NUR 2092 - Assessment Exam 2 - 100% Correct

NUR 2092 - Assessment Exam 2 1. Delirium: (Acute Confusional State) potentially preventable in hospitalized persons. Characterized by disorientation, disordered thinking and perceptions (illusions and hallucinations) ...

NUR 2092 - Assessment Exam 2 1. Delirium: (Acute Confusional State) potentially preventable in hospitalized persons. Characterized by disorientation, disordered thinking and perceptions (illusions and hallucinations), defective memory, agitation, inattention • Sudden, over hours to days • Causes: hypoglycemia, fever, dehydration, hypotension, infection, adverse drug reaction, head injury, change in environment, pain, emotional distress, substance abuse • Cognition: impaired memory, judgment, calculations, attention span, can fluctuate day to day • Level of Consciousness: Altered • Activity Level: Can be increased or reduced; restlessness; behaviors may worsen in evening (sundowners); sleep/wake cycle may be reversed • Emotional State: Rapid swings, can be fearful, anxious, suspicious, aggressive, have hallucinations and/or delusions • Speech and Language: Rapid; inappropriate, incoherent, rambling • Prognosis: Reversible with proper and timely treatment 2. Dementia: a chronic progressive loss of cognitive and intellectual functions, although perception and consciousness are intact. Characterized by disorientation, impaired judgment, memory loss. • Onset: Slowly, over months • Causes: Alzheimer disease, vascular disease, HIV, neurological disease, chronic alcoholism, head trauma • Cognition: Impaired memory, judgment, calculations, attention span, abstract thinking, agnosia • Level of Consciousness: Not altered • Activity Level: Not altered; behaviors may worsen in evening (sundowners) • Emotional State: Flat; agitation • Speech and Language: Incoherent, slow (sometimes due to effort to find the right words), rambling, repetitious • Prognosis: Not reversible; progressive 3. Suicide: 4. Mini-Mental State Exam (MMSE): used with caution with people with low education; Requires paper and pencil; person must be able to write and have no vision impairment. It is quick and easy with 11 questions and takes 5-10 min to administer. It will demonstrate worsening or improvement. It concentrates only on cognitive functioning, not mood or thought process. It is detector of organic disease; dementia and delirium and to differentiate these from psychiatric mental illness. Max score is 30, normal will score average 27; 24-30 indicates no cognitive impairment. Available only by copyright. 5. Denver II Screening: gives chance to interact with child to assess mental status; designed to detect developmental delays 6. Mini-Cog: reliable, quick and easily available to screen for cognitive impairment in older adults. Takes 3-5 min. Consists of a 3-item recall test and a clock-drawing test. 7. 4 Unrelated Words Test: tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test. It avoids the danger of unverifiable material. Pick words with semantic and phonetic diversity. Ask to repeat in 5 min, 10 min and at 30 min. Normal response for people younger than 60 is accurate 3-4 recall. People with Alzheimer will score 0-1 words. Score can be low with anxiety and depression due to inattention and distractibility. 8. Appearance, Behavior, Cognition, and Thought Processes (A, B,C,T): four main headings of mental status assessment. 9. Physical Changes in Elderly: • Vision and Hearing changes may alter alertness and leave a person looking confused. Always check sensory status before assessing any aspect of mental status. • There is no decrease in knowledge; response time is slower because it takes brain longer to process information and to react. • Recent memory is decreased • Hearing Problems: Consonants are high frequency sounds; older people have difficulty hearing them. This produces frustration, suspicion, and social isolation, and makes the person look confused. • Losses (loved ones, income…): can lead to despair and grief; can result in disorientation, disability, or depression. • Orientation: many elderly persons experience social isolation, loss of structure, a change in residence, or some short-term memory loss. You can consider them oriented if they know generally where they are and the present period. • People in their 70’s will average 2-4 words in 5 min. They will improve at 10 and 30 min after being reminded by verbal ques. 10. Assessment Techniques: • Inspection: concentrated watching; it is close scrutiny first of whole and then each body system.  Begins moment first meet and develop a general survey  Train yourself not to rush by holding hands behind back  Use person as his/her own control and compare right and left sides of the body. Should be nearly symmetric  Requires good lighting, adequate exposure, and use of tools (penlight…) • Palpation: uses sense of touch to assess texture, temperature, moisture; organ location and size; swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.  Different parts of hand:  Fingertips: best for fine tactile discrimination, as of skin texture, swelling, pulsation and determining presence of lumps  A Grasping Action of fingers and thumb: to detect the position, shape and consistency of an organ or mass  Dorsa (back) of Hands and Fingers: Best for determining temperature because skin is thinner than on palms  Base of fingers (Metacarpophalangeal) or Ulnar surface of hand: best for vibrations.  Technique should be slow and systematic, calm and gentle.  Warm hands first  Note any tender areas and do them last.  Start with light palpation to detect surface characteristics and to allow patient to get used to being touched  Use Deep palpation next: intermittent pressure is better than one long, continuous one.  Bimanual Palpation: requires use of both hands to envelop or capture certain body parts such as kidney, uterus. • Percussion: is tapping the skin with short, sharp strokes to assess underlying structures.  Mapping out location and size by where the percussion note changes between borders  Signaling density of a structure by a characteristic note  Detecting abnormal mass if it’s superficial; percussion penetrates about 5cm deep  Eliciting a deep tendon reflex using percussion hammer  Hyperextend the middle finger (the pleximeter) and place its distal joint and tip firmly against the person’s skin. Avoid ribs and scapulae. Percussing over bone yields no data because it is always a dull sound. Lift rest of hand off skin.  Use middle finger of dominant hand as the striking finger (the plexor). Strike finger just behind the nail bed or at interphalangeal joint; goal is to hit portion that has most pressure on the skin. Flex striking finger so that tip, not pad, makes contact. It hits at right angles to the stationary finger. Percuss 2 times using even, staccato blows.  Sounds:  Amplitude: or intensity; loud or soft sound  Pitch: or frequency; number of vibrations per second  Quality: or timbre; subjective difference caused by the sensitive overtones of sound  Duration: the length of time the note lingers  Resonant: medium-loud amplitude; low pitch; clear, hallow quality; moderate duration; over lung tissue  Hyperresonant: louder amplitude; lower pitch; booming quality; longer duration; normal over child’s lungs; abnormal in adults over lungs with increased air as in emphysema  Tympany: loud amplitude; high pitch; musical and drum like quality; sustained longest duration; over air-filled viscus (stomach, intestine)  Dull: soft amplitude; high pitch; muffled thud quality; short duration; relatively dense organ (liver or spleen)  Flat: very soft amplitude; high pitch; a dead stop of sound, absolute dullness; very short duration; when no air is present, over thigh muscles or bone or over tumor. • Auscultation:  Stethoscope does not magnify sound, it blocks out extraneous room sounds.  Slope of ears point forward  Diaphragm: best for high-pitched sounds- breath, bowel and normal heart sounds. Hold firmly against skin, enough to leave slight ring after.  Bell: best for soft, low-pitched sounds- murmurs or extra heart sounds. Hold lightly to skin  Hairy chest causes crackling that mimics an abnormal breath sound. Wet hair before listening. 11. Handwashing vs. Alcohol: • Hand wash when visibly dirty, contaminated with body fluids, blood. Before and after every physical contact with patient or physical contact with instruments that were used by patient, and after removing gloves. Wash hands when patients are infected with spore-forming organisms (C-diff and norovirus). Rub hand for 40-60 sec. • Use Alcohol when not visibly dirty; highly effective against gram-positive and gram-negative bacteria; Tuberculosis and most viruses including hep B and C, HIV, and enteroviruses. Rub hand with 3-5 mL of alcohol for 20-30 sec 12. Techniques used when examining an aging adult: • Frail older adults may need to be supine. • Arrange sequence to allow few position changes • Allow for rest periods; may need to break into a few visits • Use Physical touch (unless cultural contraindicated); because sense of vision and hearing may be diminished. • Don’t mistake hearing or vision loss for confusion • Still use head to toe approach 13. General Survey: study of the whole person, covering the general health state and any obvious physical characteristics. It is an introduction for the physical exam that will follow; gives an overall impression, a gestalt of the person. Gives objective parameters, that apply to whole person, not just one body system. • Begins at the moment of first encounter:  Does the person stand promptly when name called and walk easily toward you? Or does he look sick, rising slowly or with effort? Is patient sitting in bed, talking to visitors? • Make note of these areas while conducting health history: physical appearance, body structure, mobility and behavior • Adults:  Physical Appearance: person appears his/her stated age? Sexual development appropriate for sex and age? Level of consciousness? Skin color- is even, pigmentation varying; skin intact; make note of piercing…? Facial Features are symmetric? Overall appearance- no signs of acute distress.  Body Structure: Stature-height appears within normal range? Nutrition- weight appears within normal range? Symmetry, posture, position, body build  Mobility: Gait- feet shoulder width apart, foot placement accurate; walk is smooth and even? Range of Motion-  Behavior: facial expression? Mood and affect? Speech? Speech pattern? Dress? Personal hygiene? • Infant/Child:  Physical appearance, body structure and mobility: same as adult  Behavior: note response to stimuli and level of alertness appropriate for age. Infants usually look toward your voice and mimic facial expressions.  Personal Bonding: Note the child’s interaction with parents. Some signs of abuse is the child avoids eye contact; child exhibits no separation anxiety when you would expect for the age; the parent is disgusted by child’s odor, sounds, drooling, or stools  Vital Signs: reverse order for infants to respiration, pulse, temp.  Pulse: palpate or auscultate an apical rate with infants and toddlers. Over 2, use the radial site. Count for full minute  Respirations: watch infant’s abdomen for movement because infant’s respirations are more diaphragmatic than thoracic. Sleeping rate is more accurate. Count for full minute  BP: Children over 3 yrs- at least once a year. Allow crying infant to become quite for 5-10 min before doing; crying may raise systolic by 30-50 mm Hg.  Children younger than 3 is hard to hear Korotkoff sounds- use electronic BP device that uses oscillometry, or use Doppler device to amplify sound. 14. Orthostatic Vital Signs: or postural vital sign- Take serial measurements of pulse and Bp • When suspect volume depletion • When the person is known to have hypertension, and is taking antihypertensive medications • When the person reports fainting or syncope • Have person rest supine for 2-3 min, take baseline readings of pulse and BP; repeat measurements with person sitting and then standing. When position changes, normally a slight decrease in systolic may occur (less than 10 mm Hg) • Orthostatic Hypotension: when a deop in systolic pressure of more than 20 mmHg or increase in pulse greater than or equal to 20 beats/min. Caused by abrupt peripheral vasodilation without compensatory increase in cardiac output. 15. Systolic BP: maximum pressure felt on the artery during left ventricular contractions Diastolic BP: the elastic recoil, or resting pressure that the blood exerts constantly between each contraction. Pulse Pressure: difference between the two and reflects stroke volume. 16. Body Mass Index: • Underweight: Less than 18.5 • Normal Weight: 18.8- 24.9 • Overweight: 25- 29.9 • Obesity Class 1: 30- 34.9 • Obesity Class 2: 35- 39.9 • Extreme Obesity Class 3: 40 and over 17. Vital Signs: • Temperature:  Oral Temp is most convenient and accurate site- sublingual pocket has rich blood supply from the carotid arteries that quickly respond to changes in inner core temp.  Place thermometer in either of the posterior sublingual pockets-not in front of tongue. Leave in place 3-4 min if person is afebrile and up to 8 min if febrile  Wait 15 min if person just drank or 2 min if just smoke  Electronic: Blue tip oral, red tipped rectal  Rectal Temp is most accurate: and result is as close to core temp as possible  Rectal Route is best in children with suspected fever or infection  Preferred route for comatose or confused person; people in shock; who can’t close mouth because of breathing or oxygen tubes, wired mandible…  Lubricate probe and insert 2-3 cm (1 in) into adult rectum, toward umbilicus.  Tympanic Membrane Temp (TMT): senses infrared emissions of the eardrum (TM).  Place in ear canal and aim the beam at tympanic membrane. Do not occlude canal. Activate device and read in 2-3 min.  Temporal Artery Thermometer: used by sliding over forehead and behind the ear. Works by taking multiple readings and using an average. Takes 6 sec.  Oral temp: 98.6 or range 96.4- 99.1  Rectal Temp: 0.7- 1 degree F higher • Pulse:  With every beat, the heart pumps blood into the aorta. The amount is the stroke volume; about 70 mL in the adult.  Use the pads of first 3 fingers, palpate the radial pulse at the flexor aspect of the wrist.  Assess the pulse including these  Rate: Normal resting rate is 50- 90 beats/min, but we use 60- 100 beats/min  Varies by age: infants and childhood is more rapid; more moderate in older. Females have slightly faster than males after puberty  Bradycardia: resting rate less than 50 beats/min. Occur normally in well trained athlete.  Tachycardia: over 100 beats/min. Occur normally with anxiety or with increased exercise to match the body’s demand for increased metabolism.  Rhythm: pulse has a regular, even tempo.  Sinus Arrhythmia: heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration.  Force of Pulse: shows the strength of the heart’s stroke volume: a “Full, bounding” pulse denotes an increased stroke volume as with anxiety, exercise.  3+ Full, bounding  2+ Normal  1+ Weak, thread  0 Absent • Respirations: normally breathing is relaxed, regular, automatic and silent.  Pulse to Respiration ratio: 4:1  Neonate: 30-40  1 yr: 20-40  2 yr: 25-32  8-10 yr: 20-26  12-14 yr: 18-22  16 yr: 12-20  Adult: 10-20 • Blood Pressure:  Width of bladder: should equal 40% of the circumference of the person’s arm.  Length of bladder: 80% of the circumference.  Using cuff size that is too narrow yields false high BP  Cuff wrap is too loose- BP false high  The Procedure:  Take two BP measurements separated by 2 minutes  Person should be sitting or lying, with bare arm supported at heart level. When sitting, feet should be flat on the floor  Palpate the brachial, located just above the antecubital fossa, medial to the biceps tendon.  Center cuff about 1 in above the brachial artery; wrap evenly  Palpate the brachial or radial artery and inflate cuff till pulse is obliterated and go 20-30 mm Hg beyond.  Auscultatory Gap: period when Korotkoff sounds diappear during auscultation.  Diastolic is the 5th Korotkoff sound. 18. Nociceptors: specialized nerve endings that are designed to detect painful sensations from the periphery and transmit them to the CNS. Located primarily within the skin, joints, connective tissue, muscle, thoracic, abdominal and pelvic viscera. • Can be stimulated directly by mechanical or thermal trauma or by chemical mediators that are released from the site of tissue damage. 19. Neuropathic Pain: is pain that does not adhere to the typical and rather predictable phases in the nociceptive pain. • Implies and abnormal processing of pain message from an injury to nerve fibers. • Most difficult to assess and treat • Pain is perceived long after the site of injury has healed and it evolves into a chronic condition. • Nociceptive pain can change into neuropathic pain over time when pain has been poorly controlled. • Conditions that may cause:  Diabetes Mellitus  Herpes Zoster/ Shingles  HIV/AIDS  Sciatica  Trigeminal Neuralgia  Phantom Limb Pain  Chemotherapy 20. Types of Pain: • Acute Pain: short term and self-limiting; often following a predictable trajectory and stops after injury is healed.  Has self-protective purpose: warning the individual of actual or threatened tissue damage.  Incident Pain: happens predictably when certain movements take place; pain in lower back on standing or whenever turning a patient from side to side • Chronic/Persistent Pain: diagnosed when pain continues for 6 months or longer.  Malignant: cancer related  Nonmalignant: often associated with musculoskeletal conditions such as arthritis, low back pain or fibromyalgia.  Chronic pain does not stop when injury healed • Breakthrough Pain: is a transient spike in pain level, in an otherwise controlled pain syndrome. 21. Source of Pain: • Visceral: originates from the larger organs (stomach, intestines, gallbladder….)  Usually described as dull, deep, squeezing, or cramping  Pain can stem from direct injury to organ or stretching of the organ from tumor, ischemia, distention, or severe contraction.  Presents with vomiting, nausea, pallor and diaphoresis • Somatic: originates from musculoskeletal tissues or body surface  Pain is sharp and dull, it is well localized and easy to pinpoint.  Can be accompanied by nausea, sweating, tachycardia, and hypertension. • Deep Somatic: comes from sources such as blood vessels, joints, tendons, muscles and bone. Pain may result from pressure, trauma or ischemia.  Often described as aching or throbbing • Cutaneous Pain: derived from skin surface and subcutaneous tissues.  Pain is superficial, sharp or burning • Referred Pain: originates from another location. 22. Pain as it relates to elderly: • Pain indicates pathology or injury and should never be considered something to tolerate or accept in older age. • This leads to underreporting or less aggressive treatment. • Have fears about becoming dependent on meds • Most common pain producing conditions: osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies, angina, and chronic constipation. 23. Questions to ask someone in pain: • Where is the pain? • When did the pain start? • What does the pain feel like? • How much pain do you have now? • What makes pain better or worse? • How does the pain limit your function or activities? • What does the pain mean to you? 24. PQRST Method of Pain Assessment: • P= Provocation/Palliation: What were you doing when the pain started? What makes it worse or better? • Q=Quality/Quantity: What does it feel like? Use words to describe like sharp, dull, stabbing, burning.. • R= Region/Radiation: Where is the pain located? Does it radiate? Where? Does it feel as if it travels or moves? Did it start elsewhere and is now localized to one spot? • S= Severity Scale: How severe is the pain on a scale of 0-10? • T= Timing: When did the pain start? How long did it last? How often does it occur? Hourly? Daily? Weekly? 25. Pain Assessment Tools: • Initial Pain Assessment: asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. • The Brief Pain Inventory: asks patient to rate the pain within the past 24 hours using graduated scale (0-10) with respect to its impact on areas such as mood, walking ability and sleep • The Short Form McGill Pain Questionnaire: asks the patient to rank a list of descriptors in terms of their intensity and to give overall intensity rating to his/her pain • Pain Rating Scales: are unidimensional and intended to reflect pain intensity.  Numeric Rating Scales: ask patient to choose a number from 0-10  Verbal Descriptor Scale: use words to describe patient’s feelings and the meaning of pain for the person  Visual Analogue Scale: lets the patient make a mark along a 10cm horizontal line from “no Pain” to “worst pain imaginable”  Descriptor Scale: lists words that describe different levels of pain intensity such as no pain, mild pain, moderate pain, and severe pain. Older adults respond better to scales in which words are selected • For Children:  Infants are preverbial; pain assessment depends on behavioral and physiologic cues.  Children 2 years of age: can report pain and point, cannot rate pain. Ask caregiver what words the child is using to report pain.  Rating scales can be introduced to 4 and 5 year olds:  The Faces Pain Scale-Revised (FPS-R): uses 6 pictures  Oucher Scale: also uses 6 pictures; this is of a boy in pain  Wong-Baker Scale: child is asked to choose face that shows “How much hurt do you have now?” 26. Optimal Nutritional Status: is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands. 27. Undernutrition: occurs when nutritional reserves are depleted and/or nutrient intake is inadequate to meet day-to-day needs. • Groups at risk:  Infants, children, pregnant women, recent immigrants, people with low incomes, hospitalized people, and aging adults. 28. Overnutrition: caused by consumption of nutrients in excess of body needs. 29. Comprehensive Nutritional Assessment: • Dietary History and clinical information • Physical Exam for clinical signs • Anthropometric Measures • Lab Tests 30. Nutritional Screening Methods: collects current dietary intake info • 24-Hour Recall:  Easiest and most popular  Individual completes questionnaire asking to recall food eaten in past 24 hours  Source errors can occur: • Inability to remember • Intake may be atypical or unusual • May alter the truth • Snack items and use of gravies, sauces and condiments may be underreported • Food Frequency:  May be used to counter some difficulties of 24-Recall  Information is collected on how many times per week something is eaten  Drawbacks to use: • Does not quantify amount of intake • Relies on individual’s memory for how often a food was eaten • Food Diaries or Records:  Requires asking person to write down everything consumed for certain period of time  Three days, including two weekdays and one weekend day are customary  Is most complete and accurate if individual is instructed to record info immediately after eating  Potential Problems: • Noncompliance • Inaccurate recording • Atypical intake on recording days • Conscious alteration of diet during recording period • Direct Observations: can lead to detections of problems not readily identified through standard nutritional screenings. Observes feeding techniques of parents or caregiver is great for failure to thrive in kids or unintentional weight loss in elderly. • ChooseMyPlate, Dietary Guidelines, and DRIs are commonly used guides to determine adequacy or inadequacy of diet. 31. Nutrition History for Aging Adults: • How does diet differ from in 40s and 50s • Adequate Vit D • Adequate Calcium • Review of Mini Nutritional Assessment Tool (MNA) • BMI and Waist-to-hip Ratio best indicators of obesity in this group. • MAC and TSF may not be accurate and are difficult to obtain because of sagging skin, changes in fat distribution, and declining muscle mass 32. Clinical signs are late manifestations of malnutrition: • However, Nutritional deficiencies are readily detectable in: skin, hair, mouth, lips and eyes (area where rapid turnover of epithelial tissue occur) 33. Anthropometric Measures: Measurement and evaluation of growth, development and body composition • Most used:  height and weight:  skinfold thickness: provides estimate of body fat stores or extent of obesity or undernutrition. Triceps Skinfold (TSF) is most commonly selected.  elbow breadth  arm span: useful in situations when height can’t be measured like child with cerebral palsy or scoliosis, or elderly with spinal curvature. Measure tip of middle finger on one hand to the other.  head circumference • BMI is practical marker of optimal weight for height 34. Lab Studies of Nutrition: are objective and can detect preclinical nutritional deficiencies and can be used to confirm subjective finding. • Best Routine Labs for Nutritional Status:  Hemoglobin: for iron  Hematocrit: for iron  Cholesterol  Triglycerides  Total lymphocyte count  Serum Albumin: for protein deficiency 35. Marasmus: Protein-Calorie Malnutrition • Caused by inadequate intake of protein or calories • Prolonged starvation • Clinical Conditions leading to this:  Anorexia  Bowel Obstruction  Cancer Cachexia  Chronic Illness • Characterized by:  Decreased anthropometric measures: weight loss, subcutaneous fat and muscle wasting.  Visceral protein levels may remain within normal ranges 36. Kwashiorkor: Protein Malnutrition • Caused by diets high in calories but little to no protein: low protein liquid diets, fad diets, and long-term use of dextrose-containing IV fluids. • Characterized by:  Decreased visceral protein levels  Adequate anthropometric measures  Appear well nourished or even obese.  Edematous 37. Marasmus/Kwashiorkor Mix: • Cause: prolonged inadequate intake of protein and calories such as with severe starvation and severe catabolic states • Nutritional assessment shows: muscle, fat, and visceral protein wasting. • Individual’s usually undergone acute catabolic stress such as surgery, trauma, or burns in combination with prolonged starvation or have AIDS wasting. • Without nutritional support, this type of malnutrition is associated with highest risk for morbidity and mortality. • Emaciated appearance