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Assessment Exam I
NU305 - Jarvis
| Question | Answer |
|---|---|
| COMPONENTS OF ASSESSMENT | REVIEW CLINICAL RECORD, INTERVIEW, HEALTH HISTORY, PHYSICAL EXAM, FUNCTIONAL ASSESSMENT, CONSULTATION, REVIEW OF LITERATURE |
| PHASES OF THE NURSING PROCESS | ADOPIE: ASSESSMENT, DIAGNOSIS, OUTCOME IDENTIFICATION, PLANNING, IMPLEMENTATION, EVALUATION |
| NURSE DIAGNOSIS | ACTUAL AND POTENTIAL RESPONSE TO DISEASE |
| MEDICAL DIAGNOSIS | DISEASE-FOCUSED, PHYSIOLOGY |
| SUBJECTIVE DATA | WHAT IS SAID DURING HEALTH HISTORY; SYMPTOMS |
| OBJECTIVE DATA | WHAT IS OBSERVED DURING PHYSICAL EXAM, DIAGNOSTIC, AND LAB CARE; SIGN |
| TYPES OF DATA | COMPLETE, EPISODIC, FOLLOW-UP, EMERGENCY |
| COMPLETE DATA | HEALTH HISTORY, PHYSICAL EXAM DATA; EX: NURSING HOME |
| EPISODIC DATA | ONE PROBLEM, ONE BODY SYSTEM, FOCUSED; EX: CLINICS |
| FOLLOW-UP DATA | IDENTIFIED PROBLEMS EVALUATED; EX: PAP SMEAR |
| EMERGENCY DATA | RAPID COLLECTION, LIFESAVING MEASURES; EX: ER |
| INTERNAL FACTORS THAT FACILITATE COMMUNICATION | LIKING OTHERS, EMPATHY, ABILITY TO LISTEN |
| EXTERNAL FACTORS THAT FACILITATE COMMUNICATION | ENSURE PRIVACY, REFUSE INTERRUPTIONS, PHYSICAL EXAM, DRESS, NOTE-TAKING, TAPE/VIDEO RECORDING |
| COMPONENTS OF THE HEALTH HISTORY | BIOGRAPHICAL DATA, REASON FOR SEEKING CARE, PRESENT HEALTH/ILLNESS, PAST HEALTH, FAMILY HISTORY, REVIEW OF SYSTEMS, FUNCTIONAL ASSESSMENT |
| VARIABLES OF CHIEF COMPLAINT | (PQRSTU)PROVOCATIVE/PALLIATIVE, QUANTITY AND QUALITY, REGION, SETTING, ASSOCIATED FACTORS, TIMING, UNDERSTANDING PATIENT'S PERCEPTION |
| ALERT | FOLLOWS COMMANDS, RESPONDS TO STIMULI |
| LETHARGIC | DROWSY, DELAYED RESPONSE TO VERBAL STIMULI, MAY FALL ASLEEP |
| STUPOROUS | REQUIRES INTENSE STIMULI FOR RESPONSE |
| COMATOSE | DOES NOT RESPOND TO VERBAL OR PAINFUL STIMULI, CANNOT FOLLOW COMMANDS OR COMMUNICATE |
| MINI MENTAL STATUS EXAM (MMSE) | SIMPLIFIED SCORED FORM OF THE COGNITIVE FUNCTIONS OF THE MENTAL STATUS EXAM; FOCUSED; TRACKS IMPROVEMENT OR WORSENING |
| GLASGOW COMA SCALE | QUANTITATIVE TOOL THAT IS USEFUL IN TESTING CONSCIOUSNESS OF AGING PERSONS IN WHOM CONFUSION IS COMMON; NUMERICAL; EYE OPENING, BEST VERBAL RESPONSE, BEST MOTOR RESPONSE |
| FACTORS OF MENTAL STATUS ASSESSMENT | APPEARANCE, BEHAVIOR, COGNITIVE FUNCTIONS, THOUGHT PROCESS AND PERCEPTION |
| IMMEDIATE PRIORITY | (ABC) AIRWAY, BREATHING, CARDIAC/CIRCULATION |
| IMMEDIATE PRIORITY AFTER TREATMENT OF 1ST PRIORITY | (MAA-U-AR) MENTAL STATUS CHANGE, ACUTE PAIN, ACUTE URINARY ELIMINATION PROBLEMS, UNRELATED MEDICAL PROBLEMS, ABNORMAL LAB RESULTS, RISKS OF INFECTION, SAFETY AND SECURITY |
| LATER PRIORITIES | HEALTH PROBLEMS THAT DO NOT FIT INTO IMMEDIATE CONCERN CATEGORIES |
| VERBAL RESPONSES TO ASSIST THE NARRATIVE | FACILITATION, SILENCE, REFLECTION, EMPATHY, CLARIFICATION, CONFRONTATION, INTERPRETATION, EXPLANATION, SUMMARY |
| FACILITATION | GENERAL LEADS; EX: "GO ON" |
| REFLECTION | ECHOES PATIENT'S WORDS |
| CLARIFICATION | SUMMARIZE PATIENT'S WORDS TO MAKE THEM CLEARER AND ASK PATIENT IF YOU ARE CORRECT |
| INTERPRETATION | BASED ON INFERENCE AND CONCLUSION |
| SUMMARY | CONDENSING FACTS |
| EXPLANATION | HONEST, FACTUAL AND OBJECTIVE |
| NONVERBAL SKILLS | PHYSICAL APPEARANCE, POSTURE, GESTURES, FACIAL EXPRESSIONS, EYE CONTACT, VOICE, TOUCH |
| PURPOSE OF PHYSICAL ASSESSMENT | TO GATHER OBJECTIVE DATA |
| INSPECTION | SEE, SMELL, VERBAL AND NONVERBAL COMMUNICATION, LIGHTING, EXPOSURE |
| LIGHT PALPATION | DETECTS MOISTURE, SKIN TEXTURE, MASSES, FLUID, TENDERNESS |
| DEEP PALPATION | DETECTS REPRODUCTIVE AND ABDOMINAL ORGANS, MASSES |
| PERCUSSION | DETECTS PRESENCE OF AIR, FLUIDS, SOLIDS, AS WELL AS SHAPE AND POSITION |
| TYPES OF PERCUSSION | DIRECT, INDIRECT |
| AUSCULTATION | LISTENING |
| VITAL SIGNS | BASELINE, PULSE, RESPIRATION, TEMPERATURE, BLOOD PRESSURE |
| TECHNIQUES OF PHYSICAL EXAM | INSPECTION, PALPATION, PERCUSSION, AUSCULTATION, VITAL SIGNS, HEIGHT AND WEIGHT |
| GENERAL SURVEY COMPONENTS | PHYSICAL APPEARANCE, BODY STRUCTURE, MOBILITY, BEHAVIOR |
| PAIN | UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL TISSUE DAMAGE OR DESCRIBED IN TERMS OF SUCH DAMAGE |
| WE SEE PAIN AS _________ | PATIENT DESCRIBES IT |
| SOURCES OF PAIN | VISCERAL, SOMATIC, CUTANEOUS, REFERRED, PHANTOM, NEUROPATHIC |
| VISCERAL PAIN | INTERNAL ORGANS |
| SOMATIC | MUSCULOSKELETAL |
| CUTANEOUS | SUPERFICIAL |
| REFERRED | LOCATION OTHER THAN SITE OF INJURY |
| PHANTOM | LOST LIMB |
| NEUROPATHIC | ABNORMAL, INJURY TO NERVE, DIFFICULT TO TREAT AND ASSESS |
| ACUTE PAIN | EPISODIC, SELF-LIMITING, PREDICABLE TRAJECTORY, DISSIPATES AFTER INJURY HEALS |
| INITIAL PAIN ASSESSMENT | 8 QUESTIONS, BROAD |
| BRIEF PAIN INVENTORY | 24 HOUR EVALUATION, SCALES |
| SHORT-FORM McGILL PAIN QUESTIONNAIRE | RANK A LIST OF DESCRIPTORS IN TERMS OF THEIR INTENSITY AND TO GIVE AN OVERALL INTENSITY RATING TO CURRENT |
| DESCRIPTOR PAIN SCALE | WORDS FROM NO PAIN TO SEVERE PAIN; BEST FOR OLDER ADULTS |
| IMPACT OF POORLY CONTROLLED PAIN | TISSUE AND EMOTIONAL DAMAGE |
| NEUROPATHIC PATHWAY | TRANSDUCTION-TRANSMISSION-PERCEPTION-MODULATION |
| TRANSDUCTION | STIMULUS OCCURS |
| TRANSMISSION | SPINAL CORD TO BRAIN; AFFERENT |
| PERCEPTION | ARRIVAL IN INTACT BRAIN SYSTEM |
| MODULATION | EFFERENT PROCESS |
| ASSESSMENT | IDENTIFICATION OF PROBLEM, COLLECT DATA |
| DIAGNOSIS | INTERPRET DATA, VALIDATE INFERENCES, COMPARE CLUSTERS OF CUES WITH DEFINITIONS AND DEFINING CHARACTERISTICS |
| OUTCOME IDENTIFICATION | ESTABLISH PATIENT GOALS, INDIVIDUALIZE, TIME FRAME |
| PLANNING | ESTABLISH PRIORITIES, DEVELOP OUTCOMES, IDENTIFY INTERVENTIONS, DOCUMENT PLAN OF CARE |
| IMPLEMENTATION | REVIEW INTERVENTIONS, SCHEDULE, COLLABORATE, SUPERVISE CARE PLAN, COUNSEL, INVOLVE PERSON, REFER, DOCUMENT |
| EVALUATION | COMPARE ACTUAL OUTCOMES WITH EXPECTED OUTCOMES, SUMMARIZE, IDENTIFY REASONS FOR FAILURE, TAKE CORRECTIVE ACTION, DOCUMENT |
| EVIDENCE-BASED PRACTICE | USES OUTCOMES OF WELL-DESIGNED AND EXECUTED SCIENTIFIC STUDIES |
| CHIEF COMPLAINT | BRIEF DESCRIPTION OF THE PERCEIVED PROBLEM |
| PAST MEDICAL HISTORY | DATA OF CHILDHOOD AND ADULT ILLNESSES, IMMUNIZATIONS, SURGERIES, SERIOUS INJURIES, MEDICATIONS, ALLERGIES, TRANSFUSIONS |
| FAMILY HISTORY | AGE AND HEALTH OR CAUSE OF DEATH OF BLOOD RELATIVES; GENOGRAM |
| FLAT SOUND | VERY SOFT HIGH PITCHED; EX: MUSCLE, BONE |
| DULL SOUND | SOFT HIGH PITCHED; EX: DENSE ORGAN |
| RESONANT SOUND | MEDIUM/LOUD LOW PITCHED; EX: LUNG TISSUE |
| HYPERRESONANT SOUND | LOUD LOW PITCHED "BOOMING"; EX: EMPHYSEMA |
| TYMPANY SOUND | LOUD HIGH PITCHED; EX: STOMACH, INTESTINE |
| GONIOMETER | MEASURES JOINT RANGE OF MOTION |
| OTOSCOPE | EAR |
| ROSENBAUM CARD | VISION CHART, NUMBERS |
| SNELLEN CHART | VISION CHART, LETTERS |
| OPHTHALMOSCOPE | EYE |
Created by:
allyson256
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