NUR 170 Exam 1 Outline: Foundations Exam 1
AIDET – Acknowledge, Introduce & Identify, Duration, Explanation, Thank You
Assessment: Primary data, Secondary data
LPN – gather data
but not assess
Evaluation:
New SMART
goal, Based on
how patient did
Diagnosis:
Review data
, (other ques)
Planning:
Goals (long, Short) SMART
Specific
Implementation: Carrying
out goal, talking with Measurable
patient Attainable
Time
Dependent (Turning the
Realistic
patient)
Independent (ADL’s)
Clinical Pathways (Day
1,2,3)(set standard)
Assessment: Observation (sight, hearing, smell), Primary and Secondary,
Subjective (spoken) & Objective data(measurable), emotion, holistic,
Patient interview:
1. Orientation phase: HIPAA, plan, time frame, introduce
, 2. Working phase: health history, review of systems, health promotion, insurance, open-ended questions
3. Termination phase: Recap evaluations and plan
Types of Physical Assessments:Lumps Bumps Bruises
Comprehensive assessment: Interview, Review of Systems, Head to toe, Lesions Hearing, Sight
Focused assessment: Reason being seen
Emergency assessment: ABC, CAB, Stabilize the patient
(Critical and Initial): Only licensed personnel vs (UAP) – Unlicensed personnel
Techniques: Inspection, Palpation, percussion, auscultation Turgor: pop back skin on
sternum and hands < 2-3 secs
Primary Skin Lesions
Lesion
Description Size Examples
Type
Macule: <1
Macule / Flat, non-palpable; color change only. Patch = macule >1 cm
Port wine stain, flat moles
Asymmet ry Patch cm Patch: >1
cm
Border
Papule: <0.5
Color Papule / Solid, raised with distinct borders; may be domed, flat- cm Wart, psoriasis, actinic
Plaque topped, or umbilicated. Plaque = large papule Plaque: >0.5 keratosis
Diameter cm
Evolving Lipomas, squamous cell
Nodule Raised, solid, deeper than papule, well-defined borders 0.5–2 cm carcinoma
Solid mass extending through subcutaneous tissue; may Larger lipomas, cancerous
Tumor >1–2 cm
have undefined borders lesions
Vesicle:
Vesicle / Raised, fluid-filled with serous (clear) fluid. Bulla = large <0.5 cm Chickenpox, poison ivy,
Bulla vesicle Bulla: >0.5 2nd-degree burns
cm
Pustule Elevated, filled with pus (not clear fluid); often infected Variable Impetigo, acne
Irregularly shaped, transient edema in dermis; varies in Hives (urticaria), insect
Wheal Variable
color/size bites
Burrow Linear/circular, tunnel-like lesion caused by parasites Variable Scabies, ringworm
Encapsulated, fluid-filled or semisolid; deeper into
Cyst Variable Sebaceous cyst
dermis/subcutaneous
Lung
AIDET – Acknowledge, Introduce & Identify, Duration, Explanation, Thank You
Assessment: Primary data, Secondary data
LPN – gather data
but not assess
Evaluation:
New SMART
goal, Based on
how patient did
Diagnosis:
Review data
, (other ques)
Planning:
Goals (long, Short) SMART
Specific
Implementation: Carrying
out goal, talking with Measurable
patient Attainable
Time
Dependent (Turning the
Realistic
patient)
Independent (ADL’s)
Clinical Pathways (Day
1,2,3)(set standard)
Assessment: Observation (sight, hearing, smell), Primary and Secondary,
Subjective (spoken) & Objective data(measurable), emotion, holistic,
Patient interview:
1. Orientation phase: HIPAA, plan, time frame, introduce
, 2. Working phase: health history, review of systems, health promotion, insurance, open-ended questions
3. Termination phase: Recap evaluations and plan
Types of Physical Assessments:Lumps Bumps Bruises
Comprehensive assessment: Interview, Review of Systems, Head to toe, Lesions Hearing, Sight
Focused assessment: Reason being seen
Emergency assessment: ABC, CAB, Stabilize the patient
(Critical and Initial): Only licensed personnel vs (UAP) – Unlicensed personnel
Techniques: Inspection, Palpation, percussion, auscultation Turgor: pop back skin on
sternum and hands < 2-3 secs
Primary Skin Lesions
Lesion
Description Size Examples
Type
Macule: <1
Macule / Flat, non-palpable; color change only. Patch = macule >1 cm
Port wine stain, flat moles
Asymmet ry Patch cm Patch: >1
cm
Border
Papule: <0.5
Color Papule / Solid, raised with distinct borders; may be domed, flat- cm Wart, psoriasis, actinic
Plaque topped, or umbilicated. Plaque = large papule Plaque: >0.5 keratosis
Diameter cm
Evolving Lipomas, squamous cell
Nodule Raised, solid, deeper than papule, well-defined borders 0.5–2 cm carcinoma
Solid mass extending through subcutaneous tissue; may Larger lipomas, cancerous
Tumor >1–2 cm
have undefined borders lesions
Vesicle:
Vesicle / Raised, fluid-filled with serous (clear) fluid. Bulla = large <0.5 cm Chickenpox, poison ivy,
Bulla vesicle Bulla: >0.5 2nd-degree burns
cm
Pustule Elevated, filled with pus (not clear fluid); often infected Variable Impetigo, acne
Irregularly shaped, transient edema in dermis; varies in Hives (urticaria), insect
Wheal Variable
color/size bites
Burrow Linear/circular, tunnel-like lesion caused by parasites Variable Scabies, ringworm
Encapsulated, fluid-filled or semisolid; deeper into
Cyst Variable Sebaceous cyst
dermis/subcutaneous
Lung
