-
Six components to POMR
- 1.Comprehensive health history
- 2.Complete physical examination
- 3.Problem list
- 4.Assessment and plan
- 5.Baseline and problem-directed laboratory imaging studies
- 6.Progress notes
-
Define Beneficence:
do good for the patient
-
Define Nonmaleficence:
do no harm to the patient
-
Define utilitarianism:
the need to consider the appropriate use of resources for the greater good of the larger population
-
Define fairness/justice:
recognition of the balance between autonomy and competing interests of family
-
Define deontological imperatives:
the duties of care providers established by tradition and in cultural contexts
-
List the normal structure for a health history:
- Chief complaint
- History of present illness
- Past medical history
- Family history
- Personal and social history
- Review of systems
-
List the 8 components of the analysis of a symptom (PQRSTU)
- 1.Location
- 2.Quality
- 3.Quantity
- 4.Timing
- 5.Setting
- 6.Aggravating/alleviating factors
- 7.Associated factors
- 8.Patient perception
-
Describe position- Dorsal Recumbent:
Used for examining genital/rectal areas.
Pt lies supine with knees bent and feet flat on table
-
Describe position- Lateral Recumbent:
Side lying position, with legs extended or flexed.
May be used to listen to heart sounds
-
Describe position- Lithotomy:
Generally used for pelvic exam.
Begins in dorsal recumbent then stabilize feet in stirrups
-
Describe position- Sims:
Used to examine the rectum or obtaining rectal temperature.
Pt starts in lateral recumbent position. Torso is rolled toward a prone position; the top leg is flexed sharply at the hips and knee and the bottom leg is flexed slightly
-
Describe position- Fowler's:
Pt is sitting copletely upright or slightly bent back, legs can be either bent or straight out
-
Describe position- Trendelenburg:
Pt i slying supine with legs slightly higher than head
-
AKA the number of cardiac cycles per minute
heart rate
-
Describe- Dyspnea
difficult and labored breathing w/ shortness of breath
-
Describe- Orthopnea-
Shortness of breath that begins or increases when the patient lies down
-
Describe- Paroxysmal nocturnal dyspnea
a sudden onset of shortness of breath after a period of sleep
-
Describe- Platypnea-
dyspnea increases in the upright posture
-
Describe- Bradypnea-
a rate slower than 12 respirations per min, may indicate splendid level of cardiorespiratory fitness
-
Describe- Hyperpnea-
Pt is breathing laboriously, as if forced, and deeply
-
Describe- Kussmaul breathing-
always deep and most often rapid, the eponym applied to the respiratory effort associated w/ metabolic acidosis
-
Describe- Hypopnea-
abnormally shallow respirations
-
Describe- Cheyne-Strokes-
periodic pattern of breathing w/ intervals of apnea followed by crescendo/decrescendo sequence of resp; may be pattern for sleep of children and older adults, pattern for seriously ill patients w/ brain damage
-
Describe- Tachypnea-
faster than 20 breaths per minute
-
Describe- Sighing-
frequently interspersed deeper breathing
-
Describe- Air trapping-
the result of prolonged but inefficient expiratory effort
-
Describe- Biot respiration-
somewhat irregular resps varying in depth and interrpted by intervals of apnea, but lacking reptitve pattern of periodic resp. associated w/ severe and persistent increased intracranial pressure
-
Describe Bronchophony-
"99" or "1,2,3"
- Normal- sounds muffled
- Consolidated- sounds clear
-
Describe Whispered pectoriliquy-
"99" or "1,2,3" (in a whisper)
- Normal- sounds muffled
- Consolidated- sounds clear but louder
-
Describe Egophony-
"e-e-e"
- Normal- sounds like muffled "e"
- Consolidated- sounds like "a"
-
Breath sounds- Tracheal
high pitch/very loud intensity
I:E 1:1
-
Breath sounds- Bronchial
high pitch/ loud intensity
I:E 1:2
-
Breath sounds- Broncho-vesicular
med pitch/ med intensity
I:E 1:1
-
Breath sounds- Vesicular
low pitch, soft intensity
I:E 2.5:1
-
Crackles are _________, rhonchi & wheezes are _________
discontinuous, continuous
-
Identify:
Fine high pitched
popping sounds or noises
short in duration
heard more at end of inspiration
not cleared by coughing
hear in CHF, asthma, bronchitis
(sibilant)
Fine Crackles
-
Identify:
low pitched
bubbling sounds that start early in inspiration and can extend into expiration
usually longer in duration
(sonorous)
Course Crackles
-
Identify:
low pitched
coarse
loud-like snoring
primarily heard on expiration
may clear with coughing
ex.-bronchitis or pneumonia
Rhonchi
-
Identify:
high pitched
musical sound similar to a squeak
heard during expiration
often heard in asthma pt's
Wheezes
-
Identify:
Like sandpaper
not cleared by coughing
heard in both inspiration and expiration
superficial
low pitched, coarse rubbing
heard in inflammation of pleural spaces
Pleural friction rub
-
Describe the physical/developmental changes that occure in the aging client in a respiratory assessment:
- chest expansion decreased, less able to use the respiratory m.
- the AP diamter of the chest is increased in relation to the lateral diameter
- difficulty breathing deep and holding
-
Functions of the skin:
- protection
- proide sensory contact
- temperature regulation
- production of vitamin D
- excretion of sweat, urea, and lactic acid
- expression emotions
- repair
-
Layers of the epidermis:
_________- basal skin layer; deepest layer, helps to form new skin cells with keratin
stratum germinativum
-
Layers of the epidermis:
__________- outer horny layer of flattened and closly packed dead cells being shead
stratum corneum
-
gives skin pigmentation
melanocytes
-
Sweat glands:
______- dilute saline, sweat, help to cool surface of skin and reduce temp
Eccrine
-
Sweat glands:
________- activated in puberty, body order. milky secretion in folds of skin
Apocrine
-
-
normal variations in the skin:
- striae-stretch marks
- vitiligo-unpigmented skin
- freckles- small flat macules
- mole- a lot of melanin in one area
- birthmarks- tan, reddish, or brown
-
usually found on face and neck, bright red raised leasion, doesn't blanch (turn white) with pressure
strawberry hemangioma
-
Pallor
whitish overtone to skin
-
Erythema
extreme redness of skin due to excess blood and dilated superficial capillaries
-
Cyanosis
Bluish; lack of oxygen
-
Jaundice
yellow color; rising amounts of billirubin in blood; liver problem
-
Caroten
Orange color; excess orange diet
-
Normal variations:
_____- color of cherry found on trunk or neck
Cherry angioma
-
Normal variations:
_________- small red branching, blanch with direct pressure; found on face, neck, arm and upper trunk; cirosis of live
spider angioma
-
Normal variations:
_______- permanent dilation of a group of superficial capillaries and venules; tongue and nose
telangiectasia
-
Abnormal variations:
_______- small pinpoint lesions
Petechiae
-
Abnormal variations:
________- bruise
Hematoma
-
Lesions- Patterns or shape
______- circular
annular
-
Lesions- Patterns or shape
________- lesions run together (hives)
confluent
-
Lesions- Patterns or shape
________- distinct, individual lesions that remain separate (molluscum)
discrete
-
Lesions- Patterns or shape
______- clusters of lesions
grouped
-
Lesions- Patterns or shape
______- twisted, coiled or snakelike
gyrate
-
Lesions- Patterns or shape
______- resembles iris of eye with concentric rings of color (erythema multiforme)
target
-
Lesions- Patterns or shape
______- scratch, streak, line, or stripe
linear
-
Lesions- Patterns or shape
______- annular lesions that grow together (psoriasis)
polycyclic
-
Lesions- Patterns or shape
______- linear arrangement along a nerver route or dermatome (shingles)
zosteriform
-
-
AKA hair growth
hirsutism
-
caused by chronic hypoxia, nail bed exceeded 180 degrees
clubbing
-
central depression of nail, lateral elevation of nail plate
spooning
-
Primary skin lesions:
ex- measles
color change
flat
circumscribed
<l cm
macule
-
Primary skin lesions:
ex- virtiligo
color change
flat
may be irregular shape
>1cm
patch
-
Primary skin lesions:
ex- wart, mole
solid
elevated
palpable
circumscribed
<1cm
papule
-
Primary skin lesions:
ex- psoriasis
elevated
firm
rough lesion with flat top
>1cm
plaque
-
Primary skin lesions:
ex- fibroma
elevated
firm
circumscribed
extends into dermis
>1cm
nodule
-
Primary skin lesions:
ex- benign tumor
larger nodule
elevated
solid and soft or firm
deeper into dermis
larger than a few cm
tumor
-
Primary skin lesions:
ex- chicken pox
elevated
circumscribed
serous fluid filled area
<1cm
vesicle
-
Primary skin lesions:
ex- blister
vessicle greater than 1 cm
bulla
-
Primary skin lesions:
ex-acne
elevated
superficial
filled with purulent fluid(yellow, infectious puss)
pustule
-
Primary skin lesions:
ex-sebaceous cyst
encapsulated
fluid-filled cavity in dermis
cyst
-
Primary skin lesions:
ex- insect bites
superficial
elevated
irregularly shaped cutaneous edema
wheal
-
Primary skin lesions:
hives
coalesced wheals
caused by allergic reaction
note pattern or shape
urticaria
-
Primary skin lesions:
described as boil
localized collection of puss
inflammation /redness
abcess
-
Secondary skin lesions:
roughened
thickened epidermis
secondary to persistent rubbing/ itching
produces tightly packed sets of papules
looks like moss or lichen
lichenification
-
Secondary skin lesions:
Linear cracks in skin
ex- chilosis, athlete's foot
fissure
-
Secondary skin lesions:
thin to thick fibrous tissue that replaaces normal skin following injury or laceration to dermis
scar
-
Secondary skin lesions:
elevated scar
tissue grows beyond the borders of the scar
"hypertrohpic"
higher incidence among blacks
keloid scar
-
Secondary skin lesions:
ex- burn
loss of epidermis following rupture of vessicle/bulla/pustule
erosion
-
Secondary skin lesions:
loss of epidermis and dermis
stasis ulcer, decubitus ulcer
stasus ulcer- decreased venus return
ulcer
-
Staging pressure ulcers:
intact skin with non-blanchable redness
stage I
-
Staging pressure ulcers:
Partial thickness loss of dermis presenting as a shallow open ulcer
stage II
-
Staging pressure ulcers:
Full thickness tissue loss; subcutaneous fat may be visible
stage III
-
Staging pressure ulcers:
Full thickness tissue loss with exposed bone, tendon or muscle.
stage IV
-
Staging pressure ulcers:
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
Unstageable
|
|
