Exam 1: NSG 316 / NSG316 (Latest 2026–2027 Update) Health Assessment | Complete Question & Answer | Verified Solutions | 100% Accuracy | Grade A – GCU

…..DLDD Exam 1: NSG 316 / NSG316 (Latest 2026–2027 Update) Health Assessment | Complete Question & Answer | Verified Solutions | 100% Accuracy | Grade A – GCU Q. What is a general survey? ANSWERS a study of the whole person, covering the general health state and any obvious physical characteristics Q. What is included in a general survey? ANSWERS physical appearance, body structure, mobility, and behavior Q. What is ADOPIE? ANSWERS Assessment Diagnosis Outcome/ Identification Planning Implementation Evaluation Q. What is a comprehensive assessment (Complete Total Health Assessment)? ANSWERS a complete health history and a full physical examination where they describe current and past health states and form a baseline to measure all future changes (ex. home healthcare setting) Q. What is a Focused Based Assessment (Episodic/ Problem-centered)? ANSWERS a limited or short-term problem concerned with one problem, one cue (ex. urgent care) Q. What is a Follow-Up Database? ANSWERS evaluating the status of all identified problems and noting if changes have occurred (ex. primary care physician appointment) Q. What is an Emergency Database? ANSWERS RAPID collection of data, often compiled with lifesaving measure (ex. emergency room) Q. How do you know the source of information given is reliable? ANSWERS they will give the same answer even when the question is rephrased or repeated 3 times with the same answer Q. How do you know if the patient is actually ill just by how they communicate? ANSWERS a sick patient will communicate poorly Q. What is PQRST ANSWERS Provocative/ Palliative Quality/ Quantity Region/ Radiation Severity Scale 1-10 Timing/ Onset Q. What is a good way to depict gender, relationships, and age of immediate blood relatives in at least three generations such as parents, grandparents, and siblings? ANSWERS GENOGRAM (family tree) - identifies increased disease or illness they might be prone to Q. What affects health promotion and disease prevention throughout the life span? ANSWERS Age Smoking/ Drinking Weight Genetics Q. What are ADL's? ANSWERS Bathing, dressing, eating, transferring, walking, and toileting Q. What are IADL's? ANSWERS independent living situations like housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances Q. What are AADL's? ANSWERS their social relationships and resources such as nutrition, self-concept and coping, as well as their home environment Q. What is the Katz Index of Independence in ADL? ANSWERS the concept of physical disability and measures physical function in older adults and the chronically ill Q. What is the Lawton Instrumental Activities of Daily Living (IADL's)? ANSWERS measures functional abilities necessary for independent community living Q. What are examples of AADL's ANSWERS occupational and recreational activities such as occupational therapists, the Up-and-Go Test, physical performance test, and performance activities of daily living Q. How does the Health History Sequence go? ANSWERS Biographical Data Source of History Reason for Seeking Care Present Health or History of present illness Past Health Family History Review of Systems (ROS) Functional Assessment (IADL's) Q. What is a pneumonic to remember the Health History Sequence? ANSWERS Bill Sat Right Past Pete For Raw Fish Q. Biographical Data ANSWERS Patients.. Name Address/Phone Number Age/Birthdate Birthplace Sex Marital Status Q. Race ANSWERS Ethnic Origin Occupation Q. Describe Symptom: ANSWERS subjective sensations the person feels from a disorder Q. Describe Sign: ANSWERS objective abnormality that can be detected on physical examination or in lab reports Which of the following is a good example of a well-written chief complaint? A.Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest. B.Pain is a 10/10 C.Patient complaining of chest pain. R/O MI D.Patient states "I don't know what this pain is. This is the worst I have ever felt" A What is the alcohol consumption C.A.G.E. Test/ Screening? Cut down your drinking Annoyed by criticism of your drinking Guilty about your drinking Eye openers Which of the following statements by the patient would indicate a substance abuse problem? A."I have a glass of wine each day with dinner" B."My wife keeps nagging me to cut down on drinking." C."I love to have a few drinks around the holidays" D."I have a few drinks on the weekend when my friends get together" B What 3 points does a functional assessment of an older adult consist of? IADL'S ADL'S Mobility What are 2 approaches to an older adults functional assessment? Individual's self-report and observing the patients ability to perform tasks The nurse is assessing the patient's ability to bathe and dress herself. The nurse knows this type of assessment is considered: A. the Mini-Cog B. independent activities of daily living C. dependent activities of daily living D. activities of daily living D What is dementia? slow onset difficulty with word finding, naming objects, memory What is delirium? acute changes in cognition and attention What is depression? memory problems What should all caregivers be screened for? caregiver burden The nurse realizes that the patient at the highest risk for falls is the patient: A. with a history of myocardial infarction B. who uses a cane to ambulate. C. who has to climb up a flight of steps to get to the bathroom D. who had a hip replacement 2 months ago B A hispanic patient who was in a car accident has severe leg pain but is refusing analgesics and will not undergo treatment. Which is the best nursing intervention? A. Negotiate with the patient B. Inform the patient's family members C. Inform the patient of the advantages of treatment D. Provide alternative treatment according to the patient's culture D Define Acculturative Stress: losses and changes associated with integration of new beliefs What is the first step in gaining cultural competence? understanding one's own heritage-based values, beliefs, attitudes, and practices What is the order of gathering data during a physical examination? inspection -- palpation -- percussion -- auscultation When does inspection begin? when you first meet the person with a general survey What are the three requirements for an inspection? 1. good lighting 2. adequate exposure 3. occasional use of instruments including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula to enlarge your view Do you palpate lightly or deeply? lightly ONLY; provider will perform deep palpation WHEN NEEDED How are fingertips used to palpate? skin texture, swelling, pulsation, determining presence of lumps How are the fingers and thumb used to palpate? detection of position, shape, and consistency of an organ/ mass What is the best part of the hand to use when determining a patients temperature and why? dorsa of hands and fingers; thinner than palms What are the base of the fingers or ULNAR surface of the hand used for when palpating? vibrations What is percussion used for? mapping location and size of organs, signaling density of a structure by a characteristic note, detecting a superficial abnormal mass, eliciting pain if underlying structure is inflamed, eliciting deep tendon reflex using percussion hammer What is the direct method of percussion? striking hand directly contacts body wall What is the indirect method of percussion? using both hands, the striking hand contacts stationary hand fixed on person's skin Do stethoscopes magnify sound? No, they block out extraneous sounds What kind of sounds does the bell of the stethoscope listen to? low-pitched sounds (heart murmurs) What kind of sound does the diaphragm of the stethoscope listen to? high-pitched sounds What is an otoscope? used to view inside of the outer ear What is a ophthalmoscope? instrument used to view the retina When do you wear eye glasses? whenever there is a risk of fluids splashing If an ill person is in distress when you want to do your assessment, what do you do? finish a complete assessment after the initial distress has been resolved Define Nociceptors: pain receptors Where do Nociceptors carry pain to? central nervous system What are the phases of nociception? Transduction- noxious stimuli in the form of injury/ trauma Transmission- pain impulses move from spinal cord to the brain Perception- conscious awareness of painful sensation Modulation- pain message is inhibited Where is visceral pain? larger interior organs (ex. ulcer pain, cholecystitis) Where is deep somatic pain? blood vessels, joints, tendons, muscles, and bone injury Where is cutaneous pain? skin surface and subcutaneous tissues (ex. sharp burning sensation) Where is referred pain? felt at a particular site but originates from another location (ex. inflamed appendix in right lower quadrant of abdomen may have referred pain in pre umbilical area) Acute Pain: less than 6 months Chronic Pain: more than 6 months What are the types of chronic pain? malignant (cancer related) and nonmalignant Malignant Pain: Often parallels the pathology caused by the tumor cells Is induced by tissue necrosis or stretching of an organ by the growing tumor Pain fluctuates within the course of the disease Nonmalignant Pain: often associated with musculoskeletal conditions, such as arthritis, low back pain, or fibromyalgia A patient is crying and says, "Please get me something to relieve this pain." What should the nurse do next? A. Verify that the patient has an order for pain medications and administer order as directed. B. Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level. C. Assess the level of pain and give medications according to pain level, and then reassess pain. D. Reposition the patient, then reassess the pain after intervention. B Is pain a normal process of aging? No What is the difference between men and women when it comes to pain? - hormone changes are found to have strong influences on pain sensitivity for women - women are 2-3x more likely to experience migraines during childbearing years, sensitivity to pain during premenstrual periods, and are 6x more likely to have fibromyalgia What would be the explanation for why some people feel more or less pain even with the same stimulus? pain gene What are the 8 questions a patient is asked during an initial pain assessment? location, duration, quality, intensity, and aggravating/relieving factors What is asked during a brief pain inventory? patients are asked to rate pain within the past 24 hours on a scale of 0-10 What is the numeric rating scale? having the patient choose a number that rates the level of pain 0-10 What is the verbal descriptor scale? words to describe pain; preferred by older adults What is the visual analog scales? marking the intensity of the pain on a horizontal line from "no pain" to "worst pain" The nurse is reassessing a patient's pain level after pain medication administration following a pain level of 9/10. The patient states that his pain level is now a 3/10. What should the nurse do next? A. Verify med orders and offer more pain medication, if appropriate. B. Continue to assess patient's pain level C. Document the pain level in the chart D. No need for action, because the patient's pain is manageable A How to assess joints: - note size and contour - measure circumference and compare to baseline - check active + passive range of motion - usually will not cause tenderness, pain, or crepitation How to assess muscles: - inspect skin/ tissues for color, swelling, and masses How do you assess for changes in sensation? 1) break tongue blade in two lengthwise to test their ability to perceive sensation 2) lightly press the sharp ends onto the skin in a random fashion and ask if it feels sharp or dull How to assess the abdomen: - observe for contour and symmetry - palpate for muscle guarding and organ size - note any areas of referred pain What are acute pain behaviors? Guarding Grimacing Moaning Agitation Restlessness Stillness Diaphoresis Changes in VS What are chronic pain behaviors? Bracing Rubbing Diminished activity Sighing Change in appetite More variability than acute pain behaviors What are some behavioral cues that indicate a change in functional status? sudden onset of acute confusion, change in involvement in activities, slowness, rigidity, fatigue How does the PAINAD scale work? Pain Assessment in Advanced Dementia 0-2 0 with everything normal to 2 which shows signs of pain Which part of the nursing process includes the interview and health assessment and physical assessment? assessment (1st part of the nursing process) How large is the skin in square feet? 20 square feet What are the layers of the skin? epidermis, dermis, subcutaneous What layer of the skin contains collagen and elastic tissue? the dermis What layer of the skin is made up of adipose tissue and aids in insulation and temperature control? the subcutaneous layer What does the skin produce? Vitamin D What do sebaceous glands do? secrete sebum; moisturize skin What do sweat glands do and how many are there? create fluid balance and thermoregulation; eccrine and apocrine The skin is ________, __________, and _________ waterproof, protective, and adaptive The aging adults elasticity: loss of elasticity The aging adults sweat and sebaceous glands: decrease in the number and function, leaving skin dry Aging adult and senile purpura: discoloration due to increasing capillary fragility (capillaries breaking easily) What is responsible for grey hair and thinning of the hair? decreased melanocytes How do you perform a capillary refill test? depress the nail and see how long it takes to refill; return of color indicates peripheral circulation How do you determine what is wrong based off a capillary refill? if it is over 1-2 seconds to refill What can a slow capillary refill indicate? anemia, decreased oxygen saturation, decreased cardiac output What factors can affect a capillary refill? cool room/ decreased body temperature, cigarette smoking, peripheral edema What do you look for when looking at the nails? color, length, symmetry, cleanliness and configuration (160 degree angle) What is clubbing? an increase in the angle between the base of the nail and the fingernail to 180 degrees or more What is clubbing associated with? respiratory and cardiovascular disease What is the ABCDE skin assessment? A: asymmetry B: border (edges=blurred) C: color D: diameter (6mm) E: elevation and enlargement How to do a skin turgor test: pinch skin on the dorsal part of the hand or near the collar bone to assess hydration levels How do you know a patient is dehydrated? if the turgor test shows TENTING (turgor stays pinched and falls back slowly) What is edema? the excess accumulation of FLUID IN THE interstitial TISSUE spaces which is also called THIRD-SPACE FLUID What is the scale to grade pitting edema? +1: mild, slight indentation, no perceptible swelling 2+: moderate, indentation subsides RAPIDLY 3+: deep indentation, remains for a SHORT time, appears swollen 4+: very deep, indentation lasts a LONG TIME, appears very swollen What can a +4 scale to pitting be associated with? heart disease/ heart failure The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect? A. Cyanosis B. Flushing C. Rubor D. Jaundice D What is senile lentigines? liver spots What is keratoses? warts/ moles What is xerosis? dry skin What is another term for skin tags? acrohordons Annular or Circular ringworm Confluent Hives; runs together Discrete Acne; remains separate Gyrate Spiraled; scabies Grouped cluster of lesions; contact dermatitis Linear scratching Target lymes disease Zosteriform shingles Polycyclic pserosis Macule Primary Lesion Solely a color change, flat and circumscribed, of less than 1 cm (ex. freckles, flat nevi, hypo pigmentation, petechiae, measles, scarlet fever) Papule Primary Lesion Something you can feel (solid, elevated, circumscribed, less than 1 cm in diameter) caused by superficial thickening in the epidermis (ex. elevated nevus (mole), lichen, planus, molluscum, wart (verruca)) Nodule Primary Lesion - Solid, elevated, hard or soft, larger than 1 cm May extend deeper into dermis than papule (ex. xanthoma, fibroma nevi) Wheal Primary Lesion Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues) (ex. mosquito bite, allergic reaction, dermographism) Vesicle/ Bulla Primary Lesion elevated cavity containing FREE FLUID UP TO 1 CM (ex. chickenpox, burn) Cyst Primary Lesion Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin (ex. sebaceous cyst, swelling) Pustule Primary Lesion Turbid fluid (pus) in the cavity, circumscribed and elevated (ex. impetigo, acne) Crust Secondary Lesion impetigo Scale Secondary Lesion Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells - eczema, psoriasis Fissure Secondary Lesion Linear crack with abrupt edges, extends into dermis, dry or moist - ex. athletes foot- fungal Erosion Secondary Lesion Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis - Caused by friction Ulcer Secondary Lesion Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals - ex. can appear anywhere Excoriation Secondary Lesion scratching of their skin Scar Secondary Lesion causes scar tissue Atrophic Scar Secondary Lesion loss of the dermis results from someone being obese then losing weight Lichenification Secondary Lesion Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen) What ethnicity are keloids most common to develop in? African Americans Petechiae Vascular Lesion tiny hemorrhage (1-3cm) round caused by bleeding from superficial capillaries (no blanching) Purpura Vascular Lesion extensive patch of petechiae that is bigger than 3 mm and can be confused with bruising from trauma, aging, medication side effects, or drawing blood Ecchymosis Vascular Lesion Round or irregular macular lesion that is larger than petechial lesion. Color varies and changes. Black, yellow, green hues Angioma Vascular Lesion Firey red, star-shaped marking with a solid circular center Describe a Stage I Pressure Ulcer intact skin with nonblanchable redness Describe Stage II Pressure Ulcer partial thickness skin loss/ erosion involving epidermis, dermis, or both Describe Stage III Pressure Ulcer full thickness tissue loss with visible fat Describe Stage IV Pressure Ulcer Full-thickness tissue loss with exposed bone, muscle, or tendon (slough and eschar) Describe the elements of a general survey -physical appearance (age, sex, consciousness, skin color, facial features, signs of distress) -body structure (stature, nutrition, symmetry, posture, position, build, deformities) -mobility (gait, involuntary movements) -behavior (expression, mood, speech, dress, hygiene) PBMB when should you begin observing the second you see the client health assessment collection of data about the patient's health state complete database full health history and physical examination (family practice) episodic database limited or short term problem concerns 1 problem or complex or system (urgent care) follow-up database status of pervious problem at regular scheduled intervals (doctors office) emergency database rapid collection of data (ER) comprehensive assessment health history and complete physical examination, usually conducted when a patient first enters a health care setting focused assessment assessment conducted to assess a specific problem; focuses on pertinent history and body regions subjective data what the person says about himself or herself during history taking objective data information that is seen, heard, felt, or smelled by an observer; signs first level priority Emergent, life threatening, and immediate (ABCs) second level priority Next in urgency, requiring attention so as to avoid further deterioration third level priority Important to patient's health but can be addressed after more urgent problems are addressed functional assessment components -basis for care planning, goal setting, and discharge planning -self care (ADLs) -self maintenance (IADLs) -physical mobility collecting subjective data for the ill person information about health problem obtaining an accurate and current health history -subjective data -biographical data (name,DOB,sex,race,ethnic origin) -source of history (themselves or family?) -reason for seeking care (signs/symptoms) -present health/illness (location, severity, timing, setting, relieving factors) -past health (childhood illness, hospitalizations, operations, immunizations, allergies, current meds) -family history -review of systems -functional assessment (ADLs, IADLs, AADLs) cultural competence An understanding of how a patient's cultural background shapes his beliefs, values, and expectations for therapy; established through knowing your own culture first inspection -begins when you first see the patient -first examine as a whole and then systems -good lighting, exposure, and instruments palpation -examine by touch -doctor does this, if nurses do this it will be light -fingertips (skin texture, swelling, pulsation, lumps) -fingers/thumb (position, shape, consistency of organ/mass) -dorsa of hand/fingers (temperature) -base of fingers (vibration) direct percussion striking hand directly contacts body wall indirect percussion using both hands, striking hand contacts stationary hand fixed on patient's skin Auscultation -listening to body sounds -bell (low-frequency sounds: extra heart sounds or murmurs) -diaphragm (high-frequency sounds: breaths, bowels, normal heart sounds) acute pain -short term -fast onset -predictable trajectory -goes away after injury heals incident acute pain happens with movement chronic pain -lasts 6 months or longer -slow onset -malignant -nonmalignant (arthritis, fibromyalgia, low back pain) -isn't associated with injury -BRADS (bracing, rubbing, appetite, decreased activity, sighing) breakthrough pain Occurs when patient has recurrence of pain before next scheduled dose of medication visceral pain large internal organs (dull, deep, squeezing, cramping) ex. appendicitis and cholecystitis somatic pain Pain that originates from skeletal muscles, ligaments, or joints. (aching, throbbing) cutaneous pain pain from skin surface and subcutaneous tissue (superficial, sharp, nausea, sweating, tachycardia, HTN) referred pain pain felt in a part of the body other than its actual source nociceptive pain -nerve fibers are stimulated -Triggered by events outside the nervous system from actual or potential tissue damage -transduction, transmission, perception, modulation (arthritis, mechanical back pain) neuropathic pain Does not adhere to the typical phases Due to a lesion or disease in the somatosensory nervous system Implies abnormal processing of the pain message from an injury to the nerve fibers Most difficult to assess, diagnose, and treat May evolve into chronic condition May be caused by diabetes, shingles, HIV, chemotherapy, stroke, MS, a tumor, etc. PQRST provocative/palliative, quality, region/radiation, severity, timing Identify changes that occur when a client's pain is poorly controlled. Cardiac changes: tachycardia, elevated BP, increased myocardial oxygen demand, increased cardiac input Pulmonary changes: hypoventilation, hypoxia, decreased cough, atelectasis GI changes: nausea, vomiting, ileus Renal changes: oliguria, urinary retention Musculoskeletal changes: spasm, joint stiffness Endocrine changes: increased adrenergic activity CNS changes: fear, anxiety, fatigue Immune changes: impaired cellular immunity, impaired wound healing Poorly controlled chronic pain: depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life what information is important for the nurse to know when providing care for people from diverse backgrounds cultural competence which interventions will the nurse do to obtain objective data conduct physical exam, review lab reports, summon previous med records when would a nurse establish a complete database of a patient during initial home visit, in primary health setting, community health care setting ACE unit focuses on preventing functional decline in older adults during hospitalization TUG test timed up and go test; quantifies functional mobility; going outside alone safely, walking 10 ft, turn, walk back to chair and sit down, ADL activities of daily living; walking, dressing, using stairs, eating, feeding, grooming, toileting IADLs instrumental activities of daily living; shopping, meal cooking, cleaning, laundry, managing finances, counting, housekeeping, taking meds, using transportation Mini Mental State Exam Concentrates only on cognitive functioning, not on mood or thought processes Montreal Cognitive Assessment (MoCA) Mild cognitive dysfunction; Attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking calculations and orientation AADLs Advanced Activities of Daily Living; activities performed in the community- social or recreational, activities performed within the family Katz Index of ADL -Assessment for evaluation of activities of daily living -Focus: assessment of level of independence functioning and type of assistance required in six areas of ADL: 1) bathing 2) dressing 3) toileting 4) transferring 5) continence 6) feeding syncope loss of consciousness or fainting due to weakness complete skin assessment - scrutinize outer surface of skin -concentrate on underlying structures and inspect thoroughly -inspect feet, toenails, and between toes -check for color, temperature, moisture, texture, thickness, edema, mobility and turgor, vascularity or bruising, and lesions what causes true pallor (skin) could be due to blood loss or anemic; slowed circulation (immobility/inactivity, prolonged elevation) jaundice (skin) Yellowing - decreased liver function Where is jaundice first seen? In the sclera of the eye, and then the skin cyanotic (skin) blue- Not enough oxygen getting to red blood cells erythema (skin) red- indicates trauma, fever or infection; vasodilation what might multiple bruises at different stages of healing indicate physical abuse edema can indicate heart failure Scale to Grade Pitting Edema 1+ mild pitting, slight indentation, no perceptible swelling in the leg 2+ moderate pitting, indentation subsides rapidly 3+ deep pitting, indention remains for a short time, leg looks swollen 4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted complete nail assessment shape and contour, consistency, color, capillary refill, profile sign (160 deg) ABCDE skin assessment A: asymmetry B: border C: color D: diameter E: elevation and enlargement excoriation Skin sore or abrasion produced by scratching or scraping lichenification excoriation and scaling; caused by prolonged intense scratching keloids Irregular masses of scar tissue protruding from the skin surface primary skin lesions Macules Papules Patches Plaques Nodules Wheals Tumors Urticaria (hives) Vesicles Cysts Bullas Pustules macule/patch Macule: color change, flat and circumscribed, less than 1cm Patch: macules larger than 1cm (freckles, petechiae, measles) Papule/Plaque Papule: elevated, circumscribed, less than 1cm (mole or wart) Plaque: several papules coming together (psoriasis) nodule/tumor Nodule: solid, round or oval elevated lesion 1 cm or more in diameter, extends deeper into dermis Tumor: larger than few cm, extends deep into dermis, benign or malignant wheal/urticaria small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions -urticaria is a lot of wheals -hives/mosquito bite vesicle/bulla Vesicle: A membrane bound sac that contains materials involved in transport of the cell; fluid filled up to 1cm (chickenpox, shingles) Bulla: larger than 1cm, single chambered, superficial in epidermis; large blister (blister, burns) cyst sac containing fluid, elevates skin pustule elevation of skin containing pus, circumscribed and elevated (acne, impetigo) scale dry silvery, white, dead excess of keratin cells (eczema, psoriasis) secondary lesions result from the changes that take place in the primary lesion due to infection, scratching, trauma, or various stages of a disease crust, scale, fissure, erosion, ulcer, excoriation, scar, atrophic scar, lichenification, keloid vascular lesions Hemangiomas Telangiectases Purpuric lesions Lesions caused by trauma or abuse pressure ulcer- stage 1 skin is unbroken, localized (light) redness, patient is in pain pressure ulcer- stage 2 skin is broken, loss of 1st layer, open blister, red and pink wound color, nerve endings are exposed pressure ulcer- stage 3 expands into subcutaneous layer, may be crater-like, patient is not in pain pressure ulcer- stage 4 may be deeper than it appears, all layers to supporting structures; could be down to the bone clubbing profile sign of heart/lung disease, due to reduction of amount of oxygen in the blood; nail curves subjective data includes signs what does a data base consist of subjective and objective data, patient records, lab studies what does HIPAA stand for Health Insurance Portability and Accountability Act (patient confidentiality in written, verbal, or electronic communication. anything that can be linked back to the patient) Cultural Sensitive goals caregiver has basic knowledge and understanding culturally appropriate goals Applying underlying background knowledge necessary to provide the best possible health care culturally competent goals applying a universal concept of understanding to all aspects of care ethnicity -common geographical origin -migratory status -religion -race -language -shared values, traditions, symbols -food preferences religion the belief in and worship of a superhuman controlling power, especially a personal God or gods. may regularly attend services spirituality anything that pertains to a person's relationship with a nonmaterial life force or higher power Aculturation adapting traits from other cultures assimilation developing a new cultural identity and becoming members of that culture open ended questions begins the interview or helps to move on to a new topic close ended questions Questions that can be answered in short or single word responses; to get the most relevant info in the dedicated time with the client; to know specific info what is included in health history -biographical data -source of history -reason for seeking care -present health or illness -past health -systems review - Family history - ADLs what is a "reliable" person/statement when they give the same answers after the questions are repeated or rephrased later on PQRSTU P: Provocative or palliative- what makes pain better/worse Q: Quality or quantity- describe the pain R: Region or radiation- where is the pain, does it spread S: Severity scale- how bad is it, has it gone away or gotten better (usually numerical scale) T: Timing: onset, duration, frequency U: Understand patient's perception edema: 1+ pitting mild, slight indentation, no observable swelling edema: 2+ pitting indentation goes away quickly edema: 3+ pitting deep and stays for short time; observable swelling edema: 4+ pitting very deep pitting that lasts for a long time; appears very swollen complete health history (well person) lifestyle, exercise, diet, substance use, risk reduction, health promotion complete health history (ill person) info about health problems spiritual resource questions FICA -Faith (do you consider yourself a religious or spiritual person?) -Influence (how does your faith influence the way you see health) -Community (are you part of any religious/spiritual community?) -Address (would you like me to address any religious/spiritual concerns) CAGE test Felt the need to Cut down on drinking? Annoyed by people criticizing your drinking? Felt Guilty about your drinking? Need an Eye-opener in the morning? Signs vs. Symptoms Signs = Objective information; can be seen, measured, heard, or felt - Color, pulse, edema Symptoms = Subjective information - Dyspnea, pain, nausea 10 traps of interviewing 1. Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using "why" questions what does turgor measure elasticity; can indicate dehydration or extreme weight loss ecchymosis bruise purpura red-purple skin lesion due to blood in tissues from breaks in blood vessels angioma tumor composed of blood vessels stages of bruising Red/Blue or Purple within 24 hours of trauma 1-5 days Blue/purple Green 5-7 Yellow 7-10 Brown 10-14 confluent lesions lesions that run together (urticaria-hives) discrete lesions distinct, individual lesions that remain separate (skin tags, acne) grouped lesions lesions that appear in clusters (contact dermatitis) gyrate lesions twisted, coiled spiral, snakelike lesions (scabies) polycyclic lesions annular lesions grow together zosteriform lesions linear arrangement along a unilateral nerve route, will cause a lot of pain (herpes zoster) target lesions annular, but have specific red center (Lyme disease) what cultural practice is common among Turkish people hanging a glass blue eye in the home acculturative stress (societal dimensions) legal status, discrimination, political forces acculturative stress (environmental) unemployment, language barriers culture learned from birth, shared by all members, dynamic, adapted to specific conditions naturalistic beliefs Beliefs that consider illness as the result of disequilibrium between hot and cold; or yin and yang (illness occurs because of imbalance of body's 4 humors what tests should be used to assess religion/spirituality FICA and R-cope (coping) which instrument is used to examine the ear and the nose otoscope which exam visualizes neurochemical changes in the brain caused by nociception fMRI (to control the pain) which pain scale is used for a 6 year old faces pain scale which pain scale would be used for a 2 year old FLACC scale (nonverbal pain tool based on expression, leg movement, activity level, crying, and consolability) what pain scale would be used for preterm infants and neonates CRIES what pain scale would be used for patients with dementia PAINAD (uses breathing, vocalization, and facial expression) Is the general survey subjective or objective? objective socialization being raised within a culture and having characteristics of that group biomedical theory Assumes cause and effect Views the body as a machine Life can be divided into parts Endorses germ theory Heritage consistency continuum Traditional: living within norms of traditional culture Modern: acculturated to norms of dominant society informal support help from people who care about them (family, close friends, usually free of charge) formal support help from associations and institutions (welfare, social service, health care delivery agencies) where do nociceptors carry the pain to CNS HEEDSSS H- home environment E- education/employment E- eating D- drugs S- sexuality S- suicide/depression S- safety from injury/violence what can cause false pallor vasoconstriction- fear/anger, chilly room, smoking how to assess a deaf patient - use an interpreter - always look at the patient - allow them to pick the method of communication/learning style how do you assess pain palpation