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Study sets matching "nursing assessment"

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Study sets matching "nursing assessment"

12 terms
Nursing assessment
Assessing
database
database
assessment
systematic and continuous collection ,analysis, validation, a…
includes all the pertinent patient info collected by the nurs…
also helps and develops comprehensive and effective plan of c…
first step in ADPIE, gather info
Assessing
systematic and continuous collection ,analysis, validation, a…
database
includes all the pertinent patient info collected by the nurs…
30 terms
Nursing Assessment
Activities of Daily Living (ADLs)
Adventitious Breath Sounds
Auscultation
Body Mass Index (BMI)
the activities of daily living needed for independent living
abnormal breath sound heard over the lungs
listening for sounds within the body
ratio of height to weight
Activities of Daily Living (ADLs)
the activities of daily living needed for independent living
Adventitious Breath Sounds
abnormal breath sound heard over the lungs
15 terms
Nursing Assessment
Order of assessment
ABCD for assessing carcinomas
CAGE ASSESMENT
Nail clubbing
1 inspection, 2 palpation, 3 percussion, 4 auscultation
Asymmetry, border color, diameter
cut down, annoyed, guilty and eye-opener
angle between nail and base greater than 180 degrees
Order of assessment
1 inspection, 2 palpation, 3 percussion, 4 auscultation
ABCD for assessing carcinomas
Asymmetry, border color, diameter
26 terms
nursing assessment
nursing assesment
potential needs
Data collection
objective data
-is the systematic and continuous collection and analysis of…
are often listed as "at risk for"
Best sources of information about the client are the client a…
-means that only precise, accurate measurements or clear desc…
nursing assesment
-is the systematic and continuous collection and analysis of…
potential needs
are often listed as "at risk for"
53 terms
Nursing Assessment
Graphesthesia
Stereognosis
What does the tympanic membrane look l…
What response do you expect a healthy…
the ability to recognize writing on the skin purely by the se…
ability to perceive and recognize the form of an object in th…
Shiny, pearly gray, intact and mobile.
Knee-jerk reflex or sudden kicking of the lower leg.
Graphesthesia
the ability to recognize writing on the skin purely by the se…
Stereognosis
ability to perceive and recognize the form of an object in th…
66 terms
Nursing Assessment
when is the best time to assess the pt?
By who is the intial assessment perfor…
the ongoing assessment is the responsi…
what is a focused assessment?
as soon after admission as possible ... in some facilities it's…
by the RN
both the registered nurse and the LPN
when an assessment is performed when the nurse observes a cha…
when is the best time to assess the pt?
as soon after admission as possible ... in some facilities it's…
By who is the intial assessment perfor…
by the RN
122 terms
Nursing Assessment - Exam 2
Cerumen
Otalgia
Presbycusis
The Inner Ear
earwax
ear pain
Senorineural hearing loss that occurs with aging
The portion of the ear that contains the sensory organs for b…
Cerumen
earwax
Otalgia
ear pain
66 terms
Nursing Assessment
when is the best time to assess the pt?
By who is the intial assessment perfor…
the ongoing assessment is the responsi…
what is a focused assessment?
as soon after admission as possible ... in some facilities it's…
by the RN
both the registered nurse and the LPN
when an assessment is performed when the nurse observes a cha…
when is the best time to assess the pt?
as soon after admission as possible ... in some facilities it's…
By who is the intial assessment perfor…
by the RN
88 terms
Nursing assessment
Alert
Lethargic
Obtunded
stuporous
Awake, responds appropriately to auditory, tactile, and visua…
Sleeps often, arouses easily; responds appropriately
Aroused by shaking or shouting; responds appropriately then r…
responds only to painful stimulus, withdraws finger or pushes…
Alert
Awake, responds appropriately to auditory, tactile, and visua…
Lethargic
Sleeps often, arouses easily; responds appropriately
54 terms
Nursing Assessment
Assessment
First step of assessment
Primary source
Secondary source
the gathering and analysis of information about the patient's…
colletion of information from primary and secondary sources
the patient
family members, health professionals, medical records
Assessment
the gathering and analysis of information about the patient's…
First step of assessment
colletion of information from primary and secondary sources
143 terms
Nursing Assessment
Emergency
Baccalaureate
Objective
Physician
A very rapid assessment performed in life-threatening situati…
Nursing health courses with informatics content are becoming…
Body functions are what type of data?
Performs a total physical examination when the client is admi…
Emergency
A very rapid assessment performed in life-threatening situati…
Baccalaureate
Nursing health courses with informatics content are becoming…
47 terms
Nursing Assessment
Bradypnea
Tachypnea
Adult respiration
Adult blood pressure
: respirations below 12 bpm
: respirations above 20 bpm
: normal range 12-20 bpm
: 100-120 systolic and 60-80 diastolic
Bradypnea
: respirations below 12 bpm
Tachypnea
: respirations above 20 bpm
26 terms
Nursing Assessment
Discuss the relationship between criti…
Explain the process of data collection…
Explain the process of data collection…
Explain the process of data collection…
Discuss the relationship between critical thinking and nursin…
Interview, observations, and physical examination
Report and response to interviews
...
Discuss the relationship between criti…
Discuss the relationship between critical thinking and nursin…
Explain the process of data collection…
Interview, observations, and physical examination
10 terms
Nursing assessment
General Assessment
HEENT
Neuro
Pulmonary
Mental Status, Appearance, Body Movement
Palpate head, facial bones, inspect eyes, visual acuity... Inspe…
LOC, orientation, GCS, pupils, speech
Inspect chest for symmetry/expansion, rate... Palpate for deform…
General Assessment
Mental Status, Appearance, Body Movement
HEENT
Palpate head, facial bones, inspect eyes, visual acuity... Inspe…
12 terms
Nursing Assessment
assessment
auscultation
cues
inspection
first phase of the nursing process in which data are gathered…
technique of listening to body sounds with a stethoscope
piece of data, subjective or objective, about a client
systematic visual examination of the client
assessment
first phase of the nursing process in which data are gathered…
auscultation
technique of listening to body sounds with a stethoscope
85 terms
Nursing Assessment
Domestic Violence Effects on Health
Abused Women
Abused OA
Child Maltreatment
Most women are assaulted by former or current partners.... Of th…
More chronic health problems, depression, suicidality, PTSD,…
Minor pain and discomfort, life threatening injuries, changes…
Physical injuries - bruises, fractures, lacerations, burns, b…
Domestic Violence Effects on Health
Most women are assaulted by former or current partners.... Of th…
Abused Women
More chronic health problems, depression, suicidality, PTSD,…
15 terms
Nursing Assessment
five-step nursing process
nursing process
critical thinking approach to assessment
database
-assess: gather info about patient condition... -diagnose: ident…
-a variation of scientific reasoning... -practicing the five ste…
-assessment involves collecting info from patient and seconda…
-purpose of assessment it to establish a database about patie…
five-step nursing process
-assess: gather info about patient condition... -diagnose: ident…
nursing process
-a variation of scientific reasoning... -practicing the five ste…
296 terms
Nursing Assessments
The patient complains of "seeing doubl…
A patient with a middle ear infection…
Interpret the findings of a vision exa…
Which of the following statements is t…
diplopia
conduct vibrations of sounds to the inner ear.
The patient has normal vision in both eyes.
It is the most efficient pathway for hearing.
The patient complains of "seeing doubl…
diplopia
A patient with a middle ear infection…
conduct vibrations of sounds to the inner ear.
25 terms
Nursing Assessment
Five Step Nursing Process includes: ... 1…
Gather info about the patient's condit…
Identify the patient's problem
Set goals of care and desired outcomes…
Assess... Evaluate
Assess
Diagnose
Plans
Five Step Nursing Process includes: ... 1…
Assess... Evaluate
Gather info about the patient's condit…
Assess
13 terms
Nursing Assessment
Assessment
Auscultation
Confidentiality
Cues
First phase of nursing process: date gathered to identify act…
Technique of listening to body sounds with stethoscope
Practice of keeping patient information private
Pieces of data about a patient
Assessment
First phase of nursing process: date gathered to identify act…
Auscultation
Technique of listening to body sounds with stethoscope
13 terms
Nursing Assessment
assessment
auscultation
confidentiality
cues
First phase of the nursing process in which data are gathered…
Technique of listening to body sounds with a stethoscope
Practice of keeping patient information private
Pieces of data, subjective or objective, about a patient
assessment
First phase of the nursing process in which data are gathered…
auscultation
Technique of listening to body sounds with a stethoscope
38 terms
Nursing Assessment
patient-centered care approach
QSEN's definition of patient-centered…
assessment
nursing assessment includes 2 stages
holistic and essential when applying the nursing process
recognizing a patient or designee as the source of control an…
must be complete, relevant to a patient's condition, and accu…
collection of information from a primary source (a patient) a…
patient-centered care approach
holistic and essential when applying the nursing process
QSEN's definition of patient-centered…
recognizing a patient or designee as the source of control an…
114 terms
Nursing Assessment
Normal extracellular fluid electrolytes
Protein blood concentration
[Na] and [K] regulation
Hyponatremia
Na: 135- 145mEg/dL... K: 3.5- 5mEg/dL... Ca: 8.9- 10.1mg/dL (total)…
3.5- 5g/dL
via renal system.... Na: low Na activates the renin pathway that…
Cause: loss of GI fluids via vomiting, diarrhea, GI suctionin…
Normal extracellular fluid electrolytes
Na: 135- 145mEg/dL... K: 3.5- 5mEg/dL... Ca: 8.9- 10.1mg/dL (total)…
Protein blood concentration
3.5- 5g/dL
58 terms
nursing assessment
encompasses
nursing assessment
interchangeable terms
physical exam- purpose
health history(functional health pattern) and physical exam
complete health assessment
assessment and exam
-baseline data... -supplement, refute, confirm health history da…
encompasses
health history(functional health pattern) and physical exam
nursing assessment
complete health assessment
15 terms
Nursing Assessment
Assessment
Back channeling
Closed-ending questions
Concomitant symptoms
Includes two steps... 1. Collection of information from a primar…
includes active listening prompts such as "all right," "go on…
limit answers to one or two words such as "yes" or "no" or a…
when other symptoms accompany the primary symptoms
Assessment
Includes two steps... 1. Collection of information from a primar…
Back channeling
includes active listening prompts such as "all right," "go on…
17 terms
NURSING ASSESSMENT
Health History
Physical Examination
CVD: Common Signs + Symptoms
Family History of CVD
-How does the patient perceive his cardiovascular health?... -Ca…
-Do physical findings match the data obtained in health histo…
-Chest pain/discomfort... -Shortness of breath/dyspnea... -Peripher…
Immediate family members diagnosed?... -Parents, siblings, child…
Health History
-How does the patient perceive his cardiovascular health?... -Ca…
Physical Examination
-Do physical findings match the data obtained in health histo…
51 terms
Nursing Foun, Physical assessment
Assessment
Disease
Acute
Chronic
evaluation or appraisal of a condition; includes observing, g…
Any disturbance of a structure or function of the body; a pat…
Having a short and relatively severe course; a disease proces…
Developing slowly and persisting for a long period, often for…
Assessment
evaluation or appraisal of a condition; includes observing, g…
Disease
Any disturbance of a structure or function of the body; a pat…
9 terms
Nursing assessment
Subjective data
Objective data
Activities of daily living
Activities of daily living
Symptoms\what the client tells you
Signs\what is observed by the nurse
ADL's
Description of the clients lifestyle & ability for self care:…
Subjective data
Symptoms\what the client tells you
Objective data
Signs\what is observed by the nurse
17 terms
NURSING ASSESSMENT
Health History
Physical Examination
CVD: Common Signs + Symptoms
Family History of CVD
-How does the patient perceive his cardiovascular health?... -Ca…
-Do physical findings match the data obtained in health histo…
-Chest pain/discomfort... -Shortness of breath/dyspnea... -Peripher…
Immediate family members diagnosed?... -Parents, siblings, child…
Health History
-How does the patient perceive his cardiovascular health?... -Ca…
Physical Examination
-Do physical findings match the data obtained in health histo…
15 terms
Nursing Assessment
Five Stages of the Nursing Process
What does SOAP stand for?
What is subjective data?
What is objective data?
Assessment; Diagnosis; Planning; Implementation; and Evaluation
Subjective Data... Objective Data... Assessment... Plan
Info. reported by patient; is not factual; details of illness…
Results of physical exam; use with subjective data to form di…
Five Stages of the Nursing Process
Assessment; Diagnosis; Planning; Implementation; and Evaluation
What does SOAP stand for?
Subjective Data... Objective Data... Assessment... Plan
15 terms
Nursing Assessments
Albuterol
Alprazolam
Digoxin
Furosemide
o Assess lung sounds, pulse, and BP, note color and character…
o assess degree and manifestations of anxiety and mental stat…
o Monitor apical pulse for 1 minutes before administering. Wi…
o Assess fluid status through daily weight, I&O, degree and l…
Albuterol
o Assess lung sounds, pulse, and BP, note color and character…
Alprazolam
o assess degree and manifestations of anxiety and mental stat…
34 terms
Nursing Assessment
Subjective Data
Objective Data
Hereditary
Degenerative
symptoms are perceived by patient
signs are observed by nurse
...
...
Subjective Data
symptoms are perceived by patient
Objective Data
signs are observed by nurse
8 terms
nursing assessment
nursing process
assessmetn
purpose of assessment is
data collection
critical thinking process that professional nurses use to app…
collection of information from pary source, secondary source,…
establish a database about the pt perceived needs, health pro…
gathering information... pt through interview, observations, phy…
nursing process
critical thinking process that professional nurses use to app…
assessmetn
collection of information from pary source, secondary source,…
10 terms
Nursing assessment
Nursing Process
Parts of nursing process
Assessment
Data Collection
Is a critical thinking process that professional nurses use t…
Each time you meet a patient you apply the nursing process.... A…
The deliberate and systematic collection of information about…
Information comes from:... Patient through interview, observatio…
Nursing Process
Is a critical thinking process that professional nurses use t…
Parts of nursing process
Each time you meet a patient you apply the nursing process.... A…
16 terms
Nursing Assessment
Assessment: collection techniques
Assessment: biological
Assessment: psychological ... (MSE)
Thought processes (1)
Pt observations ... Interviews with active listening ... Mental sta…
Past & present health status ... Physical examination: body syst…
Appearance... Behavior ... Attitude ... LOC/orientation ... Speech and la…
Circumstantial thinking: delay in reaching point; unnecessary…
Assessment: collection techniques
Pt observations ... Interviews with active listening ... Mental sta…
Assessment: biological
Past & present health status ... Physical examination: body syst…
54 terms
Nursing Assessment
Assessment
First step of assessment
Primary source
Secondary source
the gathering and analysis of information about the patient's…
colletion of information from primary and secondary sources
the patient
family members, health professionals, medical records
Assessment
the gathering and analysis of information about the patient's…
First step of assessment
colletion of information from primary and secondary sources
49 terms
Nursing Assessment
Hypoventilation
Hyperventilations
Hemopytsis
White Sputum
CO2 builds up
CO2 blown off
coughing up blood
bronchitis or viral
Hypoventilation
CO2 builds up
Hyperventilations
CO2 blown off
19 terms
Nursing Assessment
Blood Pressure
Systolic Pressure
Diastolic Pressure
Snellen Chart
Force of the blood pushing against the side of its container…
Maximum pressure felt on the artery during left ventricular c…
Elastic recoil or resting pressure that the blood exerts cons…
Tests visual acuity.
Blood Pressure
Force of the blood pushing against the side of its container…
Systolic Pressure
Maximum pressure felt on the artery during left ventricular c…
22 terms
Nursing Assessment
Nursing Process [standard of practice]
Nursing Process 5 steps... [each time yo…
Assessment (quick define)
nursing diagnosis (Dx) (quick define)
-is critical thinking process that professional nurses use to…
1.assessment... 2.diagnosis... 3.planning... 4.implementation... 5.evalua…
gather and analyze data
make clinical judgements from the assessment to identify pt's…
Nursing Process [standard of practice]
-is critical thinking process that professional nurses use to…
Nursing Process 5 steps... [each time yo…
1.assessment... 2.diagnosis... 3.planning... 4.implementation... 5.evalua…
14 terms
Nursing Assessment
Nursing process
Admission assessment
Focus assessment
Time-lapse assessment
a systematic problem-solving approach toward giving individua…
also referred to as the initial assessment. Performed when th…
collects data about a problem that has already been identifie…
takes place after the initial assessment to evaluate any chan…
Nursing process
a systematic problem-solving approach toward giving individua…
Admission assessment
also referred to as the initial assessment. Performed when th…
12 terms
Cranial nerves nursing assessment
I Olfactory
II Optic
III Oculomotor
IV Trochlear
Sensory -ask patient if can smell a vial of coffee
Sensory , test vision, ask patient to read Snellen chart
Motor, ask patient to follow pen light in six directions from…
Motor, moves eyeball down and laterally, ask patient to follo…
I Olfactory
Sensory -ask patient if can smell a vial of coffee
II Optic
Sensory , test vision, ask patient to read Snellen chart
9 terms
Nursing Assessment
Objective data
Subjective data
Health Interview (Nursing History)
Data Analysis
Measurable and observable pieces of info about the client and…
Consists of the clients opinions or feelings about what is ha…
Way of soliciting information from the client.
Critically examine each piece of info to determine relevance…
Objective data
Measurable and observable pieces of info about the client and…
Subjective data
Consists of the clients opinions or feelings about what is ha…
6 terms
Nursing Assessment
Assess
Two Stages of Assessment
Critical Thinking Approach to Assessment
Subjective Data
Gather information about the client's condition
Verify and validate information/data
Knowledge, skill, attitude and experience
Feelings, perceptions, and self-report of symptoms (what the…
Assess
Gather information about the client's condition
Two Stages of Assessment
Verify and validate information/data
Nursing Assessment
Palpation
inspection
auscultation
percussion
nurse uses hands to touch patient in order to detect tenderness
purposeful observation
process of listening to sounds produced by body
typically done by an NP tapping the body to produce and analy…
Palpation
nurse uses hands to touch patient in order to detect tenderness
inspection
purposeful observation
33 terms
Nursing Assessment
Nursing process
Assessment
Primary Source
Secondary Source
is a standard of care.
Deliberate and systematic collection from patient about curre…
Patient. Their history is the most important part of assessme…
Family (possible primary if patient is n/a), medical records,…
Nursing process
is a standard of care.
Assessment
Deliberate and systematic collection from patient about curre…
29 terms
Nursing Assessment
Nursing Process
Five steps to the nursing process
What should you do each time you meet…
Assessment
Critical thinking process that professional nurses use to app…
assessment... diagnosis... planning... implementation... evaluation
Apply the nursing process (five steps)
deliberate and systematic collection of information about a p…
Nursing Process
Critical thinking process that professional nurses use to app…
Five steps to the nursing process
assessment... diagnosis... planning... implementation... evaluation
50 terms
Nursing Assessment
Bradypnea
Tachypnea
Adult respiration
Adult blood pressure
: respirations below 12 bpm
: respirations above 20 bpm
: normal range 12-20 bpm
: 100-120 systolic and 60-80 diastolic
Bradypnea
: respirations below 12 bpm
Tachypnea
: respirations above 20 bpm
8 terms
nursing assessment
nursing process
five components of nursing process
assessment
two stages of assessment
is a variation of scientific reasoning ... organized and systema…
1. assessment ... 2. diagnosis ... 3. planning ... 4. implementation…
involves collecting information to form a complete database
collection and verification of data ... analysis of data
nursing process
is a variation of scientific reasoning ... organized and systema…
five components of nursing process
1. assessment ... 2. diagnosis ... 3. planning ... 4. implementation…
31 terms
Nursing Assessment
Health Assessment
Communication
Health History
Present Problem
Subjective data- tells where to focus from what pt says to yo…
read both verbal and nonverbal... Non-verbal is most reliable…
Complete Exam - 1st time... -complaint... -presenting problem... -heal…
Current complaint... any significant negatives (nausea but not
Health Assessment
Subjective data- tells where to focus from what pt says to yo…
Communication
read both verbal and nonverbal... Non-verbal is most reliable…
192 terms
Fundamentals Nursing PHYSICAL ASSESSMENT
health assessment
nursing assessments focus on....
what are the purposes of a physical as…
where would you do a comphrehensive as…
comprehensive assessment of the physical, mental, spiritual,…
the clients functional abilities and physical responses to il…
to obtain base line data, to identify collaborative problems,…
annual physical, outpatient appointment, inpatient setting, a…
health assessment
comprehensive assessment of the physical, mental, spiritual,…
nursing assessments focus on....
the clients functional abilities and physical responses to il…
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