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Flashcards in 168.123 General questions Deck (137)
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1

What is a nursing assessment?

"a process of systematically collecting and analysing data to make judgements about the health and life processes of individuals, families and communities"

2

What are the 4 types of health assessment?

Comprehensive
Focused/problem orientated
Follow up/on going/episodic or partial
Emergency

3

What is the focus of nursing?

Human response to actual and potential health problems

4

What are the nurses responsibilities when abnormalities are detected?

Assess (collect data)
Diagnose (interpret, validate, compare clusters, identify related factors and document)
Outcome identification (realistic, individualised and timeframed)
Implement (review, collaborate, counselling, document)
Evaluate (summarise, identify success/failure, correct where can)

5

What are 5 perceived barriers to health assessment skills?

Lack of:
Resources
Equipment
Time
Patient acceptance
AND
Poor equipment

6

What are the key skills when attaining a health history - hint have to do with communication.

Facilitation - active listening
Silence - patience
Reflection
Empathy - be accepting
Clarification - don't assume-clarify and confirm

7

What are some traps nurses fall into with patients when discussing health histories?

False assurance
Unwanted advice
Using authority
Using professional jargon
Interrupting

8

What four things are the focus of the Complete Health History?

Biographical data (name, DOB, gender etc)
Source of history ( reliable source)
Reason for seeking care (annual exam, acute)
Present and past health history (overall health)

9

What does the acronym COLDSPA mean?

Character
Onset
Location
Duration
Severity
Pattern
Associated factors/how it affects the client

10

What systems are reviewed in a complete health history?

General appearance
Skin
HEENT (Head, Eyes, Ears, Nose, Throat)
Respiratory
Cardiovascular
Gastro Intestinal
Genital urinary
Sexual
Neurological
Musculoskeletal
Gynaecological
Endocrine
Haematological
Lymphatic
Mental

11

What are the five Vital signs?

Temperature
Blood Pressure
Heart Rate
Respiratory rate
Pain

12

Why do we monitor vital signs?

To see if there is any change in a physical condition

13

When would we monitor vital signs?

Pre and/or Post and or During;
Operations
Transfusions
Medications
Patient reports of nonspecific complaints
Frequency

14

What is the normal body temperature range?

35.8-37.5 degrees Celsius

15

What can you expect from a rectal temperature

Can be 0.4 to 0.5 degrees higher

16

At what temperature do we call a patient with mild hypothermia?

< 35 degrees Celsius

17

What temperature is moderate hypothermia?

28 - 32.2 degrees Celsius

18

What temperature is a patient with severe hypothermia?

< 28 degrees celsius

19

What is an elevated temperature range?

37.5 - 38 degrees Celsius

20

AT what temperature does a patient have hyperpyrexia?

> 40 degrees Celsius

21

Where do you place an oral thermometer and for how long?

In the sublingual pocket for 2 minutes

22

How long is a rectal thermometer kept in place?

3 minutes

23

Where does a tympanic thermometer get placed?

In the ear

24

How long do you measure a pulse if it is a regular heart beat?

30 seconds and x 2

25

How long do you take a pulse if the heart beat is irregular?

1 full minutes

26

What are you assessing when you take a pulse - 4 things?

Rate
Rhythm
Force
Elasticity

27

What is the normal range for heart rates?

60 - 100 beats per minute

28

What is bradycardia heart rate?

< 60 beats per minutes

29

What is the tachycardia heart rate?

> 100 beats per minute

30

What are you assessing with the rhythm of pulse rates?

Regular or irregular