Assessment Techniques & Safety in the Clinical Setting: Ch. 8 Flashcards

1
Q

What is the Nursing Process?

A

AAPIE
-Assessment: collection of subjective (1st) and objective data (2nd)

  • Analyze: interpret and analyze data by comparing clinical findings with normal and identifying clusters that are associated (form a hypothesis)
  • Planning: identify expected outcomes (goals); prioritize (level 1 - 3)
  • Implementation: Implement evidence based interventions (EBI), collaborate with providers, health teaching, coordinate delivery of care, documentation
  • Evaluate: Compare actual outcomes with goals; identify reasons for failure to achieve goals and take corrective action to modify plan of care.
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2
Q

What are the critical thinking priorities during the planning phase of the nursing process?

A

1st Level: ABC + Vitals
Airway, Breathing, Cardiovascular + abnormal vitals and labs

2nd Level: Everything else physical
Pain, elimination

3rd Level: Psychosocial, coping, education

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3
Q

What is the magic nursing question?

A

“can you tell me more about how you are feeling?”

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4
Q

What 7 items are included in the Complete Health History?

what type of data is obtained?

A

Subjective Data!
-Biographical: name, contact info. DOB, birthplace, gender, marital status, race, occupation, primary language

  • Chief complaint
  • History of present illness (HPI): PQRSTU
  • Past Medical History (PMH): illness, hospitalization, immunizations, operations, last exam, allergies, medications
  • Family History of disease
  • Review of Symptoms: HTTA, abnormal symptoms for each body system, health promotion activities
  • Functional Assessment (preception of health): education level, activity and exercise, ability to preform ADLs, sleep & rest, nutrition and elimination, personal habits (smoking, drinking, drugs), intimate partner violence, occupation health
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5
Q

What is the nursing assessment?

A

IPPA = “I’ll Properly Preform Assessment”

  • Inspection: visual exam of the body
  • Palpitation: using hands to feel
  • Percussion: using hands to determine density & organ location
  • Auscultation: listening to sounds in the body using a stethoscope
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6
Q

Stethoscope: diaphragm vs bell

A

-Diaphragm: high-pitched sound, normal heart sounds, bowel, breath
Used most of the time

-Bell: soft, high-pitched sound, extra heart sounds, murmurs, bruits (abnormal murmur heard through a stethoscope).
Press lightly when using

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7
Q

Moro Effect

what it is, and when to do it during the exam

A

The “startle” reflex measured in infants. Do at the end of the exam as it may cause the baby to cry.

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8
Q

Emphysema

what will it sound like during percussion

A

A lung condition that causes shortness of breath. The air sacs in the lungs (alveoli) are damaged resulting in an accumulation of air in the alveoler spaces

-During percussion will sound hyperresonate

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9
Q

Things to be mindful of when assessing an adolescent

A
  • Work around clothing as much as possible
  • Give constant feedback while assessing
  • Provide privacy by ensuring the parent is not in the room
  • Use the HTTA
  • Do not treat them like a child, but do not overestimate and treat them like an adult either
  • Positive attitudes developed now may last through adult life. Focus your health teaching on ways the adolescent can promote wellness
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