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Fund. ch 47

data collection process

QuestionAnswer
DETERMINED BY A PHYSICIAN. IT EMPHASIZES THE DISEASE PROCESS. MEDICAL DIAGNOSIS
IT'S FORMULATED BY THE NURSING TEAM. IT'S A CONCISE PROBLEM CENTERED DESCRIPTION OF ACTUAL OR POTENTIAL HEALTH PROBLEMS NURSING DIAGNOSIS
HAPPENS SUDDENLY AND RUN'S ITS COURSE IN A FEW DAYS TO WEEKS ACUTE DISEASE
CAN CONTINUE FOR MONTHS, YEARS, OR LIFE CHRONIC DISEASE
OCCURS BY ITSELF PRIMARY DISEASE
RESULTS FROM OR DEPENDS ON ANOTHER DISORDER SECONDARY DISEASE
CAN BE SEEN OR MEASURED OBJECTIVE
SENSATION THAT ONLY CLIENT KNOWS AND CAN REPORT SUBJECTIVE
A PATIENT IS REPORTING THAT THEY HAVE SOME BURNING AND ITCHING. SUBJECTIVE BECAUSE THE PATIENT CAN FEEL THIS AND REPORTING IT TO YOU
DURING AN EXAM YOU NOTICE THE PATIENT HAS A RASH ACROSS THE ABDOMEN. OBJECTIVE BECAUSE YOU CAN SEE THIS
DURING AN EXAM A PATIENT IS REPORTING THE REASON FOR PRESENTING SELF TO ER IS THAT THEY HAVE BEEN LIGHT-HEADED, RUNNING A FEVER OF 102, AND N&V SUBJECTIVE THIS IS WHAT THE PATIENT FEELS AND IS REPORTING
ALL TEAM MEMBERS OF THE HEALTHCARE TEAM PARTICIPATE IN CARRYING OUT THE PLAN NURSING CARE PLAN
LIST SOME RISK FACTORS FOR DISEASE DIET, SMOKING, EXCESSIVE USE OF ALCOHOL OR OTHER DRUGS, AGE, OBESITY, LACK OF EXERCISE, IMMOBILITY, HEREDITY RACE
WHAT RISK FACTOR IS THIS? EXCESS INTAKE OF FATTY FOODS DIET
WHAT RISK FACTOR IS THIS? DECREASES ABILITY TO PERFORM USUAL PHYSICAL ACTIVITIES OBESITY
INVASION OF CELLS, TISSUES, OR ORGANS BY PATHOGENS. ITS HARMFUL TO THE BODY AND MAY RESULT IN INFLAMMATION, TISSUE DESTRUCTION, TISSUE OR ORGAN DYSFUNCTION, OR EVEN CELLULAR, TISSUE OR ORGAN DEATH. INFECTION
BODY'S RESPONSE TO AN INJURY IRRITANT OR FOREIGN SUBSTANCE. IT CAN AFFECT EVERY BODY ORGAN, TISSUE,AND SYSTEM. CAN CAUSE HEAT REDNESS,A DN SWELLING INFLAMMATION
CLEAR DRAINAGE( SERUM) SEROUS
BLOODY SANGUINEOUS
COMBINATION OF SERUM AND BLOOD SEROSANGUINEOUS
CONTAINS PUS PURULENT
IF A CULTURE AND SENSITIVITY STUDY IS ORDERED ALONG WITH ANTIBIOTICS WHICH ONE WOULD YOU DO FIRST? CULTURE
LIST SOME STEPS IN IN PREPARING A CLIENT FOR DIAGNOSTIC PROCEDURES HAVE AN INFORMED CONSENT SIGNED IF REQUIRED, EXPLAIN PROCEDURE AND REASON, WOULD ASSIST CLIENT TO MAINTAIN NPO OR AND SPECIAL ORDERS FOR THAT PARTICULAR TEST, PROVIDE PRIVACY DRAPE PT, V/S MONITORED
LIST SOME OF THE GOALS OF DATA GATHERING AND PHYSICAL ASSESSMENT BY NURSE KNOW DIFFERENCE B/T NORMAL AND ABNORMAL, IDENTIFY POTENTIAL PROBLEMS, REPORT ANY CHANGES TO APPROPRIATE PERSON, DELIVER CLIENT CARE WITHIN THE PRESCRIBED SCOPE OF PRACTICE.
LIST THE 5 TECHNIQUES A HEALTHCARE EXAMINER WILL USE TO EXAM CLIENT OBSERVATION, INSPECTION, AUSCULTATION, PALPATION, PERCUSSION
WHEN EXAMINING A CLIENT WHAT ARE SOME DIFFERENT OBSERVATIONS YOU COULD NOTE FOR THE SKIN, HAIR AND NAILS. NOTE THE COLOR OF SKIN, ANY LESIONS ON SKIN, TEMPERATURE, TURGOR, AND EDEMA NOTED TO SKIN, INSPECT SCALP AND HAIR AND CHECK NAILS FOR CAPILLARY REFILL.
WHEN OBSERVING THE HEAD AND NECK LIST SOME OBSERVATION THAT YOU MAY NOTE IN NOTES OBSERVE FACE, HEAD, FOR SYMMETRY, SIZE AND SHAPE, RESPONSE TO VERBAL STIMULI, PERRLAC, LEVEL OF CONSCIOUSNESS, ABILITY TO SEE, HEAR, SMELL AND DISTINGUISH TACTILE SENSATION
WHEN NOTING THE MUSCULAR SYSTEM WHAT ARE SOME AREA YOU WOULD BE LOOKING AT AND NOTING CHECK BOTH ARMS AND LEGS AND COMPARE STRENGTH AND SHAPE, SIZE. CHECK ROM TO JOINTS CHECK FLEXIBILITY OF MOVEMENT TO JOINTS AND SPINE
IN OBSERVATION OF THE CHEST WHAT WOULD YOU OBSERVE RESP MOVEMENT, SYMMETRY OF CHEST, ABNORMAL LUNG SOUNDS, TAKE PULSE
WHAT ARE SOME REASONS WHY A MD WOULD ORDER A METABOLIC PANEL SUCH AS CMP OR BMP TO PROVIDE A BASELINE SET OF VALUES FOR THE CLIENT BEFORE SURGERY, DIFFERENTIATE MENTAL ILLNESS FROM OTHER DISORDERS, EVALUATE A PERSONS TOTAL BODY SITUATION AND TO ASSESS A NUMBER OF ORGANS AT ONCE
WHAT IS A CT USED FOR? USED FOR THE HEAD,ABDOMEN AND BODY TO ASSESS ABNORMALITIES, TUMORS, ANEURYSMS AND MANY OTHER DISORDERS
WHAT IS A KUB? ITS AN X-RAY OF THE KIDNEY, URETER AND BLADDER IT EVALUATES THE ANATOMY OF THE URINARY SYSTEM STRUCTURES.
THESE TEST ARE USED TO EVALUATE THE RESPIRATORY SYSTEM SPIROMETRY AND PFT( PULMONARY FUNCTION TEST
A SCOPE THAT IS USED TO EXAMINE THE STOMACH GASTROSCOPY
A COPE THAT IS USE TO EXAMINE THE RECTUM SIGMOIDOSCOPY
IT CAN DETERMINE THE INTRACRANIAL PRESSURE WITHIN THE HEAD AND SPINAL CORD AND THE PRESENCE OF ABNORMAL COMPONENTS SUCH AS BLOOD, PATHOGEN, OR PUS IN THE CEREBROSPINAL FLUID OR IT CAN BE DONE TO INJECT DRUGS OR SPINAL ANESTHESIA LUMBAR PUNCTURE OR CALLED A SPINAL TAP
LIST SOME DIFFERENT EXAMINATION FORMATS HEAD TO TOE, BODY SYSTEMS, AND FOCUSED PHYSICAL EXAMINATION
WHEN ASSESSING THE ABDOMEN LIST THE ORDER IN WHICH YOU WOULD ASSESS INSPECTION, AUSCULTATION THEN PALPATION
A TECHNIQUE OF LOOKING AT THE CLIENT OR WATCHING FOR GENERAL CHARACTERISTICS SUCH AS OVERALL APPEARANCE , SKIN COLOR, GROOMING AND OTHER FACTORS THAT DO NOT REQUIRE CLOSE SCRUTINY OR THE USE OF MEASUREMENT AIDS OBSERVATION
TAPPING OR STRIKING THE FINGERS OR A SPECIAL HAMMER AGAINST THE BODY NOT DONE BY STUDENT NURSE REQUIRES HIGH LEVEL OF EXPERTISE PERCUSSION
LISTENING FOR SOUNDS FROM WITHIN THE BODY USUALLY WITH THE AID OF A STETHOSCOPE OR AN ULTRASOUND AUSCULTATION
FEELING BODY TISSUES OR PARTS WITH THE HANDS OR FINGERS PALPATION
HOW WOULD YOU CHECK A CLIENTS SKIN TURGOR? BY PINCHING A FOLD OF SKIN RELEASING IT AND WATCHING THE SKIN RETURN TO ITS NATURAL SHAPE.
WHAT PART OF THE BODY WOULD YOU USE TO CHECK FOR SKIN TURGOR? THE FOREARM OR UPPER CHEST
MASSIVE GENERALIZED EDEMA ANASARCA
SKIN DENTS REMAINS FOR > 2 SEC AFTER PRESSURE IS RELEASED IS CALLED PITTING EDEMA
SKIN IS SHINY HARD AND DOES NOT DENT NON-PITTING EDEMA
SMALL WELL DEFINED BORDER < 1 CM IN DIAMETER FLAT AND NON PALPABLE ON SKIN SURFACE, NO COLOR CHANGE? LIST SOME EXAMPLES MACULE FRECKLES, AGING SPOTS, AND SOME SKIN RASHES
SMALL ,0.5 CM PALPABLE, ELEVATED SOLID TISSUE? LIST SOME EXAMPLES PAPULE MOLE OR WART
SLIGHTLY IRREGULAR IN SHAPE, TRANSIENT SUPERFICIAL ELEVATES ARE OF LOCALIZED EDEMA? LIST SOME EXAMPLES WHEAL HIVES ANS INSECT BITES
SMALL, 0.5 CM IN DIAMETER WELL DEFINED BORDER; ELEVATED CAVITY FILLED WITH SEROUS FLUID? LIST SOME EXAMPLES VESICLE BLISTERS, HERPES SIMPLEX AND CHICKENPOX
WELL DEFINES BORDER; ELEVATED SUPERFICIAL CAVITY FILLED WITH PUS? LIST SOME EXAMPLES PUSTULES ACNE, IMPETIGO AND BURNS
LINEAR CRACK IN SKIN? LIT EXAMPLES FISSURE CHAPPED LIPS FUNGAL INFECTION SUCH AS ATHLETE'S FOOT
LOSS OF TOP LAYERS OF SKIN TISSUE? LIST SOME EXAMPLES ULCER PRESSURE ULCER VENOUS STASIS ULCER
SMALL WELL DEFINED BORDER; PALPABLE ELEVATED MASS? LIST SOME EXAMPLES NODULE FATTY TUMOR
1-2 CM IN DIAMETER; IRREGULAR BORDER; PALPABLE ELEVATED. LIST SOME EXAMPLES TUMOR LARGER LIPOMA OR MALIGNANCY
LOW PITCHED BUBBLING MOIST SOUNDS THROUGH OUT EXPIRATORY CYCLE, SOUNDS LIKE VELCRO BEING PULLED APART COARSE CRACKLES
HIGH-PITCHED POPPING SOUNDS DURING INSPIRATION, SIMULATED BY ROLLING STRAND OF HAIR NEAR YOUR EAR; MAY BE CLEARED BY COUGHING FINE CRACKLES OR CALLED CREPITUS USED TO BE CALLED RALES
HIGH-PITCH CONTINUOUS MUSICAL SOUND ON INSPIRATION AND EXPIRATION WHEEZE ( SIBILANT STRIDOR)
LOW-PITCHED MOANING OR GRUNTING SOUND USUALLY HEARD IN EXPIRATION MAY BE CLEARED BY COUGHING WHEEZE ( SONOROUS) RHONCHI
Created by: rosegraffagnini