nurse assessment Flashcards Preview

nurse assessing > nurse assessment > Flashcards

Flashcards in nurse assessment Deck (21)
Loading flashcards...
1

look at patient obtain data organize document data

assessing

2

analyze data, identify health problem give name for problem

diagnosing

3

prioritize problems/ diagnoses select nursing interventions independent things you can do for yourself, goal setting for patient

planning

4

put hands on patient what needs to be done supervise delegated care

implementing

5

collect data outcome, compare data outcomes, see if implementation was successful

evaluating

6

what is nurse assessment

physical most important head to toe, listen feeling, smelling.
mental, spiritual, economic, cultural status

7

what are skills for nurse assessment

IPPA- inspection, palpation, percussion, auscultation

8

seated position

sitting

9

flat on back-lying position with legs extended

supine

10

60 degree angle sitting with head up

fowlers

11

30-40 degree angle sitting with head up

semi-fowlers

12

laying on back with knees flex

dorsal recumbent

13

legs open getting pap smear, legs in stirrup

lithotomy

14

laying on side with top knee toward chest

sims

15

lies on abdomen with head to the side

prone

16

linear crack with sharp edges extending into dermis ex: cracks at corners of mouth hand athlete's foot

fissure

17

translucent, dry, paper like wrinkled skin, thinning or wasting of skin due to loss of collagen ex: striae, aged skin

atrophy

18

rough thick hard epidermis ex: chronic dermatitis

lichenification

19

deep irregular shape area of skin may bleed ex: pressure ulcers, stasis, ulcers chancres

ulcer

20

elevated irregular darkened area of excess scar tissue ex: keloid from ear piercing or surgery

keloid

21

Linear erosion ex: scratches some chemical burns

excoriation