Study sets matching "nursing assessment"

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Study sets matching "nursing assessment"

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
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…
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"
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
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
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
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…
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
31 terms
Nursing Assessment
OPENING PROTOCOL
General Survey
SKIN
INSPECTION FOR COLOR
Verify order ... Gather equipment... Wash hands prior to touching p…
Skills utilized: Inspection and Olfaction :... Overall physical…
Skills utilized: Inspection, Palpation, and Olfaction Inspect…
Cyanosis ... Pallor ... Erythema ... Jaundice ... Ecchymosis ... Petechiae…
OPENING PROTOCOL
Verify order ... Gather equipment... Wash hands prior to touching p…
General Survey
Skills utilized: Inspection and Olfaction :... Overall physical…
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.
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…
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
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
6 terms
Nursing Assessment
Glascow Coma Scale
Pitting Edema
Describing Skin Lesions
Integument Assessment Irregularities
1+ Mild: 2mm, slight indent, no observable swelling ... 2+ Moder…
Type/ structure ... Size, shape, texture... Colour... Distribution... Con…
Hyperhidrosis: excessive perspiration ... Bromhidrosis: foul sme…
Glascow Coma Scale
Pitting Edema
1+ Mild: 2mm, slight indent, no observable swelling ... 2+ Moder…
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…
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
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…
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…
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,…
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…
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
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
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…
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
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
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…
56 terms
Skin Nursing Health Assessment
Annular
Confluent
Discrete
Grouped
Circular (ringworm)
lesions run
distinct, individual lesions that remain separate
cluster of lesions
Annular
Circular (ringworm)
Confluent
lesions run
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
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
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…
24 terms
Nursing Assessment
Nursing Assessment
"at risk for"
Two types of data collecion
objective data
the systematic and continuous collection and analysis of info…
existing needs often are the priority over potential needsd
subjective and objective
all measurable and observable pieces of information about the…
Nursing Assessment
the systematic and continuous collection and analysis of info…
"at risk for"
existing needs often are the priority over potential needsd
41 terms
nursing assessment
stridor
hemopneumothorax
palpating client precordium
epigastric pain
narrowing of the upper airway caused by an obstruction or ede…
no audible breath sounds, because lungs cannot fill up with air
palpable pulsation over the mitral area
focus on cardiovascular, respiratory and gastrointestinal
stridor
narrowing of the upper airway caused by an obstruction or ede…
hemopneumothorax
no audible breath sounds, because lungs cannot fill up with air
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
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…
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
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…
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…
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…
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…
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…
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
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
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
Nursing assessment
Nursing process
Assessment
Database
Cue
A critical thinking process that professional nurses use to a…
Two steps: 1) collection of information from a primary source…
The patients perceived needs, health problems, and responses…
Information that you obtain through the use of the senses
Nursing process
A critical thinking process that professional nurses use to a…
Assessment
Two steps: 1) collection of information from a primary source…
Nursing Assessment
epidermis
basal cell layer
horny cell layer
dermis
thin tough outer layer of skin that forms a rugged protective…
forms new skin cells and consists of keratin and melanin
skin layer that consists of dead keratinized cells that are i…
inner supportive layer of the skin that consists of connectiv…
epidermis
thin tough outer layer of skin that forms a rugged protective…
basal cell layer
forms new skin cells and consists of keratin and melanin
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
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