NR 302: Final Exam

NR 302: Final Exam Culturally sensitive Possessing basic knowledge of and constructive attitudes toward diverse cultural populations Culturally appropriate Applying underlying background knowledge necessary to provide the best possible health care Culturally competent implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences cultural diversity the existence of a variety of cultural or ethnic groups within a society. Level of Consciousness our awareness of ourselves and our environment Mood Durable, prolonged display of feelings that color the whole emotional life Affect temporary expression of feelings or state of mind General Survey physical appearance, body structure, mobility, behavior, and measument Overall appearance no signs of acute distress are present Speech Articulation (the ability to form words) is clear and understandable. Personal Hygiene Appears clean and groomed appropriately for his or her age, occupation, and socioeconomic group. Assisted devices special equipment that helps a person who is ill or disabled perform activities of daily living; also called adaptive devices Health History a collection of subjective information that provides information about the patient's health status and family history Pain scale assessment tool used to rate the severity of pain on a scale from 1 to 10. Face pain scale Has faces on it with different expressions to express children's pain level. Acute Pain short-term, self-limiting, often predictable trajectory; stops after injury heals Chronic Pain Persistent or recurring pain that is often difficult to treat. Includes any pain lasting longer than 3 to 6 months, pain lasting longer than 1 month after healing of an acute injury, or pain that accompanies a nonhealing tissue injury. Referred Pain pain that is felt in a location other than where the pain originates Radiating Pain starts at the origin but extends to other locations Edema Abnormal accumulation of fluid in interstitial spaces of tissues. skin cancer risk factors Overexposure to UV radiation Frequent irritation of skin Skin cancer detectors (ABCDE) Asymmetry Border Color Diameter Evolving Melanoma Assessment Asymmetrical Borders are abnormal Multiple Colors Larger than 1/4 Change in size How to check for turgor? Gently pinch up a bit of skin over the arm or sternum. If the skin is slow to return to flat position, patient is likely to be dehydrated. If the skin returns to original position in less than 3 seconds, the turgor is brisk Pruitis itching Lesions areas of tissue that have been pathologically altered by injury, wound, or infection Psoriasis chronic skin condition producing red lesions covered with silvery scales Eczema chronic inflammatory skin condition that is characterized by erythema, papules, vesicles, pustules, scales, crusts, and scabs and accompanied by intense itching (pruritis); also called atopic dermatitis Impetigo Moist, thin-roofed vesicles with thin, erythematous base. Rupture to form thick, honey-colored crusts. Contagious bacterial infection of skin; most common in infants and children. Hair assessment includes Hygiene Color Texture Distribution Hirsutism -Excessive body hair in females forming a male sexual pattern. -Caused by endocrine or metabolic dysfunction Toxic Alopecia Patchy, asymmetric balding that accompanies severe illness or use of chemotherapy where growing hairs are lost and resting hairs are spared. Regrowth occurs after illness or discontinuation of toxin. Traction Alopecia -Hair loss through repetitive and excessive pulling or stretching of the hair. -Hair loss is linear or oval along hairline, a part in hair, or scattered Pediculosis Capitis - Head lice * Nits shed into the environment and are able to hatch up to 7-10 days* Tinea Corporis -Ringworm of the body -Scales -Found on chest, abdomen, back of arms forming circular lesions with clear centers. Nail Assessment -Color, shape, and contour. -Capillary refill 3 sec. Clubbing Abnormal curving of the nails that occurs with congenital cyanotic heart disease, lung cancer, and pulmonary disease. Splinter hemorrhages Red-brown linear streaks from damage to nail bed capillaries BMI (body mass index) -Underweight: 18.5 -Normal: 18.5 - 24.9 -Overweight: 25 - 29.9 -Obese: 30 - 39.9 BMI Formula weight (lbs) / height^2 (In) all times 703a Nutritional Assessment 24 hour recall Food diary Food frequency Direct observation What does it mean if you gain more than 2 lbs in one day? Fluid Retention Head assessment -Symmetry of facial features -Lesions or infestations in hair -Check for TMJ -ROM Tension Headaches -Bandlike tightness -Both sides of head -Mild to Moderate -Stress, anxiety, depression, and poor posture are aggravating symptoms -Fatigue, anxiety, stress, Photophobia, phonophobia all are associated factors Migraine Headaches Moderate to severe, throbbing, pulsating headaches usually on one side of the head. -Caused by sleep deprivation, sensory stimuli and physical activity -Aura, nausea, vomiting, photophobia, phonophobia Cluster Headaches -One sided, usually behind eye. -Continuous, burning, piercing, excruciating pain. -Clusters, severe pain. -Exacerbated by alcohol, stress, or daytime napping. Neck Assessment -Palpate lymph nodes for swelling or masses -Palpate thyroid (not palpable unless very thin person) -Check trachea (Midline/No Masses) -Check for carotid pulse/bruits -Check ROM Lymph nodes of the neck -Submantal -Submandibular -Preauricular -Posterior Auricular -Occipital -Jugular -Superficial Cervical -Posterior Cervical -Supraclavicular Hyperthyroidism (Graves Disease) -Autoimmune Disease with increased production of thyroid hormones causes an increased metabolic rate. -Bulging eyeballs, nervousness, fatigue, weight loss, heat intolerance, tachycardia, SOB, muscle tremors Hypothyroidism (Myxedema) -Deficiency of thyroid hormone; reduces metabolic rate and when severe, causes no pitting edema or myxedema. -S/S include: fatigue and cold tolerance/puffy, edematous face, especially around eyes, puffy hands and feet, coarse facial features, and cold, dry skin Eye Assessment -Eyes, eyelids, eyebrows - position, shape, symmetry, movement -Conjunctivae: Pink, No discharge or inflammation -Sclera: white -PERRLA Snellen chart chart containing symbols that is used in the testing of visual acuity Rosenbaum chart used to assess near vision acuity