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Study sets matching "term:general survey = daily/ ongoing assessment observe head to toe observe environment"

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Study sets matching "term:general survey = daily/ ongoing assessment observe head to toe observe environment"

24 terms
Head to Toe Assessment Rubric
IPPA
General Rules for Assessment
#1 - Introductions
#2 - General Survey
IPPA !... Inspect! (look)... Palpate! (touch)... Percuss! (tap/thump…
If it moves, observe it moving!... It has any specific function…
1 - Gather all Equipment needed for Head to Toe Exam... 2 - Was…
1 - Observe Appearance... 2 - Assess vital signs.(Verbalize thi…
IPPA
IPPA !... Inspect! (look)... Palpate! (touch)... Percuss! (tap/thump…
General Rules for Assessment
If it moves, observe it moving!... It has any specific function…
14 terms
Head to toe assessment
Inspection
Palpation
Percussions
Auscultation
Visual observation of the client; the nurse is looking at the…
Sense of touch; the nurse uses fingertips to assess texture,…
This cannot be performed by an LPN: short tapping strokes on…
Listening to sounds in the body that are created by movement…
Inspection
Visual observation of the client; the nurse is looking at the…
Palpation
Sense of touch; the nurse uses fingertips to assess texture,…
41 terms
head to toe assesment exam 1
admission assesment
shift assesment
focused assesment
techniques used for assesment in order…
health history and physical exam, asses fall risks, skin risk…
head to toe, just highlights/concern areas, compare to baseli…
done when a patient has a new complaint or data is needed for…
inspection, palpation, percussion, ausculation
admission assesment
health history and physical exam, asses fall risks, skin risk…
shift assesment
head to toe, just highlights/concern areas, compare to baseli…
50 terms
Head to toe assessment checkoff
1
2
3
4
Begin with a survey of the client's overall hygiene and physi…
Assess mental status and level of consciousness... -Orientation…
Assess skin of the scalp and head.
Assess temperature (with back of hand), texture and moisture
1
Begin with a survey of the client's overall hygiene and physi…
2
Assess mental status and level of consciousness... -Orientation…
5 terms
Intro, Infection Control, General Survey
Intro:
Hand Hygiene
Outro
Infection control
-Hi I am _________... - 2 pt identifiers... - I'm going to do a hea…
-before touching patient... -after assessment
-thank you... -hand hygiene... -any questions?
-hand hygiene... -throw trash away (don't set it down)... -use glov…
Intro:
-Hi I am _________... - 2 pt identifiers... - I'm going to do a hea…
Hand Hygiene
-before touching patient... -after assessment
32 terms
Foundations: Head to Toe Assessment
Purpose of Head to Toe Assessment
How can we be culturally sensitive to…
What examination to integrate during r…
Preparation for an Examination
-Gather a health history (Orient the interview to the client,…
-Consider health beliefs, use of alternative therapies, nutri…
-Vital signs... -Bathing... -Range of motion... -Activities of daily l…
-Infection control- will use good hand hygiene and will follo…
Purpose of Head to Toe Assessment
-Gather a health history (Orient the interview to the client,…
How can we be culturally sensitive to…
-Consider health beliefs, use of alternative therapies, nutri…
20 terms
head to toe terms
Activities of Daily Living (ADL's)
Adventitious Breath Sounds
Ascites
Auscultation
daily self-care activities within persons place of residence…
sounds that are not normally heard in the lungs on auscultati…
Accumulation of serous fluid in the peritoneal cavity
Act of listening with a stethoscope to sounds produced within…
Activities of Daily Living (ADL's)
daily self-care activities within persons place of residence…
Adventitious Breath Sounds
sounds that are not normally heard in the lungs on auscultati…
9 terms
Chapter 22: Health Assessment
Purpose of Physcial Examination
Comprehensive Physical Assessment
Focused physical assessment
System specific Assessment
Obtain Baseline data: physical status and functional abilitie…
Health history interview and complete head to toe examination…
Focuses on Particular problem, body part, or functional abili…
Limited to one body system
Purpose of Physcial Examination
Obtain Baseline data: physical status and functional abilitie…
Comprehensive Physical Assessment
Health history interview and complete head to toe examination…
169 terms
Health Assessment 1
symptom
sign
health history components
objective data
subjective sensation that the person feels from the disorder
an objective abnormality that you as the examiner could detec…
biographical data, reason for seeking care/chief complaint, h…
signs; information perceived by the interviewer and/or lab data
symptom
subjective sensation that the person feels from the disorder
sign
an objective abnormality that you as the examiner could detec…
167 terms
THE CONCEPT OF ASSESSMENT
Is the first phase of the nursing proc…
Is a systematic and continuous collect…
1.comprehensive ... 2. Ongoing partial... 3.…
The initial or comprehensive assessmen…
Assessment
Assessment
4 types of assessments
Comprehensive assessment
Is the first phase of the nursing proc…
Assessment
Is a systematic and continuous collect…
Assessment
15 terms
Head to toe assessment (mcGovern) Physical assessment
What equipments do you need for the he…
Upon entering the room you do what?
What do you do assess for consciousness?
what is step 4?
stethoscope, Appropriate sized blood pressure cuff, pulse oxi…
Perform hand hygiene, identify self, identify patient, verify…
assess level of consciousness and orientation to person, time…
perform pain, pulse oximetry, blood pressure, and temperature…
What equipments do you need for the he…
stethoscope, Appropriate sized blood pressure cuff, pulse oxi…
Upon entering the room you do what?
Perform hand hygiene, identify self, identify patient, verify…
120 terms
Unit 2 : Assessing the Patient's Health Status copy 2
Assessment Begins...
Two Main Areas of Assessment
Four Major Assessment Activities
Assessment is
the nursing process
nursing health history... assessment/exam
collection... organization... validation... documentation
systematic, continuous, deliberative & interactive
Assessment Begins...
the nursing process
Two Main Areas of Assessment
nursing health history... assessment/exam
62 terms
Head to Toe Assessment
1st thing you should do
General Survey
Ask patient to remember 3 words
Discriminatory Sensations
Wash hands or use sanitizer
appearance, facial expression, speech, mental state
Test short term memory at the very end of the examination and…
soft and sharp object to face. Trigeminal Nerve V
1st thing you should do
Wash hands or use sanitizer
General Survey
appearance, facial expression, speech, mental state
96 terms
physical assessment
types of data
sources of data
methods of data collection
orientation phase
subjective... objective
primary... secondary
interview... nursing health history... physical examination... diagnos…
begins at introduction
types of data
subjective... objective
sources of data
primary... secondary
26 terms
Components of Comprehensive Examination
2 phases of Health Assessment
2 ways to organize the exam
Types of Physical Exams
Comprehensive Exam
General Survey... Physical Examination
Head to Toe... Body Systems
Comprehensive... Focused... Ongoing
Interview plus head to toe examination
2 phases of Health Assessment
General Survey... Physical Examination
2 ways to organize the exam
Head to Toe... Body Systems
164 terms
Chapter 16 health assessment TTC nut 102
Focus health assessment
Objective data
Subjective data
Three major frameworks organizing data
General survey, taking vital, and assesing specific areas tha…
Can be directly observed or measured such as vital signs or a…
Symptoms feelings perceptions preference values and information
Functional health framework, head to toe framework, and body…
Focus health assessment
General survey, taking vital, and assesing specific areas tha…
Objective data
Can be directly observed or measured such as vital signs or a…
122 terms
NURS 366: Week 2, General Approach to Physical Assessment
What is the purpose of the physical ex…
What are some basic considerations to…
T/F by law if over 14 full privacy to…
how should to exam proceed? (where do…
-validate the chief complaint... -screen for general well-being…
-trusting relationship... -explain as you go and before doing (w…
true, will not tell parents
head to toe
What is the purpose of the physical ex…
-validate the chief complaint... -screen for general well-being…
What are some basic considerations to…
-trusting relationship... -explain as you go and before doing (w…
Ch. 25 Health Assessment
health history
physical assessment
purpose of health assessment
comprehensive assessment
collection of subjective information that provides informatio…
collection of objective data that provides information about…
Establish the nurse-patient relationship.... Gather data about t…
conducted when a patient first enters a healthcare setting wi…
health history
collection of subjective information that provides informatio…
physical assessment
collection of objective data that provides information about…
82 terms
BASIC NURSING Chapter 21 Physical Assessment pg.485
Health assessment
Nursing assessments
Medical assessments
Physical examination, or physical asse…
This is a comprehensive assessment of the physical, mental, s…
This term focus on the client's functional abilities and phys…
This focus on disease and pathology.
This is the techniques used to gather objective data about th…
Health assessment
This is a comprehensive assessment of the physical, mental, s…
Nursing assessments
This term focus on the client's functional abilities and phys…
48 terms
General Survey & Assessment Techniques
health assessment
two main focuses of a nursing assessment
purpose of a physical assessment
4 steps to prepare for a physical asse…
a comprehensive assessment of the physical, mental, spiritual…
clients ability to function, physical response to illness and…
obtain baseline data, identify nursing diagnosis, monitor sta…
develop a systemic approach to physical assessment, prepare y…
health assessment
a comprehensive assessment of the physical, mental, spiritual…
two main focuses of a nursing assessment
clients ability to function, physical response to illness and…
26 terms
Health Assessment
Comprehensive assessment
Ongoing assessment
Focused assessment
Emergency assessment
Head to toe of each body system & health history on admission
Regular intervals ... Every shift ... Home visits
Specified problem ... Example - abdo pain
Rapid ... Focused to determine potential for fatal situation
Comprehensive assessment
Head to toe of each body system & health history on admission
Ongoing assessment
Regular intervals ... Every shift ... Home visits
27 terms
Health Assessment - Robin's Lecture - Chapter 25
health assessment
health history
subjective
objective
the collection, validation and analysis of subjective data (s…
a collection of subjective information that provides informat…
known only to patient
nurse can observe
health assessment
the collection, validation and analysis of subjective data (s…
health history
a collection of subjective information that provides informat…
38 terms
Personal Care 101-07
Routinely Scheduled Care
Benefits of bathing
Patient preferences
Categories of personal care
Early morning... Morning... Afternoon... Bedtime
Cleanses... Skin assessment... Circulation... Sensation... Comfort and re…
Timing(unless there's a Dr.'s order, usually after breakfast,…
Self care(perfom ADL's without help)... Assisted Care(needs a li…
Routinely Scheduled Care
Early morning... Morning... Afternoon... Bedtime
Benefits of bathing
Cleanses... Skin assessment... Circulation... Sensation... Comfort and re…
20 terms
Secondary survey
Vital signs
Next?
Neurological exam
If GCS altered consider
O2 Sat, BGL (prn), Pulse, Blood Pressure respirations.
Neurological exam
GCS... Assess pupils for PERRL... Motor - can pt move fingers and t…
blood glucose, O2 sat, narcotic overdose.
Vital signs
O2 Sat, BGL (prn), Pulse, Blood Pressure respirations.
Next?
Neurological exam
13 terms
Chapter 19~ Health Assessment Data Collection
Complete assessment
Focused assessment
Prone position
Supine position
Admission assessment
Beginning and end of shift, of complete body, or specific bod…
Laying flat on stomach
Laying flat on back
Complete assessment
Admission assessment
Focused assessment
Beginning and end of shift, of complete body, or specific bod…
54 terms
Assessment (related content)
Health assessment
Nursing assessments
Physical assessment
What are the purposes of a physical ex…
-Comprehensive assessment of the physical, mental, spiritual,…
-Focus on the client's functional abilities and physical resp…
-Physical examination consists of the techniques used to gath…
-Obtain baseline data... -Identify nursing diagnoses, collaborat…
Health assessment
-Comprehensive assessment of the physical, mental, spiritual,…
Nursing assessments
-Focus on the client's functional abilities and physical resp…
83 terms
IPPA, General Survey and Health History
assessment
subjective
objective
inspection, palpation, percussion, aus…
first step in the nursing process
what the patient says
what you observe
IPPA
assessment
first step in the nursing process
subjective
what the patient says
103 terms
Chapter 22 Health Assessment
What are some reasons a physical asses…
Comprehensive physical assessment
Give an example of a situation where a…
Focused physical assessment
~to obtain baseline data... ~to identify nursing diagnoses, coll…
Includes a health history interview and a complete head to to…
at an outpatient facility for yearly physical or on a clients…
pertains to a particular topic, problem, body part, or functi…
What are some reasons a physical asses…
~to obtain baseline data... ~to identify nursing diagnoses, coll…
Comprehensive physical assessment
Includes a health history interview and a complete head to to…
95 terms
Head to Toe skills
ADPIE
Health History
Primary Data
Secondary Data
Assessment... Diagnosis... Planning... Implementation... Evaluation
Gathers subjective data... Purposeful communication... Collect da…
From the Client
From everyone and everything else
ADPIE
Assessment... Diagnosis... Planning... Implementation... Evaluation
Health History
Gathers subjective data... Purposeful communication... Collect da…
Health Assessment Week 2 - General Survey
Subjective data
Objective data
IPPA
Caphalocaudal Assessment
what the patient says
what you observe
- inspection ... - palpation... - percussion ... - auscultation
head to toe
Subjective data
what the patient says
Objective data
what you observe
33 terms
EMR First On Scene 10th Edition: Chapter 13, Principles of Patient Assessment
Scene Size - Up
primary assessment
signs
symptoms
an overview of the scene to identify an obvious or potential…
a quick assessment of the patient's airway, breathing, circul…
something that can be observed or measured when assessing a p…
something the patient complains of or describes during a seco…
Scene Size - Up
an overview of the scene to identify an obvious or potential…
primary assessment
a quick assessment of the patient's airway, breathing, circul…
16 terms
Health History
Objective data
Subjective data
Health Assessment 3 step approach
Data collection... 1.symptoms... 2. signs... 3.…
Data relating to a client's health problem that are obtained…
things a person tells you about that you cannot observe throu…
1. History (70%)... 2. Physical Exam (20%)... 3. Laboratory data (1…
1. subjective, what the patient feels/communicates to you... 2.…
Objective data
Data relating to a client's health problem that are obtained…
Subjective data
things a person tells you about that you cannot observe throu…
201 terms
Physical Assessment Examination Study Guide 202
Nursing Assessment
Nurses use physical assessment skills…
We gather data using
Subjective data
Part of the nursing process
1. Obtain baseline data and expand the data base from which s…
subjective data and objective data... Document: SOAPIER
is what is SAID by the client
Nursing Assessment
Part of the nursing process
Nurses use physical assessment skills…
1. Obtain baseline data and expand the data base from which s…
15 terms
Med Surg Ch4
Asking for more detailed info about on…
The current reason the client is seeki…
Include the clients age, occupation, r…
Ask the client questions to gather dat…
Focus Assessment
Chief complaint
Psychosocial history & cultural history
Use open-ended questions
Asking for more detailed info about on…
Focus Assessment
The current reason the client is seeki…
Chief complaint
38 terms
Health Assessment - Robin's Lecture - Chapter 25
health assessment
health history
subjective
objective
the collection, validation and analysis of subjective data (s…
a collection of subjective information that provides informat…
known only to patient
nurse can observe
health assessment
the collection, validation and analysis of subjective data (s…
health history
a collection of subjective information that provides informat…
29 terms
NUR 310 general survey
General survey
Objective data
Subjective data
Physical appearance
Capture snapshot assessment of client
Nurse observes
Patient reports
Age, sex, LOC, skin color, facial features, signs of acute di…
General survey
Capture snapshot assessment of client
Objective data
Nurse observes
18 terms
Nursing 212 Assessment Beginning
General Survey
Objective Data
Subjective Data
Measurements
All about observing ... Patience appearance... Body Structure... Beha…
Vital signs and other measurements
What the patients tells you
Vital Signs, Temperature. pulse, and Respiration
General Survey
All about observing ... Patience appearance... Body Structure... Beha…
Objective Data
Vital signs and other measurements
Chapter 2
Two Modes of Thinking
Heuristics
Representative Heuristics
Availability Heuristics
Heuristics
Mental shortcuts or rules off thumb that we use daily... Reduce…
...
...
Two Modes of Thinking
Heuristics
Heuristics
Mental shortcuts or rules off thumb that we use daily... Reduce…
27 terms
Assessing the Hospitalized Patient
Outpatient Differences
Hospital Patients
Perfecting your method
Key to assessment
Compensated state... Makes own decisions... Familiar environment... In…
Decompensated state... Others make decisions... Strange environment…
Organized ... Systematic... Same way each time... Use all senses... Inspe…
do it systematically - the same way each time
Outpatient Differences
Compensated state... Makes own decisions... Familiar environment... In…
Hospital Patients
Decompensated state... Others make decisions... Strange environment…
13 terms
Fundamentals of Nursing Chapter 22 Health Assessment and Physical Examination
What is a physical examination
What are the purposes of a physical ex…
What are the types of physical examina…
How do you prepare to perform a physic…
the techniques used to gather objective data about the body
1. to obtain baseline data... 2. to identify nursing diagnoses... 3…
1. Comprehensive physical assessment... 2. focused physical asse…
1. prepare yourself... 2. prepare the environment... 3. prepare the…
What is a physical examination
the techniques used to gather objective data about the body
What are the purposes of a physical ex…
1. to obtain baseline data... 2. to identify nursing diagnoses... 3…
40 terms
Musculoskeletal assessment
Sprain
Strian
Assessment of Condition & Function of…
assessment of Condition & Function of…
- An injury in a joint, caused by the ligament being stretche…
- muscle injury
- Problems including joint pain (arthralgia), movement limita…
Problems including muscle pain (myalgia), cramps, weakness (M…
Sprain
- An injury in a joint, caused by the ligament being stretche…
Strian
- muscle injury
115 terms
Physical Examination
Data Collection
Subjective Data
Objective Data
Assessment Techniques
- Subjective... - Objective
what the patient says... o "Ow my stomach hurts"
what we observe ... o The client holding on to their stomach wit…
- Inspection... - Palpation... - Percussion... - Auscultation
Data Collection
- Subjective... - Objective
Subjective Data
what the patient says... o "Ow my stomach hurts"
31 terms
Chapter 22
Health assessment
Nursing assessments
Physical assessment
Comprehensive physical assessment
A comprehensive assessment of physical, mental, spiritual, so…
Focus on the clients functional abilities and physical respon…
Consist of the techniques used to gather objective data about…
Includes a health history interview and a complete head to to…
Health assessment
A comprehensive assessment of physical, mental, spiritual, so…
Nursing assessments
Focus on the clients functional abilities and physical respon…
Psychology 107 Chapter 2
facilitators
facilitated communication
prefrontal lobotomy
heuristics
dozens of controlled studies examines the phenomenon and foun…
autism treatment used from communication
the neural fibers connecting frontal lobes to the thalamus we…
are mental shortcuts or rules of thumb that we use daily
facilitators
dozens of controlled studies examines the phenomenon and foun…
facilitated communication
autism treatment used from communication
57 terms
Chapter 25
Comprehensive Assessment
Ongoing partial assessment
Focused Assessment
Emergency Assessment
*Assess everything... *Health history and complete physical exam…
*Conducted at regular intervals... *Ex: at the beginning of each…
*Assess specific health problems... *Ex: abdominal pain
*Rapid focused assessment done to determine potentially fatal…
Comprehensive Assessment
*Assess everything... *Health history and complete physical exam…
Ongoing partial assessment
*Conducted at regular intervals... *Ex: at the beginning of each…
104 terms
General Survey and Health History HA
what is assessment?
subjective data
objective data
skills required for assessment
first step in the nursing process and a systematic way of col…
what your patient says
what you observe
inspection, palpation, percussion and auscultation
what is assessment?
first step in the nursing process and a systematic way of col…
subjective data
what your patient says
59 terms
Health Assessment CH31
Every time
Discover baseline, uncover significant…
Physical, mental, spiritual, socioecon…
Nursing history, physical examination
When do you assess you pt?
Why assess pt every time?
Comprehensive assessment (5)
Included in health assessment (2)
Every time
When do you assess you pt?
Discover baseline, uncover significant…
Why assess pt every time?
49 terms
Health assessment Chapter 25
comprehensive assessment
ongoing partial assessment
focused assessment
emergency assessment
with a health history and complete physical examination is us…
at the begininng of each shift. or follow up assessment is on…
is conducted to assess a specific problem.
is a type of rapid focused assessment conducted when addressi…
comprehensive assessment
with a health history and complete physical examination is us…
ongoing partial assessment
at the begininng of each shift. or follow up assessment is on…
78 terms
Fundamentals of Nursing Ch 19: Health Assessment
Health Assessment
Comprehensive physical assessment
focused assessment
system-specific assessment
a comprehensive assessment of the physical, mental, spiritual…
includes health history and head to toe physical examination…
performed to obtain data about and actual, potential, or poss…
is a focused assessment limited to one body system. ... e.g. the…
Health Assessment
a comprehensive assessment of the physical, mental, spiritual…
Comprehensive physical assessment
includes health history and head to toe physical examination…
39 terms
Gen Survey/Hair, Skin, Nails (Lecture 3)
assessment equipment
Tools of assessment
What is General survey?
Why do a general survey?
stethescope, otoscope, etc.
1. Inspection (vision, smell, listen)... 2. Palpation (light, de…
* initial observation or impression... * documents patient's sta…
* helps determine nursing care (emergency vs. well care)... * es…
assessment equipment
stethescope, otoscope, etc.
Tools of assessment
1. Inspection (vision, smell, listen)... 2. Palpation (light, de…
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