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Exam 2 nursing
Terms in this set (74)
Rest and activity
assessment, diagnosis, outcome identification, planning, implementation, evaluation
Collection, organizing, validation, recording of and communication of patient data
analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
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
carrying out the plan of care
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
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
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
assessment conducted to assess a specific problem; focuses on pertinent history and body regions
things a person tells you about that you cannot observe through your senses; symptoms
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
inspection, auscultation, percussion, palpation
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
Self care deficit
(Cause) of the problem - specific factors that relate to or contribute to a the problem
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"
Determine how to prevent reduce or resolve the identified patient problems
Determine patient centered goals and expected outcomes
Planning can be short and long term? True false
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?
Consume 40% of each meal by October 25,2019. Short term or long term goal?
Specific, Measurable, Attainable, Realistic, Timely
Patient centered measurable outcome should include
Subject, verb, condition, performance criteria, target time
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"
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
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?
Physical assessment is what type of data?
Health Assessment includes
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
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
Aggravating/ alleviating symptoms
Radiation (does it move anywhere)
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
Head and neck
Eyes and ears
Male & female reproductive system
Head to toe each body system
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
Know normal characteristics
Body size, shape, position, symmetry, movement
Note normal findings and deviations
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?
Tender areas are palpated last? True false
Tapping or striking the patients skin surface with the fingertips or hands to elicit sound, detect pain or tenderness
High pitched, drum like sound, air containing space; usually heard over the distended abdomen
Loud, booming sound, is usually heard over a hyperinflated lung, as in a patient with 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.
Low pitched, hollow sound, is usually heard over normal lung tissue
Soft high pitched, thus-like sound, can generally be heard over dense organs, such as the liver
Soft, high pitched sound, generally heard over bones, muscles, and tumors
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.
Appearance and behavior
Height and weight
Neurological system: level of consciousness
Time, place, person
Awake and alert
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
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
Absent or impaired ability to communicate by speech, writing, or signs because of brain dysfunction
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)
Follows commands appropriately
(+) full ROM
Hand grasping strong & equal
Documenting neurologic & musculoskeletal abnormal findings
GCS < 13
Change in level of consciousness
Speech: slurred, garbled
Loss of function of extremity
Swelling, pain, on movement, and erythema of major joint
Fracture of the bone
redness of the skin
pupils equal, round, reactive to light and accommodation
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