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NUR101 > Nur 101 Exam 1 > Flashcards

Nur 101 Exam 1 Flashcards

1
Q

Principals of health

assessment

A

Assessment - continuous process.
-initiates the first step of the nursing process
- systematic, deliberate, interactive process
Overall process includes
Data collection validation of perception and observation
Diagnosis
Judgment

-focuses on specific functional abilities
The abilities to do (ADL) activities of daily living

  • data collected
    From several sources
    Using various methods
    Confidentional
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2
Q

Exam techniques

IPPA

A 
Performed in this order ( except with abs ass. IAPP)
Inspection
Palpation
Percussion
Auscultation
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3
Q

Exam techniques

Inspection

A

Use of the senses of vision, smell, hearing

To observe and detect normal and abnormal findings

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4
Q

Exam techniques

Palpation

A 
Using parts of the hand to touch and feel
- texture (rough smooth)
- temperature
- moisture
- mobility( fixed/ moveable, still, vibrating) 
Consistency ( soft hard fluid filled)
Strength of pulse
Size
Shape
Pain or tenderness
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5
Q

Exam techniques

Percussion

A

Tapping on body parts to produce sound waves/ vibration to assess underlying structures
Percussion for location, size, shape density masses reflexes

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6
Q

Exam techniques

Auscultation

A 
Use of stethoscope to listen for sounds
Heart 
Lung
Blood vessels
Abdomen
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7
Q

Assessment

A

1987 Marjory Gordon RN developed Gordon’s Functional Health patterns

A framework for organizing data by 11 areas of health status or function

Focus on a more holistic look at patients

Continuous process that requires skill

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8
Q

Lydia hall

A

1950s she developed the nursing process APIE

today nursing process is known as ADPIE

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9
Q

ADPIE

A

Assessment
Diagnosis
Planning
Implementation

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10
Q

NANDA

A

Developed in 1973 by North American Nursing Association

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11
Q

(ND ) nursing diagnosis is used to

A
  • a problem that can be independently managed by the RN WITHIN THE scope of the nursing practice
  • diagnose and treat human response to health problems
  • over 200 NDs in use
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12
Q

Clinical problem= medical diagnosis

A

The health problem , usually a medical diagnosis

  • can’t be independently managed by the RN.
  • RN has a major role in monitoring and working with the physician and other healthcare providers.
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13
Q

Confidentiality

HIPPA

A
  • Any information a relates will not be made public.
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14
Q

Informed concent

A

The pt has been informed about the procedure/ treatment etc including the risks involved in order to make decisions

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15
Q

Written informed concent

A

Protects pt, facility, caregivers

Signature is done in presence of witness who also signs the form

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16
Q

critical thinking

A 
The way a nurse processes the information using:
Knowledge 
Past experience 
Intuition
Cognitive abilities 
- to formulate conclusion or diagnosis
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17
Q

ESSENTIAL ELEMENTS OF

Critical thinking

A

Be open minded

Use rational to support opinions/ decisions

Reflect on thoughts before reaching a conclusion

Use past clinical experience to build knowledge

Acquire adequate knowledge base that continues to build

Be aware of : interactions of others/ environment

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18
Q

Nursing assessment

A

Is a systematic, deliberate and interactive process. It focuses on specific patient characteristics, functional ability to perform activities of daily living (ADL). The nursing assessment includes data collection and validation of pertinent observation.

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19
Q

Evolution of health assessment in nursing

A
  • 1900: public health nursing came about
  • 1950: Lydia hall introduced the nursing process (APIE)
  • 1960: nurse practitioner emerged
  • 1970: expansion of specialities: exam techniques began.
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20
Q

Confidentially

A 
Any info a pt relats will not be made public or available to others
HIPPA
H- health
I- insurance
P- probability
A-Accountability 
A- act
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21
Q

Critical thinking

A

The way a nurse processes information using:

  • be open minded
  • use rationale to support opinions and decisions
  • reflect on thought before reaching conclusion
  • use past clinical experiences to build knowledge
  • Aquire adequate knowledge base that continues to builds
  • be aware of others and the environment
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22
Q

Hand washing procedure

The quickest, easiest, and cheapest way to prevent disease.

A

Protects patients, healthcare worker and family
1. Rec. 30 sec. Hand washing
2 at least 15 sec between pt

23
Q

Assessment of vital signs

A

Include BP, TEMP, PULSE, RESP., AND PAIN ASSESSMENT
SHOULD BE COMPARED TO BASELINE
Prime indicator of body function
Essential in order to detect changes in pt condition
Report changes promptly

24
Q

Temperature

A

NORMAL RANGE 98.6F (96.4-99.1) 37.0c (35.8-37.3)

Body temp is controlled by hypothalamus

Brain cells are sensitive to body temp and if greater 106.0 F can die

O2 requirement increase 10% for every 1.0 C in temp.

25
Q

Measuring temperature

A

Oral- electronic thermometer in sublingual pocket

Axillary- common for infants and children. Less accurate

Tympanic- in ear with prob cover. Ear tug up for adults and down for children.

Rectal- taken less frequent. Considered safe and accurate for adults. Use lube and gloves.

26
Q

Influential factors to temp

A

Age, exercise, infection, time of day, smoking, illness, stress, hemorrhage, emotions, hot/cold liquids.

27
Q

Temperature Terminology

FEBRILE

A

Fever, increased/ elevated temperature above normal range

28
Q

Temperature Terminology

AFEBRILE

A

No temp, normal range

29
Q

Temperature Terminology

HYPERTHERMIA

A

Temperature grater than 102.2 F can lead to brain injury

30
Q

Temperature Terminology

HYPOTHERMIA

A

Temperature between 77.0 and 95.0F

31
Q

Temperature Terminology

Frostbite

A

Local hypothermia (one area)

32
Q

Temperature Terminology

Documentation of temp

A

Must indicate the rout if not taken orally

33
Q

Pulse

A

Pulse indicates heart function and is the number of beats per min.

Need arterial site to assess.

Arteries are high pressure vessels

34
Q

Normal pulse rates

A

Adult- 60-100 BPM

Child- 80-100BPM

Infant- 100 BPM

35
Q

Abnormal pulse rates

Tachycardia

A

-greater than 100 BPM( rapid/ fast)

36
Q

Abnormal pulse rates

Bradycardia

A

Less than 60 BPM( slow)

37
Q

Pulse is influenced by

Autonomic nervous system(ANS)

A

Parasympathetic nervous system decreases rate(Vagus nerve)

Sympathetic nervous system increases rate (epinephrine )

SA Nod rate is 60-100 BPM

AV node rate is 40-60 BPM

Ventricular rate 30-40 BPM

38
Q

Other factors influencing pulse

A

When BP INCREASES P may decrease due to cardiac workload

O2 / Co2 levels

Flu is and electrolyte values

Drugs

Exercise

Acid based status

Emotion

39
Q

Components of Health assessment

Health history

A

Subjective data- collected by pt

Symptoms

40
Q

Components of Health assessment

Physical examination

A

Objective data

Signs ex BP, lab reports, do testing (measurable )

41
Q

Gordon’s 11 Functional Health Patterns

A
  1. Health perception/ health management
  2. Nutritional - metabolic
  3. Elimination
  4. Activity- exercise
  5. Cognitive- perceptual
  6. Sleep rest
  7. Self-perception / self concept
  8. Roles and role relationship
  9. Sexually - reproductive
  10. Coping- stress tolerance
  11. Values- beliefs
42
Q

Gordon’s 11 Functional Health Patterns

Health perception health management

A

Assessment is focused on the person s perceived level of health and well- being, and on the practices for maintaining health

43
Q

Gordon’s 11 Functional Health Patterns

Nutritional - metabolic

A

Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. Actual or potential problems related to fluid metabolic need. Actual or potential problem R/T fluid balance, tissue integrity, and host defenses may be identified.
Includes:
Diate, appetite, N/V, dentition, skin condition , edema, wound drain, IV, etc…

44
Q

Gordon’s 11 Functional Health Patterns

Elimination

A

Assessment is focused on excretory patterns (bowl, bladder, skin)
Excretory problems include: incontinence, constipation, diarrhea , and urinary retention may be identified. Includes abdominal assessment, bowel sounds bowel and bladder patterns, I&O, etc…

45
Q

Gordon’s 11 Functional Health Patterns

Activity - exercise

A

Assessment is focused on activities of daily living requiring energy expenditure, including self care activities, exercise and leisure activities. The status of major body systems involved with activity and exercise is evaluated including the respiratory, cardiovascular, musculoskeletal systems. Includes: CV data( pulse, cap. Refill, chest pain etc) respiratory data ( resp. Patterns, lung sounds, chest tube, oxygen, ect), musculoskeletal data( activity level, mobility status etc)

46
Q

Gordon’s 11 Functional Health Patterns

Cognitive perceptual

A

Assessment is focused on the ability to comprehend and use the information and on sensory function. Sensory experience such as pain and altered sensory input may be identified and further evaluated. Includes: Loc, reflexes, pupil responce, grip, leg strength , numbness, tingling, pain and cognition, etc…

47
Q

Gordon’s 11 Functional Health Patterns

Sleep- rest

A

Assessment is focused on the persons sleep, rest and relaxation practices. Dysfunctional sleep patterns, fatigue and response to sleep deprivation may be identified. Includes: sleep patterns, numbers of hours, methods to promote sleep, factors that affect sleep, and aids etc..

48
Q

Gordon’s 11 Functional Health Patterns

Self perception/ self-concept

A

Assessment is focused on the persons attitude towards self. Including: identity, body image and self worth. The persons level of self esteem and Response to treat ones self -concept may be identified. Includes: self assessment, non verbals etc…

49
Q

Gordon’s 11 Functional Health Patterns

Roles and role relationships

A

Assessment is focused on the persons role in the world and the relationships with others. Satisfaction with roles, role strain or dysfunctional relationships may be further evaluated. Includes marital status, family members, role in family, employment, role changes due to illness, etc…

50
Q

Gordon’s 11 Functional Health Patterns

Sexuality- reproductive

A

Assessment is focused on the persons satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may be identified. Includes: female reproductive data( menstrual patterns, birth control, breast exams, etc) male data ( testicular exam, prostate problems etc)

51
Q

Gordon’s 11 Functional Health Patterns

Coping stress tolerance

A

Assessment is focused on the persons perception of stress and their coping strategies in terms of stress tolerance may be further evaluated. Includes: stressful situations, how hospitalization affects, stress management, relaxation techniques, support groups, counseling etc..

52
Q

Gordon’s 11 Functional Health Patterns

Values beliefs

A

Assessment is focused on the persons values and beliefs including speritul, or the goals That guide their choices or decisions. Includes: religious practices, and affiliation, cultural background, family tradition etc.

53
Q

Steps of assessment

A

Preparation

Data collection

Validation

Documentation

NUR101 (4 decks)

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