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NURS 1019 Week 1
Stack #67391
| Question | Answer |
|---|---|
| What is assessment? | Collection of data aout an individual's health state |
| What is the purpose of assessment? | collect relevant info; make judgements; plan activities to address health concerns; evaluate actions taken; |
| Types of assessment | * complete - complete health history and physical exam * episodic - for limited short term prob * follow-up - Ex: gave a tylenol. Did it work? * emergency - rapid data collection, interpretation, and intervention |
| The steps of the nursing process | ADPIE * assessing * diagnosing * planning * implementing * evaluating |
| Assessing | * collect data - objective and subjective assessment * validate data * document/communicate data |
| Diagnosing | * Analyze data - cluster, hypothesize, identify gaps * Identify health problems/risks (pot. probs) * Formulate nursing dx (problem statement) |
| Planning | * prioritize pt probs * formulate goals/desired outcomes * select nursing interventions * consult w/other healthcare professionals * write nursing care plan inc nursing interventions * communicate care plan |
| Implementing | * Reassess client * Determine need for assistance * Implement interventions * Delegate/supervise * Document nsg actions, give verbal reports as necessary |
| Evaluating | Did what we do work? * Reassess pt * Relate nrsg actions to client goals/outcomes * Draw conclusions abt prob status * Continue, modify, or terminate pt's care plan |
| Assessment Ex - COLD | * gather data (subjective & objective) * Formulate hypotheses, gather supporting info & pt data, organize/cluster data * Make a nursing diagnosis * Formulate nrsg care plan * Carry out care accordingly * Evaluate and reassess |
| What is partnership? | Complex interpersonal relationship btwn people who work together to achieve a mutually defined goal |
| ABC's | Airway; Breathing; Circulation; Consciousness; Safety; always do ABC's first! esp for Initial and Emerg Assessments |
| Medical Dx | finding the etiology of disease Ex: Cold |
| Nursing Dx | evaluate the response of the whole person to actual or potential health probs |
| Pain Assessment | LOTARP |
| LOTARP -- L | Location Where does it hurt? |
| LOTARP -- O | Onset How long have you had this problem? |
| LOTARP -- T | Timing; Is the pain/problem constant? Rate the pain on a scale between 1 and 10. Type; What does the pain feel like? |
| LOTARP -- A | Associated symptoms like nausea, vomiting, fever, dizziness, etc Aggravating/Alleviating Factors What makes it better or worse? |
| LOTARP -- R | Radiation Does the pain move anywhere else? |
| LOTARP -- P | Precipitating Event What was happening when the pain started? |
| Symptom | subjective sensation |
| Sign | objective abnormality |
| Mental Status Exam | ABCT |
| ABCT -- A | Appearance |
| ABCT -- B | Behavior |
| ABCT -- C | Cognition |
| ABCT -- T | Thought process |
| Aphasia | Language comprehension and production secondary to brain damage |
| Dysarthia | Distorted speech sounds; basic language (word choice, grammar, comprehension) intact |
| Global aphasia | No language comprehension or language production |
| Expressive aphasia | No language production but language comprehension present |
| Receptive aphasia | No language comprehension but language expression present. |
| Diaphoresis | profuse sweating |
| Skin Color Changes | pallor (white); erythema (red); cyanosis (blue); jaundice (yellow) |
| Function of the skin | protection; perception; first line of immune defense; temperature regulation |
| Components of Skin | epidermis; dermis; subcutaneous layer; hair; sebaceous glands; sweat glands |
| Skin Assessment | CWMS; edema; integrity; lesions; turgor; nails; hair |
| Communication techniques | FUSE CIRL; Facilitation, Use of Silence, Summarizing, Empathy, Clarification/Confrontation, Interpretation, Reflecting, Leading |
| Nonverbal Communication | PPG FEET V; Physical appearance; posture; gestures; facial expressions; eye contact; touch; voice |
| Communication traps | providing false reassurance; giving unwanted advice; using authority; using avoidance language; distancing; professional jargon; leading or biased questions; interrupting; "why" questions |
Created by:
clarashin
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