NUR 100 Assessment
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| nursing process is defined as | systematic, rational method of planning/providing nursing care, assuring pt needs are met
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| assessment | collect, organize, validate, document pt data
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| diagnosing | analyze and synthesize data
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| planning | determine how to prevent, reduce, resolve pt problems
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| implementing | perform planned nursing interventions, reassess pt and document effectiveness of interventions
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| evaluation | measure the achievement of goals earlier created
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| 4 types of assessment | initial, problem focused, emergency, time lapsed
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| collecting data | gathering info about pt health status
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| organizing data | putting data into organized format
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| validating data | verifying data is complete and accurate
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| documenting data | recording data in factual manner
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| health history includes | biographic data, chief complaint of visit, history of present illness, past/family history, lifestyle, social data, psych data, patterns of healthcare
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| subjective data | symptoms, described, observed-anything measurable
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| objective | anything patient or healthcare personnel or family member says about patient and/or illness
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| interviewing | planned communication, conversation with a purpose
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| directive interview | structure that obtains specific info
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| nondirective interview | builds understand & relationship between nurse and pt
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| closed-ended ?'s | restrictive, "yes" or "no" answers
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| open-ended ?'s | allow pt to explore & express feelings
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| neutral ?'s | pt answers without influence or direction from nurse
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| leading ?'s | direct pt's answers to assessment ?'s
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| Maslow's hierarchy of needs | self-actualization, esteem, love/belonging, safety, physiological
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| 2 components of health status | health history & physical examination
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| purpose of physical exam | obtain baseline data, validate data obtained in nursing history, aid in establishing nursing diagnoses and plan of care for pts
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| health exam materials | stethoscope, pen light, sphygmomanometer, thermometer, otoscope, nasal speculum, lubricant, tongue blades, reflex hammer, gloves, cotton applicators
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| position of pt lying on back, bent knees, hips externally rotated, small pillow under head and soles of feet on surface | dorsal recumbent
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| position of pt lying on back, legs extended with or without pillow under head | supine
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| position of pt lying on back, feet supported in stirrups, hips in line with edge of table | lithotomy
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| position of pt side lying with lower arm behind body, upper leg flexed at hip and knee, upper arm flexed at shoulder and elbow | sims'
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| position of pt lying on abdomen with head turned to side with/without pillow | prone
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| observations of visual inspection | moisture, color, texture of skin/surfaces, shape, position, size, symmetry
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| observations during palpation | texture, temperature, vibration, position, size, mobility of organs, distention, pulsation, tenderness/pain
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| observations during percussion | shape & size by establishing borders of organs, indication of fluid buildup, air buildup, or if it's solid
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| 5 sounds to listen for during percussions | flatness, dullness, resonance, hyperresonance, tympany
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| 2 types of percussion | direct: striking area with finger pads
indirect: strike object held against body
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| 2 types of auscultation | direct: use of unaided ear
indirect: use of stethoscope
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| ausculation sounds referred to using | pitch: frequency of vibrations, intensity: loudness or softness, duration: length of sound, quality: description of sound
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| general survey | involves observing pt's general appearance, socioeconomic status, current situation
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| what to look for in general survey | appearance and mental status, culture, education level, socioeconomic status, current situation
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| vital signs are for | establishing baseline data, detect health problems
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| vital signs | temperature, pain, pulse, respiration, blood pressure, o2 saturation
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| gerontology | study of aging or older adults
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| geriatrics | medical care of older adults
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| role of geriatric nurse | provider of care, teacher, manager, advocate, research consumer
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| care settings for older adults | acute care, long term care, hospice, rehabilitation, community
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| neuromuscular effects of aging | loss of height, bone mass, weight, joint stiffness, impaired balance
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| interventions for neuromuscular aging | active/passive ROM, P.E. programs, adequate vit D and Ca+ intake, fall prevention
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| changes in vision | decreased visual acuity, decreased adaptation to darkness, decreased near and far vision, difficulty distinguishing colors
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