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Nur101 Exam01
| Question | Answer |
|---|---|
| OREM Self Care Model Three Variations | Wholly Compensatory (WC), Partly Compensatory(PC), Supportive-Educative (SE) |
| Mother of modern nursing | Florence Nightingale |
| Introduced the Nursing Process in 1950 | Lydia Hall |
| ADPIE | Assessment, Diagnose, Planning, Implementation, Evaluation |
| This began with the expansion of specialties in the 1970's. | Exam techniques |
| Purpose of Health Assessment | Identify state of wellness, Identify strengths and weaknesses, Identify problems/needs, Evaluate effects of therapeutic plan of care |
| Overall health assessment process includes | Data Collection, Evaluation, Decisions |
| Marjory Gordon, RN Developed this in 1987 | Gordon's Functional Health Patterns (GFHP) |
| Framework of GFHP | Organized data by 11 areas of health status or function |
| Gordon's 11 functional health patterns | Health perception/management, Nutrition-metabolism, Elimination, Activity-exercise, Sleep-rest, Cognitive-perceptual, Self-perception/self concept, Role-relationship, Sexuality-reproduction, Coping-stress tolerance, Value-belief |
| Functional classification of GFHP | Optimal level of function, Identify strengths, State of wellness or health |
| Dysfunctional classification of GFHP | Deficits, Health problems, Illness |
| Potentially dysfunctional classification of GFHP | Can develop, At risk for disability or illness |
| Exam Techniques IPPA | Inspection, Palpation, Percussion, Auscultation |
| Abdominal assessment | IAPP |
| Developed in 1973 and used to diagnose and treat human responses to actual or potential health problems | NANDA Nursing Diagnosis (ND) |
| Confidentiality | Any information a pt/client relates will not be made public or available to others. |
| Pt/client has been informed about the procedure/treatment/surgery etc including the risks | Informed Consent |
| The way a nurse processes information using knowledge, past experiences, intuition, and cognitive abilities. | Critical Thinking |
| Types of Assessment | Comprehensive, ongoing/partial, focused/problem, emergency |
| Components of health assessment | Health history, Physical Exam, Documentation of Data |
| Steps of assessment | Preparation, Data collection, Validation, Documentation |
| Data collection includes | subjective data, objective data, wholistic data |
| Preparation includes | Charts, tests |
| Validation includes | Relevant data, ID missing data, Make sure info is important and factual |
| Documentation | Provides data for health care team |
| The foundation for interviewing | Therapeutic communication |
| Three phases of health assessment interview | Introduction, Discussion, Summary |
| Gathering data before seeing patient is called | Pre-interaction phase |
| A clinical judgement about an individual/family/community response to actual/potential health problems providing a basis for selection of nursing interventions | Nursing Diagnosis |
| Managed with physician | Collaborative problem |
| Steps of data analysis | Noticing, interpreting, responding, reflecting |
| Types of nursing diagnosis | Actual, At Risk/High Risk |
| Three categories of intervention | Diagnostic, Therapeutic, Teaching |
| Importance of Health perception and health management | Verifies client understanding and identifies non-adherence to therapeutic regimen |
| Major concepts for assessing health behaviors | Self responsibility, Adherence behavior |
| Three levels of health promotion | Primary prevention, secondary prevention, tertiary prevention |
| Primary Prevention | Prevent disease, promote healthy lifestyle |
| Secondary Prevention | Screening to promote detection |
| Tertiary Prevention | Minimize the disability from acute/chronic disease/injury, maximize health |
| General survey includes | Appearance, Grooming, dress, hygiene, mobility, level of constance (LOC), facial expressions. |
| Normal Temperature | 98.6F (range 96.4-99.1) or 37.0C (range 35.8 - 37.3) |
| Body temp controlled by this | hypothalamus |
| BMR | Basal metabolic rate |
| Febrile | increased/elevated temperature |
| afebrile | no temperature |
| hyperthermia | temperatures greater than 102.2 |
| hypothermia | temperatures between 77.0 ad 95.0F |
| frostbite | local hypothermia |
| Normal pulse | adults 60-100 bpm, child 80-100 bpm, infant 100bpm |
| tachycardia | >100 bpm |
| bradycardia | <60bpm |
| parasympathetic nervous system's affect on pulse | decreases rate |
| sympathetic nervous system's affect on pulse | increases rate |
| pulse is influenced by this | autonomic nervous system (ANS) |
| normal respiration rate | 12-20 breaths per minute |
| tachypnea | >20 breaths per minute |
| bradypnea | < 12 breaths per minute |
| dyspnea | difficulty breathing or shortness of breath (SOB) |
| apnea | with no respirations |
| orthopnea | breathe in upright position |
| Systolic BP | the first sound heard |
| pulse pressure | the difference betseen systolic and diastolic |
| diastolic | the sound change heard/lower bp number |
| prehypertension | systolic 120-140 mmHg and diastolic 80-90 mmHg |
| hypertension | consistent bp >140/90 |
| somatic pain | from bones, joints, muscles, skin or connective tissue |
| visceral pain | from internal organs |
| neuropathic | abnormal processing of sensory input |
| phantom | from amputated body part |
| pain threshold | point at which pain is felt |
| pain tolerance | pain endurance |
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