Upgrade to remove ads
Only $2.99/month

Exam 2 nursing

Terms in this set (74)

PERSON
Psychosocial
Elimination
Rest and activity
Safe environment
Oxygen
Nutrition
Nursing Process
assessment, diagnosis, outcome identification, planning, implementation, evaluation
Assessment
Collection, organizing, validation, recording of and communication of patient data
Diagnosing
analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
Planning
Specification of patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnosis and related nursing interventions to develop an individualized plan of nursing care and identify strengths
Implementation
carrying out the plan of care
Evaluation
Measuring the extent to which the patient has achieved the outcomes specified in the plan of care; identifying factors that positively or negatively influenced outcome achievement
wellness-illness continuum
Constantly changing state: illustrates the ever changing state of health as a person awaits to changes in internal and external environment to maintain a state of well-being
Initial Assessment
comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

Head to toe
focused assessment
assessment conducted to assess a specific problem; focuses on pertinent history and body regions

Emergency
Specific problem
subjective data
things a person tells you about that you cannot observe through your senses; symptoms
objective data
information that is seen, heard, felt, or smelled by an observer; signs, data measured
Methods of Data Collection
Health history, physical examination, review records, diagnostic and lab data, review literature, reports of health team members
physical examination
inspection, auscultation, percussion, palpation
Nursing Diagnosis
A statement that describes the patients actual or potential response to a health problem that the nurse is licensed and competent to treat
Nursing diagnosis examples
Ineffective airway clearance
Disturbed body image
Risk for unstable blood sugar
Impaired mobility
Self care deficit
Etiology
(Cause) of the problem - specific factors that relate to or contribute to a the problem
defining characteristics
The subjective and objective data that signals the existence of the actual or possible health problem are the third component of the nursing diagnosis
Must be included in the assessment!
Clustering data analysis
Grouping of patient data or cues that point to the existence of a health problem

"Refusing to eat, preferring bed rest to scheduled ambulation, reporting increase discomfort, unhealthy patterns"
Planning
Determine how to prevent reduce or resolve the identified patient problems
Establish priorities
Determine patient centered goals and expected outcomes
Select interventions
Planning can be short and long term? True false
True
Impaired skin integrity r/t ulceration of sacral area. Diagnosis right?
No. Correct : impaired skin integrity r/t immobility
Impaired skin integrity r/t improper positioning. Diagnosis right?
No. Correct: Impaired skin integrity r/t immobility
Fluid replacement r/t fever. Diagnosis right?
No. Correct : fluid volume deficit r/t fever
Establish priorities for planning using?
Maslow's hierarchy of needs
Physiological, safety, social, esteem, self-actualization
Will increase BMI to 18.5 by November 17,2019. Long term or short term goal?
Long term
Consume 40% of each meal by October 25,2019. Short term or long term goal?
Short term
SMART
Specific, Measurable, Attainable, Realistic, Timely
Patient centered measurable outcome should include
Subject, verb, condition, performance criteria, target time
Implementation
To help patient achieve valued health outcomes; promotes health, prevent disease and illness, restore health, facilitate coping with altered functioning
Types of interventions (implementation)
Nurse initiated "independent"
Physician initiated "dependent"
Collaborative "interdependent"
Examples of interventions
Assess the patients food preferences and dietary history
Offer small frequent meals
Monitor weight daily
Provide socialization during mealtimes
Teach the patient about the prescribed diet
Teach the patient and the family about medications that affect appetite
Nutrition consultation
Evaluation (5 components)
1. Identifying evaluative criteria and standards (what you are looking for when you evaluate)
2. Collecting data to determine whether these criteria and standards are met
3. Interpreting and summarizing findings
4. Documenting your judgment
5. Terminating, continuing, or modifying the plan
When does discharge planning begin?
the moment a patient is admitted to a health care facility, sometimes before admission.
Health history is what type of data?
subjective data
Physical assessment is what type of data?
Objective data
Health Assessment includes
Comprehensive
Ongoing partial
Focused
Emergency
Chief Complaint (CC)
the main reason for the patient's visit
Health history questions should be?
Open ended questions
When documenting health history how should it be documented?
Quotations "" and worded exactly how the patient said it. AVOID PARAPHRASING
seven attributes of a symptom
1. Location
2. Quality
3. Quantity or severity
4. Timing (including onset, duration, and frequency)
5. The setting in which it occurs
6. factors that have aggravated or relieved the symptom
7. associated manifestations
OLD CART
Onset
Location
Duration
Characteristics
Aggravating/ alleviating symptoms
Radiation
Timing
OPQRST
Onset
Provoking factors
Quality
Radiation (does it move anywhere)
Site
Timing
CAGE questions
cut down, annoyed, guilty, eye opener
Can be used for drinking or other narcotics
Review of Systems (ROS)
A series of questions concerning each organ system and region of the body. Asked during history taking and physical exam. Normally subjective data
ROS organ systems
General overall health state
Integumentary system
Musculoskeletal system
Head and neck
Eyes and ears
Endocrine system
Neurologic system
Cardiovascular system
Pulmonary system
GI system
Genitourinary system
Male & female reproductive system
Psychological status
physical examination
Head to toe each body system
Inspection
Palpation
Auscultation
Percussion
Olfactation (smelling)
purpose of physical examination
gather baseline data about the patient's health status
supplement, confirm, or refute data obtained in history
confirm and identify nursing diagnoses
make clinical judgments about patient's health status
evaluate the outcomes of care
Inspection
Systematic observation
Know normal characteristics
Body size, shape, position, symmetry, movement
Note normal findings and deviations
Palpation
an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts, temperature, moisture, vibration, turgor
Can you palpated both carotid are the same time?
No.
Tender areas are palpated last? True false
True
Percussion
Tapping or striking the patients skin surface with the fingertips or hands to elicit sound, detect pain or tenderness
Percussion sounds
Tympany
Hyperresonance
Resonance
Dullness
Flatness
Tympany
High pitched, drum like sound, air containing space; usually heard over the distended abdomen
Hyperresonance
Loud, booming sound, is usually heard over a hyperinflated lung, as in a patient with emphysema
Emphysema
a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. A serious disease that destroys lung tissue and causes breathing difficulties.
Resonance
Low pitched, hollow sound, is usually heard over normal lung tissue
Dullness
Soft high pitched, thus-like sound, can generally be heard over dense organs, such as the liver
Flatness
Soft, high pitched sound, generally heard over bones, muscles, and tumors
Auscultation
listening to sounds within the body
Performed last- except during abdominal examination
When examine the abdomen should you palpate first then auscultate?
No. Auscultate first then palpate.
General survey
Appearance and behavior
Vital signs
Pain
Height and weight
BMI
Neurological system: level of consciousness
Time, place, person
Awake and alert
Lethargic
Stuporous
Obtunded
Comoros
Stuporous
unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements
Obtunded
Aroused only by painful stimuli; response is nonverbal, never fully awakens; often as a result of intoxication, metabolic illness, infection or neurologic catastrophe
GCS (Glasgow Coma Scale)
Measures consciousness using an objective numerical scale; used to evaluate three key categories of behavior; eye opening, verbal response, motor response

Scoring range : 15 to 3
No injury : 13 - 15
Coma : 7 or less
Aphasia
Absent or impaired ability to communicate by speech, writing, or signs because of brain dysfunction
Musculoskeletal palpation
Bones, joints, and surrounding muscles
Range of motion (ROM)
Muscle tone and strength
Muscle rating for physical exam
5 - full ROM
4- full ROM against gravity, some resistance
3- full ROM, active
2- full ROM, passive
1- slight contractility; no movement
0- no voluntary contraction
Documenting neurologic & musculoskeletal normal findings
Awake, alert, oriented x3 (time, place, person)
GCS =15
Follows commands appropriately
Speech clear
(+) full ROM
Hand grasping strong & equal
Gait steady
Documenting neurologic & musculoskeletal abnormal findings
GCS < 13
Change in level of consciousness
Disorientation, confusion
Speech: slurred, garbled
Restlessness
Flat affect
Gait unsteady
Loss of function of extremity
Muscular atrophy
Decreased ROM
Swelling, pain, on movement, and erythema of major joint
Joint swelling
Fracture of the bone
erythema
redness of the skin
PERRLA
pupils equal, round, reactive to light and accommodation
OTHER SETS BY THIS CREATOR