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NUR 100 Assessment

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