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Nurs 251 Exam 1
Terms in this set (69)
What is the nursing process?
systematic problem-solving approach to identifying and treating human responses to actual or potential health problems
5 Steps of the Nursing Process
Assessment, Diagnosis, Planning, Implementation, Evaluation
What is assessment?
Collecting subjective and objective data; first and most critical part of nursing process
What makes assessment unique/different from the other steps of the nursing process?
What is subjective data?
Information stated by the patient
Sensations or Symptoms
Feelings, perceptions , preferences, beliefs, desires, values
What is objective data?
Directly observed by examiner (Signs)
Physical Exam or Diagnostic tests
Examples of subjective data
Past Health History
Health and Lifestyle Practices
Examples of Objective data
Appearance and behavior
Results of measurements
What are the four types of assessment?
initial, ongoing, focused, emergency
When is an initial assessment completed?
Occurs when the client first presents to health care system
All inclusive or overall picture of "health"
Subjective & Objective Data
Doctors office, Driver's license, Sports, School application
When is an ongoing assessment completed?
Occurs after comprehensive database is established
Reassessment of initial problem or baseline looking for Improvement /Deterioration
Beginning of shift assessment in hospital
Weekly home visits
When is a focused assessment completed?
Occurs in relation to a specific health concern
Does not replace comprehensive health assessment
Patient is admitted with a complaint of "Shortness of Breath" (c/o SOB)
Begin with Cardiorespiratory System Assessment
Not skin or GI or Neurological Assessments for instance
Follow-up with Comprehensive Assessment
When is an emergency assessment used?
Occurs rapidly when life-saving action needs to be taken
Immediate diagnosis needed to begin treatment
What is culture?
The learned, shared, and transmitted values, beliefs, norms, and way of life of a particular group that guides their thinking, decisions, and action in patterned ways
Why is cultural sensitivity and cultural competence important?
What is stereotype?
A simplified, generally inflexible conception of the members of a group or subgroup
What is ethnocentrism?
A tendency to view people unconsciously by using your own group and your own customs as standards for all judgments
Why does an RN conduct a spiritual assessment?
How does spirituality impact care?
some care methods go against certain religions/beliefs
What are Standard Precautions?
A set of precautions that the Centers for Disease Control and Prevention (CDC) has called for in order to minimize the risk that you will catch an infection from a patient or spread infection among patients.
What does HIPPA mean and require?
What are the 4 types of physical assessment techniques?
auscultation, palpation, percussion, inspection
When is each type appropriate to use?
Which technique is always used first?
What is the purpose of each type of palpation?
What are the various sounds of percussion?
What are the various sounds of auscultation?
What is normal temperature?
96.9-99.9 F (98.6 F is core normal)
Which methods do we use to conserve/lose heat?
What is the definition of a pulse?
Shock wave produced by blood pumped from heart as it travels through artery
What is the normal range for an adult pulse?
Below normal range; <60 bpm
Above normal range; >100 bpm
What factors may increase pulse rate?
Blood loss (Try to Increase Cardiac Output)
What factors may decrease pulse rate?
Athletes (Strong heart muscle)
Medications (beta blockers for example)
Rate: Beats per minute
Rhythm: Regular or irregular
1+ Thready or Weak
Easy to obliterate with minimal pressure
Obliterate with moderate pressure
Unable to obliterate
What is the definition of blood pressure?
The pressure exerted on the walls of the arteries when the ventricles contract (systole) and relax (diastole)
Systolic BP (definition and range)
Cardiac cycle at high point
Diastolic BP (definition and range)
Cardiac cycle at low point
What should the nursing student do if the vital signs are not within normal ranges for their patient?
retake them, ask questions about current state of patient, alert doctor, inform instructor
What is the normal range for respirations?
12-20 breaths per minute
What factors may increase respiratory rate?
What factors may decrease respiratory rate?
How is pain defined?
How is pain measured?
On a scale from 0-10
What are the parameters/characteristics of pain assessment?
In general, how is an MSK assessment conducted?
What are the various joints? How do they work? (examples of each)
What is the curvature of the normal spine?
*What are the abnormal conditions of the spine? How are they assessed?
How do you assess the ROM, strengths, muscle tones, etc for UE?
How do you assess the ROM, strengths, muscle tones, etc for LE?
How is Osteoarthritis assessed?
How is RA assessed?
How is Carpal Tunnel assessed?
In general, how is the neuro exam conducted? (order)
How is the cerebrum assessed?
How is the cerebellum assessed?
How is the Brain stem assessed?
What are the various exam/tests for assessing judgement, intellect, memory, etc?
Which part of the brain do you assess with the cranial nerves?
What are the sensory tests?
What are the various cerebellar exams?
Describe the spinal reflexes and the Glasgow Coma scale
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