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NUR 100 Assessment
| Question | Answer |
|---|---|
| nursing process is defined as | systematic, rational method of planning/providing nursing care, assuring pt needs are met |
| assessment | collect, organize, validate, document pt data |
| diagnosing | analyze and synthesize data |
| planning | determine how to prevent, reduce, resolve pt problems |
| implementing | perform planned nursing interventions, reassess pt and document effectiveness of interventions |
| evaluation | measure the achievement of goals earlier created |
| 4 types of assessment | initial, problem focused, emergency, time lapsed |
| collecting data | gathering info about pt health status |
| organizing data | putting data into organized format |
| validating data | verifying data is complete and accurate |
| documenting data | recording data in factual manner |
| health history includes | biographic data, chief complaint of visit, history of present illness, past/family history, lifestyle, social data, psych data, patterns of healthcare |
| subjective data | symptoms, described, observed-anything measurable |
| objective | anything patient or healthcare personnel or family member says about patient and/or illness |
| interviewing | planned communication, conversation with a purpose |
| directive interview | structure that obtains specific info |
| nondirective interview | builds understand & relationship between nurse and pt |
| closed-ended ?'s | restrictive, "yes" or "no" answers |
| open-ended ?'s | allow pt to explore & express feelings |
| neutral ?'s | pt answers without influence or direction from nurse |
| leading ?'s | direct pt's answers to assessment ?'s |
| Maslow's hierarchy of needs | self-actualization, esteem, love/belonging, safety, physiological |
| 2 components of health status | health history & physical examination |
| purpose of physical exam | obtain baseline data, validate data obtained in nursing history, aid in establishing nursing diagnoses and plan of care for pts |
| health exam materials | stethoscope, pen light, sphygmomanometer, thermometer, otoscope, nasal speculum, lubricant, tongue blades, reflex hammer, gloves, cotton applicators |
| position of pt lying on back, bent knees, hips externally rotated, small pillow under head and soles of feet on surface | dorsal recumbent |
| position of pt lying on back, legs extended with or without pillow under head | supine |
| position of pt lying on back, feet supported in stirrups, hips in line with edge of table | lithotomy |
| position of pt side lying with lower arm behind body, upper leg flexed at hip and knee, upper arm flexed at shoulder and elbow | sims' |
| position of pt lying on abdomen with head turned to side with/without pillow | prone |
| observations of visual inspection | moisture, color, texture of skin/surfaces, shape, position, size, symmetry |
| observations during palpation | texture, temperature, vibration, position, size, mobility of organs, distention, pulsation, tenderness/pain |
| observations during percussion | shape & size by establishing borders of organs, indication of fluid buildup, air buildup, or if it's solid |
| 5 sounds to listen for during percussions | flatness, dullness, resonance, hyperresonance, tympany |
| 2 types of percussion | direct: striking area with finger pads indirect: strike object held against body |
| 2 types of auscultation | direct: use of unaided ear indirect: use of stethoscope |
| ausculation sounds referred to using | pitch: frequency of vibrations, intensity: loudness or softness, duration: length of sound, quality: description of sound |
| general survey | involves observing pt's general appearance, socioeconomic status, current situation |
| what to look for in general survey | appearance and mental status, culture, education level, socioeconomic status, current situation |
| vital signs are for | establishing baseline data, detect health problems |
| vital signs | temperature, pain, pulse, respiration, blood pressure, o2 saturation |
| gerontology | study of aging or older adults |
| geriatrics | medical care of older adults |
| role of geriatric nurse | provider of care, teacher, manager, advocate, research consumer |
| care settings for older adults | acute care, long term care, hospice, rehabilitation, community |
| neuromuscular effects of aging | loss of height, bone mass, weight, joint stiffness, impaired balance |
| interventions for neuromuscular aging | active/passive ROM, P.E. programs, adequate vit D and Ca+ intake, fall prevention |
| changes in vision | decreased visual acuity, decreased adaptation to darkness, decreased near and far vision, difficulty distinguishing colors |
Created by:
cjanicek7842
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