Vital Signs and Pain
ways to assess temperature
oral, temporal artery, tympanic, axillary, rectal
subjective: OLDCARTS
objective: vitals
actions nurses can take to provide holistic care
be respectful and advocate for patients, create a positive environment, open-ended questions
definition of wheezing and a clinical example; definition of crackles and a clinical example
wheezing: high pitched, musical = asthma, COPD
crackles: fine, coarse like velcro, fluid in lungs = pneumonia, pulmonary edema
where are all the valves of the heart located?
bro you should know this
a way a nurse can assess pain
ask pt, use standardized tool, observe behaviors, assess vital signs
different types of health histories
comprehensive, focussed, episodic
how does one's culture develop?
family, community, education, social experiences, religion, history, geographic economic, and political context
assessment findings/abnormalities of pt with COPD
clubbing, barrel chest, tripod position, dyspnea, low oxygen
describe S1 and S2 and the valves
you should know this
normal HR and RR for newborn
120-160 and 30-60
difference between history of present illness vs present health status
History of Present Illness = is the story of this specific problem (when it started, what it feels like, what makes it better/worse), while Present Health Status is a quick update on all your existing, ongoing health issues
common risk factors for depression and anxiety
female, isolation, family history, substance use, and trauma
what is crepitus?
crackling/popping sensation under skin due to air in subcutaneous tissue
when does S3 occur and when does S4 occur and what are the sounds they make?
you should know
difference between somatic vs visceral pain
somatic: from skin, muscles, bones
visceral: in internal organs
the basic techniques for physical assessment
inspection, palpation, percussion, auscultation
common signs of anxiety
restlessness, tachycardia, sweating, trembling, hyperventilation
what is (vocal) tactile fremitus?
vibrations felt on chest wall when pt speaks
venous vs arterial insufficiency
Edema (pitting, worse at end of day), brownish skin pigmentation, venous stasis ulcers (medial ankle), varicose veins, aching pain relieved by elevation
Intermittent claudication, pale/cool skin, diminished/absent pulses, hair loss, thin/shiny skin, ulcers (toes/lateral ankle), pain at rest, worse with elevation
difference between pain threshold and pain tolerance
threshold: pain at which stimulus is perceived as pain
tolerance: duration, intensity of pain a person is willing to endure before responding
the four main equipment used during the examination
thermometer, stethoscope, blood pressure cuff, and pulse oximeter
how to screen for alcohol use and addiction
CAGE and AUDIT
questions: how often do you drink? how many?
pack years: a client smokes 5 cigs per day. the client states that she smoked for 5 years, quit for 1 and then has been smoking for 2 more years? what is this client's pack year exposure?
1.75
deep vein thrombosis vs varicose veins
Unilateral edema, warmth, erythema, tenderness along vein, positive Homan’s sign (not reliable), calf pain on dorsiflexion
Dilated, tortuous superficial veins, aching/heaviness, worse with standing, may have edema, skin changes if chronic