Chapters 1-3 Flashcards Preview

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Flashcards in Chapters 1-3 Deck (28)
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1
Q

Name the 5 phases of the nursing process.

A

Assessment, Diagnosis, Planning, Intervention/ Implementation, Evaluation (ADPIE)

2
Q

Assessment

A

The collection of subjective and objective data

3
Q

Diagnosis

A

The analysis of subjective and objective data to make a professional nursing judgment

4
Q

Planning

A

Determination of outcomes/ goals and intervention plan

5
Q

Implementation

A

Carrying out the plan

6
Q

Evaluation

A

Assess whether outcomes/ goals have been met; revising plan as necessary

7
Q

Name 4 basic types of nursing assessment

A

1) Initial comprehensive, 2) Ongoing or Partial, 3) Focus/ Problem-Oriented, 4) Emergency

8
Q

Initial Comprehensive

A

Collection of subjective data about the client’s perception of health of all body systems, PMH, family history, lifestyle and health practices.

9
Q

Ongoing, Partial

A

Data collection that occurs after comprehensive database is established, or transfer to another unit

10
Q

Focused/ Problem Oriented

A

Full assessment of a particular problem, not inclusive of other systems

11
Q

Emergency

A

Rapid assessment in a life threatening event/ situation

12
Q

2 assessment types essential for complete patient care

A

Holistic nursing assessment and physical medical assessment

13
Q

Holistic nursing assessment

A

Includes holistic subjective and objective data to determine overall level of functioning

14
Q

Physical medical assessment

A

Focuses primarily on physiologic development status

15
Q

6 components of subjective data assessment

A

1) Biographical
2) HPI (and CC)
3) PMH
4) family history
5) health & lifestyle practices
6) review of systems (ROS)

16
Q

5 components of objective data assessment

A

1) Measurements (height, weight, BMI)
2) Vital signs (Temperature, HR, BP, RR)
3) General survey (appearance, behavior)
4) Physical findings, characteristics (inspection, palpation, percussion, auscultation; head-to-toe)
5) Results from lab, radiology, procedure testing

17
Q

3 phases of subjective interviewing

A

1) Introduction
2) Working
3) Summary/ Closing

18
Q

The 6 components of subjective data assessment occur during which phase of subjective interviewing?

A

2, working

19
Q

List 4 objective physical exam techniques

A

1) Inspection
2) Palpation
3) Percussion
4) Auscultation

20
Q

What is the general order of body system review?

A

General survey; skin, hair, nails; head, neck; eyes; ears; mouth, throat, nose, sinuses; thorax, lungs; breasts, lymph; heart, neck vessels; peripheral vascular; abdomen; genitalia; anus, rectum, prostate; musculoskeletal; neurologic

21
Q

Which part of the hand should you use when you’re palpating for pulse, texture, size, consistency, shape?

A

Fingerpads

22
Q

Which part of the hand should you use when you’re palpating for vibrations, thrills, fremitus?

A

Ulnar or palmar surface

23
Q

Which part of the hand should you use when you’re palpating for temperature?

A

Dorsal (back) surface

24
Q

Define percussion

A

Directly tapping an area or body part with one or two fingers to elicit possible sounds, size/ shape, vibrations or tenderness

25
Q

Define palpation

A

Using parts of the hand to touch/ feel for various characteristics, including texture, temperature, moisture, mobility, consistency, pulse strength, size, shape, tenderness

26
Q

Define auscultation

A

Listening for heart sounds, movement of blood through the cardiovascular system movement of the bowel, and movement of air through respiratory tract

27
Q

Define diaphragm

A

High-pitched sounds (breath sounds)

28
Q

Define bell

A

Light pressure for low-pitched sounds (bruits)