Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
HealthAssess Exam1
Chapters 8-11
| Question | Answer |
|---|---|
| what info is considered in the assessment? | subjective data, objective data, pt's record, lab results |
| collecting & documenting data are apart of which part of the nursing process | assessment |
| what happens in the diagnosis of nursing process? | compare values with norms interpret data document diagnosis validate diagnosis |
| the following are apart of which process of ADOPIE: - identify expected outcomes - create timeline - establish SMART goals | outcome identification |
| the planning process includes | prioritization identify interventions document plan of care develop outcomes/timelines |
| the implementation is composed of | collabing with colleagues coordinate delivery provide health promotion document implement and modification |
| during the evaluation of the nursing Process be sure to | progress towards outcomes include pt and s/o give results to pt/fam |
| these nurses uses rules to guide performance | novice |
| competency nurses have _____ | 2-3 yrs see actions in context of pt's goals |
| an expert nurse: | intuitive analysis attained mastery of area |
| a proficient nurse is | 3+ years adding to time and experience understands the pt situation as a whole rather individual apply long term goals |
| emergency, life threatening ABC - airway, breathing, circulation | 1st level priority |
| 2nd level priority | requires attn to avoid further deterioration |
| - mental status changes - urinary retention - abnormal lab values - risk of infection - acute pain are examples of what priority | 2nd level priority |
| ___ are problems that involve multiple disciplines, diabetes being an example | colloborative |
| 3rd level priority | important but can be addressed after urgent issues |
| this priority is related to coping, knowledge deficits and rest patterns | 3rd level |
| complete total health database is compromised of | complete health history full physical (often in PCP) |
| limited, short term concerns. 1 body system, 1 problem. what type of data is this? | episodic or problem centered database |
| what is included in an emergency database | rapid collection of data, urgent. full complete hx is collected later |
| what is the purpose of the health history? | to collect SUBJECTIVE data |
| components of health history | 1. biographic data 2. source of history 3. reason for seeking care (chief complaint) 4. present health or hx or present illness 5. past health 6. family hx 7. ROS 8. ADL's - functional assessment |
| what notations are necessary when collecting allergy information? | allergen and reaction |
| how to verify reliability of source? | 1. record who gives info 2. judge reliability 3. note if that person seems ill/well |
| the reason for seeking care is not a diagnostic statement. T or F. | true |
| Identify how to appropriately document a Reason for Seeking Care | -brief, spontaneous statement. -in person's own words -focus on pt's prioritized reasons for seeking care |
| what question should be asked after the person gives the reason for seeking care? | is there anything else we should take care of today? |
| true or false. pain is always subjective. | true |
| P: provocative or palliative ask | what makes it better? worse? |
| Q: quality or quantity | how does it look, feel, sound? ex: burning, sharp, dull, profuse bleeding, etc. |
| what question do we ask when talking about R: region or radiation | does it spread anywhere? |
| S: severity scale, 1-10 | how bad is it on a scale of 1-10? |
| What question is asked when dealing with T: timing or onset | onset: exactly when did it 1st occur? duration: how long do they last? frequency: how often? |
| U: understand the pt's perception | what do you think this means? |
| what is the purpose of medicine reconciliation? | to reduce errors and promote safety. comparison list of current and previous meds. |
| what questions do you ask when asking a pt about their medication list? | - name - dose - schedule - any side effects? - why'd you stop taking it? |
| what is the purpose of the review of systems? | - evaluate past/present health state of each body system - double check to make sure no important info was omitted - evaluate health promotion practices |
| Identify components of the CAGE assessment and when further evaluation is necessary | C: cut down A: annoyed G: guilty E: eye opener if yes to 2+. suspect alcohol abuse |
| How to assess Stress and Coping in the Functional Assessment | - types of stresses in life (in last year) - lifestyle changes - current stresses - what methods do you use to relieve stress? do they work? |
| What does the ABCT stand for? | appearance. behavior. cognitive functions. thought processes/perception |
| what is included in appearance? | posture body movements dress (appropriate?) grooming/hygiene |
| what's included in behavior? | -level of consciousness (LOC) -facial expression -speech -mood and affect |
| normal Level of consciousness findings include: | awake alert aware of stimuli (responds appropaitely) |
| is the mental examination subjective or objective? | objective |
| cognitive functions of the ABCT | orientation: time, place, situation or self attention span: can they concentrate? recent memory: 24hr diet remote memory |
| mental exam: alert | awake easily aroused oriented fully aware of stimuli responds appropriately |
| mental exam: lethargic | not fully alert drifts to sleep when not stimulated looks drowsy delayed responses (fuzzy/slow thinking) |
| mental exam: coma | completely unconscious no response to pain or stimuli |
| if a patient doesn't push the trach back when being suctioned, this is what mental state.. | coma |
| disoriented unconsciousness agitation impaired recent memory dulled cognition impaired alertness indicates ___ on the mental exam | delirium |
| What is stroke volume | amount of blood ejected from ventricles |
| This vital sign is an indicator of rate and rhythm of heartbeat and local condition of artery | Pulse |
| what happens to the respiratory rate as we age? | it slows |
| with infants, respiratory rate does what? | faster |
| a normal person's breathing should be ___ , ___, ___ and ___ | relaxed regular automatic silent |
| what factors affect BP? | - age - gender - race -diurnal rhythm -weight -exercise -emotions -stress |
| females BP is lower than men until when? | post-menopausal |
| force of a pulse is : | strength of heart's stroke volume |
| what happens to a person's regulatory mechanism as they age? | it leaves, harder for them 2 get fever, easier to get hypothermia |
| acute pain v chronic | |
| which pain is self limiting and short term? | acute pain |
| this type of pain is a protective type of pain, alerting you when something is wrong | acute |
| fractures, headache due to sinus pressure, chest pain and appendicitis are all examples of what kind of pain | acute |
| this pain is persistent, lasting 6+ more months & generally affects quality of life (negatively) | chronic |
| this pain generally serves no type of purpose | chronic |
| chronic pain usually happens if tissues | are healed but pain still there |
| chronic pain behaviors include: | bracing diminished activity sighing change in appetite |
| poorly controlled pain effects on the cardiac system | - tachycardia - elevated BP - increased in heart demands - increased CO |
| poorly controlled pain effects on the pulmonary system | hypoxia hypoventilation complete or partial collapse of lung decreased cough |
| Identify how to appropriately assess pain (initial questions) | do you have pain where is your pain when did your pain start what does your pain feel like how much pain do u have now |
Created by:
Mariahj25
Popular Nursing sets