has decreased ablity to change in size to accommodate for near vision (presbyopia)
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What is the most common cause of blindness?
breakdown of cells in the macula
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What type of patients should have an annual eye examination?
patients with hypertension or diabetes
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Which way should you pull the pinna for an adult and older child?
up and back
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Which way should you pull the ear for a child under 3
pull pinna down
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Two images seen at the same time
diplopia
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a ringing or hissing in the ear
tinnitus
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the projected part of the external ear.
pinna
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Environmental sanitation
Immunizations
Primary Prevention (Protection)
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Cure and prevent disease process
prevent complications
Secondary prevention (early diagnosis and prompt treatment)
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Rehabilitation to attain optimal level of functioning
tertiary prevention (restoration and rehabilitation)
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PIE
Problem Intervention evaluation
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SOAP
subjective Objective Assessment Plan
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airway breathing problems, and circulation. What type of priority?
first level priority
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mental status changes, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infections, risk of safety or security is what type of priority.
second level priority
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low self esteem, diagnoses of knowledge deficit, altered family processes.
third level priority
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