Module 1: Introduction to adult health assessment Flashcards
(44 cards)
What is diagnostic reasoning?
The process of analyzing health data and drawing conclusions to identify diagnoses.
4 major components
1) attending to initially available cues
2) formulating diagnostic hypotheses
3) gathering data relative to the tentative hypothesis
4)Evaluating each hypothesis with the new data collected, that’s arriving at a final diagnosis
5 phases of nursing process
Assessment, nursing diagnosis, planning, implementation, evaluation
*What are first level priority problems?
Emergencies, life-threatening, and immediate.
Ex. Establishing an airway or supporting breathing
For first-level priority problems, remember “ABCs + V”, which is
Airway problems Breathing problems Cardiac/circulation problems Vital sign concerns (I.e. High fever) (Exception: CPR for cardiac arrest, begin chest compressions immediately)
*What are second level priority problems?
Urgent, necessitating prompt intervention to forestall further deterioration.
(mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of infection, risk to safety or security)
*What are third level priority problems?
Important to the patient’s health but can be addressed after more urgent problems
*What are collaborative problems?
Approach to treatment involves multiple disciplines, and nurses often have a primary responsibility to diagnose the onset and monitor the change in status.
What is the difference between a medical diagnosis and a nursing diagnosis?
Med diagnosis- deals with disease or medical condition
Nursing diagnosis- deals with human response to actual or potential health problems and life processes (ex. Risk for falls, impaired verbal communication)
Evidence informed practice is a systemic approach to practice and uses
The best evidence, the clinicians experience, and the patient’s preferences and values to make decisions about care and treatment
What are social determinants of health?
The social, economic, and political conditions that shape the health of individuals, families, and communities
What is The difference between health inequity and health inequality?
Health inequality – refers to differences, variations, and disparities in health status of individuals and groups
Health inequity – refers to inequalities in health that are unnecessary and avoidable and differences that are considered unfair and unjust
According to the biomedical model, and narrow definition of health is
The absence of disease
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
Complete
What is a complete database?
Used to perform a thorough or comprehensive health history and physical examination
It is a focused database?
For a limited or short term problem usually consisting of one problem, one cue complex, or one body system
What type of perspective has been promoted to counter the tendency toward culturalism in healthcare?
Critical cultural
Physical examination requires a sequential use of 4 assessment techniques. What are they?
Inspection, palpation, percussion, and auscultation
*What is inspection as a physical examination?
Close, careful observation of the patient as a whole and then of each body system.
Inspection is always perform first.
(use the patient’s body is the control and compare the right and left side of body to determine symmetry)
*What is palpation as a physical examination?
Follows and often confirms points you noted during inspection.
-apply your sense of touch to assess texture, temperature, moisture, and organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain
The fingertips are best for assessing…
For fine tactile discrimination such as skin texture, swelling, pulsation, and determining presence of lumps
Grasping with the fingers and thumb is ideal for detecting…
Position, shape, and consistency of an organ or mass
The backs of the hands and fingers are good for determining…
Temperature
The base of the fingers or the ulnar surface of the hand is best for assessing
Vibration
*Differentiate between light and deep palpation
Light palpation evaluate surface characteristics and identifies areas of tenderness.
Do you palpation assesses an organ or mask deeper in a body cavity