Exam 2 Review
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| Four Types of Nursing Assessments | Initial,
Problem-Focused,
Emergency,
Time-Lapsed Reassessment
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| Assessment Activity: Step 1 | Collecting Data: gathering information about the client's health status
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| Assessment Activity: Step 2 | Organizing Data: writing data into an organized format
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| Assessment Activity: Step 3 | Validating Data: verifying that data is complete and accurate
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| Assessment Activity: Step 4 | Documenting Data: recording data in a factual manner
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| When collecting data you should... | Form a database including:
physical assessment
primary health care providers history and physical
results of labs and diagnostics
healthcare teams documentation
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| Components of a nursing health history | biographic data, chief complaint/reason for visit, history of present illness, past history, family history of illness, lifestyle, social data, psychological data, patterns of health care
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| Subjective Data | Symptoms
Described, verified by the person affected which includes sensations, feelings, values, beliefs, attitudes and perceptions
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| Objective Data | Signs
Can be observed, measured, and tested
Obtained by observation or physical examination
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| Sources of Data | Client
Support People
Client Records
Health Care Professionals
Literature
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| 3 Data Collecting Methods | Observing
Interviewing
Examining
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| What do you do when you observe patient | Gather data using your five senses
Skill developed over time,
Observe mainly through sight,
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| Interviewing | Planned communication or conversation with a purpose
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| Directive Interview | Structure and obtains specific information
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| Non-directive Interview/ Rapport | Builds a relationship understanding between the patient and nurse
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| Restrictive "yes" or "no" answers | Closed Question
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| Short Factual Answers | Closed Question
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| Allow clients to explore and talk about feelings | Open-ended questions
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| Client may answer without influence of the nurse | Neutral Questions
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| Closed ended that directs the client's answer | Leading Questions
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| What to consider when setting up an interview with client | time, place, seating arrangement, distance, language
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| What do you do in the opening of your interview? | Establish rapport with the patient and orientation
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| What do you do in the body of your interview? | Client responds to the nurse's questions
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| What is examinining | A systematic process of gathering data through using observation to detect health problems
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| Four ways of examining | Inspection,
Auscultation,
Palpation,
Percussion,
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| Maslow's Hierarchy of Needs (pyramid) | physiological, safety, love/belonging, esteem, self-actualization
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| To validate information you should... | "Double check" data to confirm accurate
Ensure that assessment info is complete
obj. and subk. data agree
differ between cues and inferences
avoid jumping to conclusions
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| To document data you should.... | Record in a factual manner
include all data collected about client's health status
Subjective data recorded in client's own words
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| Four things assessment involves | Collecting, Organizing, Validating, and Recording Data
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| What is the Nursing Process? | A systematic, rational method of planning and providing nursing care. Orderly, logical approach to providing nursing care and ensuring that the patients needs are met.
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| Five Steps of Nursing Process | Assessment, Diagnosis, Planning, Implementing, Evaluating
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| Two Components of Health Status | Healthy History and Physical Examination
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| Purpose of Physical Examination | Obtain baseline data
To validate data obtained in the nursing history
To aid in establishing nursing diagnoses and the plan of care for patients
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| Purpose of Physical Examinations | Evaluate the physiological outcomes of healthcare and the patients progression
Make clinical judgments
Identify areas for health promotion and disease prevention
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| What should you do when preparing the client? | Explain what you are going to do
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| What should you do when preparing the environment? | Prepare your equipment
good lighting, warm room temp
provide privacy
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| Health Exam Equipment | Stethoscope
Pen light
Blood pressure cuff
Thermometer
Otoscope
Nasal speculum
Lubricant
Tongue blades
Reflex hammer
Tuning fork
Cotton applicators
Gloves
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| Dorsal Recumbrant | Back-lying position with knees flexed and hips externally rotated; small pillow under head; side of feet on the surface
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| Supine | Back lying position with legs extended; with or without pillow under the head. Laying on their back.
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| Lithotomy | Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table
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| Sims | Side-lying position with lowermost arm behind the body, uppermost leg is flexed at hip and knee, upper arm flexed at shoulder and elbow.
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| prone | lies on stomach. Lies on abdomen with head turned to the side with or without pillow supporting head.
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| Visual Inspection | Moisture, color, texture of body surfaces
Shape, position, size, symmetry
Can also use olfactory and auditory senses
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| During Palpation you should determine... | Texture,
Temperature,
Vibration,
Position, size, and mobility of organs,
Distention,
Pulsation,
Tenderness or pain
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| What does percussion determine? | Determines shape and size of internal organs by establishing their borders.
Indicates whether tissue is filled with air, fluid or is solid
Five types of sound:
Flatness, dullness, resonance, hyperresonance, tympany
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| Two types of percussion | Direct-strike area with pads of fingers
Indirect- strike an object (finger) held against the body
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| Two types of auscultation | Direct- use of unaided ear
Indirect- use of stethescope
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| Auscultated sounds are described according to.. | Pitch: frequency of vibrations
Intensity: loudness or softness
Duration: length of sound
Quality: description of sound
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| Involves observation of client's general appearance. Assessed while taking client's health history. | General Survey
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