NURSING PROCESS ASSESSMENT Flashcards by Athea Ordis

A systematic, client-centered method for structuring the delivery of nursing care.

Nursing Process

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What is the difference of Shamans to People who practiced medicine?

Shamans don’t do documentations

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Goal oriented method of caring.
Provides structure for nursing practice.
Entails gathering and analyzing data and in order to identify client strengths and potential or actual problem.

Nursing Process

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NANDA stands for?

North American Nursing Diagnosis Association

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ACTUAL OR POTENTIAL PROBLEM

This refers to a health condition that is currently present and observed in the patient.
It is supported by defining characteristics (signs and symptoms).
Nursing interventions aim to manage, treat, or resolve the issue.

Example: Acute Pain related to surgical incision as evidenced by verbal complaints of pain, facial grimacing, and guarding behavior.

Actual Problem

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ACTUAL OR POTENTIAL PROBLEM

This refers to a condition that has not yet occurred but the patient is at risk of developing.
It is identified based on risk factors rather than existing symptoms.
Nursing interventions focus on prevention to reduce the likelihood of the problem occurring.

Example: Risk for Infection related to invasive procedure and compromised immune response. (No current signs of infection, but the patient is at risk due to a wound or surgery.)

Potential Problem

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The Nursing Process is a structured, scientific method used by nurses to provide patient care.

Give 4 Characteristics of the Nursing Process.

Systematic

The nursing process follows a logical and organized sequence to assess, diagnose, plan, implement, and evaluate care.
Each step builds on the previous one, ensuring consistency and accuracy in patient care.

Cyclic and Dynamic

It is continuous and ever-changing based on the patient’s condition and response to interventions.
If a nursing intervention is not effective, the process loops back to reassessment and modifications are made accordingly.

Client-Centered

The nursing process is tailored to the individual patient rather than following a one-size-fits-all approach.
It considers the patient’s needs, preferences, values, and participation in their own care.

Interpersonal and Collaborative

Nursing care requires effective communication with the patient, family, and healthcare team.
Collaboration with doctors, physical therapists, dietitians, and other professionals ensures holistic and coordinated care.

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FAMILIARIZE ONLY!

“Purposes of the Nursing Process”

To identify client’s health status.
To identify actual or potential health care problems or needs.

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What are the 5 Phases of the Nursing Process?

Assessment
Diagnosis
Planning
Implementation / Intervention
Evaluation

REMEMBER THE ACRONYM ADPIE

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WHAT IS THIS?

Systematic & continuous collection, organization, validation, & documentation of data.
A continuous process.
Focuses on client’s responses to a health problem.

Assessment

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What are the 2 components of Assessment?

Subjective and Objective Data

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A type of data that is elicited or directly quoted by the patient.

Subjective Data

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A type of data that is measured and observed.

Objective Data

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What are the 4 Types of Assessment?

Initial or Comprehensive Assessment
Problem-focused assessment
Emergency Assessment
Time-lapsed reassessment

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WHAT TYPE OF ASSESSMENT IS THIS?

Purpose:

To establish a complete database for problem identification, reference, & future comparison.

Time Performed:

Within a specified time after admission to a health care agency.

Example:

Nursing admission assessment

Initial Assessment or Comprehensive Assessment

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WHAT TYPE OF ASSESSMENT IS THIS?

Purpose:

To determine the status of a specific problem identified in an earlier assessment.

Time Performed:

Ongoing process integrated with nursing care.

Example:

Hourly assessment of a client’s I&O in an ICU.

Problem-focused assessment

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WHAT TYPE OF ASSESSMENT IS THIS?

Purpose:

To identify life-threatening problems
To identify new or overlooked problems

Time Performed:

During any physiologic or psychologic crisis

Example:

Rapid ABC assessment during a cardiac arrest

Emergency Assessment

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WHAT TYPE OF ASSESSMENT IS THIS?

Purpose:

To compare the client’s current status to baseline data previously obtained.

Time Performed:

Several months after initial assessment.

Example:

Reassessment of a client’s functional health patterns in a home care.

Time-lapsed reassessment

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What are the 4 Related Activities done during assessment?

Collecting data
Organizing data
Validating data
Documenting data

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WHAT IS THIS?

This is getting a client’s DATA BASE.

Collecting Data

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In Collecting Data, what are the DATABASE sources?

Give 4.

Health History
Physical assessment
Laboratory and diagnostic tests
Materials contributed by other health personnel

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WHAT IS THIS?

The FF are the PURPOSE of this:

Identify…

Patterns of health and illness
Risk factors for health problems
Deviations from normal
Available resources for adaptation

Health History

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FAMILIARIZE ONLY!

“Guidelines in Health History Taking”

Sources of Information:

Client, family or significant others, health team members & client’s health record.

Most of the data are SUBJECTIVE.
Focus on data/information from all the client’s dimensions.
Record data using clear, concise and appropriate terminology.

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FAMILIARIZE ONLY!

“Basic Components of Health History”

Source and Reliability of Information
Reasons for seeking care or Chief Complaint
Present Health or History of Present Illness
Past Medical History/Past Health
Family History
Socio-economic Data or Social History
Psychosocial Assessment
Functional Assessment

Health Perception - Health Management Pattern
Nutritional - Metabolic Pattern
Elimination Pattern
Activity - Exercise Pattern
Sleep - rest Pattern
Cognitive - Perceptual Pattern
Self - Perception - Self - Concept Pattern
Role Relationship Pattern
Sexuality - Reproductive Pattern
Coping - Stress Tolerance Pattern
Value - Belief Pattern

Review of Systems

General Survey
Skin/Integument
Head
Eyes
Hearing
Nose and Sinuses
Mouth and Throat
Neck
Breast
Thorax and Lungs (Respiratory)
Heart (Cardiac)
Gastrointestinal
Urinary
Genitalia (Male or Female)
Peripheral Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric

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Under BASIC COMPONENTS OF HEALTH HISTORY **Should be in narrative form (*describe specifically according to the patient's manifestation or capability*)**. **Sample Statements**: * The patient was competent to provide information. She was able to speak clearly; conscious and coherent; oriented to time, place and person.

Source and Reliability of Information

Under BASIC COMPONENTS OF HEALTH HISTORY **Recorded as direct quotes**. **Examples**: * "I am going to college and I need to get a physical check-up; the college is requiring me to get a hepatitis B vaccine..." * "I need to find a new health care provider to treat my asthma because it is starting to bother me again..."

Reasons for seeking care or Chief Complaint

Under BASIC COMPONENTS OF HEALTH HISTORY **It is a crucial component of a health history assessment, helping nurses and healthcare providers understand a patient's current health status.**

Present Health or History of Present Illness (HPI)

BASIC COMPONENTS OF HEALTH HISTORY Under the **Present Health or History of Present Illness (HPI)** The ff is for __________: * The focus is on the **general state of health** and any health maintenance behaviors. * Example: *"The patient describes himself as a healthy male without any significant medical problems."* * Includes lifestyle factors such as **diet, exercise, sleep, and stress management.**

For a Well Person

BASIC COMPONENTS OF HEALTH HISTORY Under the **Present Health or History of Present Illness (HPI)** The ff is for __________: * A **chronological account** of how the illness developed, structured to gather detailed information about the chief complaint (CC). * Timing * Location * Quality (Character) * Quantity (Severity, Volume, Number) * Setting in which symptoms occur * Associated Phenomena/Manifestations * Aggravating/Alleviating Factors * Meaning and Impact of Chief Complaint (CC) on the Client

For an Ill Person

FAMILIARIZE ONLY! **"KEY Elements of HPI (History of Present Illness)"**

1. **Timing** * **Onset**: When did the symptoms start? * **Frequency**: How often do they occur? * **Duration**: How long do they last? 2. **Location** * Where is the symptom felt? (E.g., chest pain, abdominal pain) 3. **Quality (Character)** * How does the symptom feel? (E.g., sharp, dull, burning, throbbing pain) 4. **Quantity (Severity, Volume, Number)** * How severe is the symptom? (E.g., rating pain on a scale of 1-10) * How much is present? (E.g., amount of sputum in a cough) 5. **Setting in which symptoms occur** * What was the patient doing when symptoms appeared? * Does it occur at a specific time of day or during specific activities? 6. **Associated Phenomena/Manifestations** * Are there any other symptoms that occur alongside the main complaint? (E.g., fever with a cough, nausea with a headache) 7. **Aggravating/Alleviating Factors** * What makes the symptoms worse? (E.g., movement, eating, stress) * What makes them better? (E.g., rest, medications, home remedies) 8. **Meaning and Impact of Chief Complaint (CC) on the Client** * How does the illness **affect the patient’s daily life**? * How does the patient **perceive the illness**? (E.g., Is the patient anxious, scared, or dismissive?)

FAMILIARIZE ONLY! **"History of Present Illness (a sample):"** *"The patient was in their usual state of good health until one week ago, when they developed shortness of breath (SOB) accompanied by mild wheezing and chest tightness. The patient has been using albuterol MDI (2 inhalations qid), which usually improves breathing. No other medications have been taken. The patient, who typically runs 5 miles daily, has not felt well enough to do so this past week. Yesterday, the patient recorded a temperature of 37.0°C and reported a sore throat and fatigue. However, the patient denies sputum production, cough, sinus pressure, tooth pain, nasal discharge, or nasal polyps. The patient noticed that symptoms began the day after performing yard work before a recent storm."*

**Analysis of the HPI Sample:** 1. **Timing (Onset, Frequency, Duration):** * Symptoms began **one week ago.** * Shortness of breath (SOB) has persisted, affecting daily activities. 2. **Location:** * **Chest tightness** is mentioned, indicating the symptom's location. 3. **Quality (Character):** * SOB is described along with **mild wheezing** and **chest tightness.** 4. **Quantity (Severity, Volume, Number):** * Severity is implied as significant enough to require albuterol inhaler **four times daily (qid)**. * The patient usually runs **5 miles daily** but has been unable to due to symptoms. 5. **Setting:** * Symptoms started **the day after doing yard work before a storm.** 6. **Associated Phenomena/Manifestations:** * Positive symptoms: → Sore throat → Fatigue → Mild fever (37.0°C) yesterday * Negative symptoms (denials): → No sputum, cough, sinus pressure, tooth pain, nasal discharge, or nasal polyps. 7. **Aggravating/Alleviating Factors:** * **Albuterol MDI (2 inhalations qid) helps ease breathing.** * No other medications taken. 8. **Impact on Client's Life:** * Unable to continue **his usual 5-mile daily run** due to symptoms.

Under BASIC COMPONENTS OF HEALTH HISTORY The FF are referring to what? * Review of previous illness * Injuries & hospitalizations * Obstetric history (female) * Surgeries/operations * Allergies * Immunizations * Use of medications

Past Medical History/Past Health

Under BASIC COMPONENTS OF HEALTH HISTORY The FF are referring to what? * Health status of the immediate family members & other blood relations (age, cause of death, or present state of health) * Genogram or family tree

Family History

Under BASIC COMPONENTS OF HEALTH HISTORY The FF are referring to what? * Information about patient's lifestyle that can affect health.

Socio-economic Data or Social History

Under BASIC COMPONENTS OF HEALTH HISTORY The FF are referring to what? * Evaluation of mental health, social status, and functional capacity. * Specific for the current developmental stage of the Client * Use Erik Erikson's Psychosocial Dvelopment Theory

Psychosocial Assessment

Under BASIC COMPONENTS OF HEALTH HISTORY The FF are referring to what? * Includes a person's ability to perform activities of daily living and physical self-maintenance activities. * Assists the nurse in collecting, organizing and categorizing data.

Functional Assessment

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's description of his current health * Activities that the person does to improve or maintain his health * Person's knowledge about links between lifestyle choices and health * Extent of person's problem on financing health care, if any * Person's knowledge of the names of current medications he is taking and their purpose/s * Activities that the person does to prevent problems related to allergies, if any * Person's knowledge about medical problems in the family * Any important illnesses or injuries in this person's life

Health Perception - Health Management Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's nourishment * Person's food choices in comparison with recommended food intake * Any disease that affects nutritional - metabolic function

Nutritional - Metabolic Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's excretory pattern * Any disease of the digestive system, urinary system or skin

Elimination Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's description of his weekly pattern of activities, leisure, exercise and recreation * Any disease that affects his cardio-respiratory and/or musculoskeletal system

Activity - Exercise Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Description of the person's sleep-wake cycle * Person's physical appearance (rested and relaxed?)

Sleep-rest Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Any sensory deficit and if corrected * Person's ability to express himself clearly and logically * Person's education * Any disease that affects mental or sensory function * Person's pain description & causes, if any

Cognitive - Perceptual Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Anything unusual about the person's appearance * If person is comfortable with his appearance * Description of the person's feeling state.

Self - Perception - Self - Concept Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's description of his various roles in life * Positive role models of his roles, if any * Important relationships at present * Any big changes in role or relationship

Role Relationship Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's satisfaction with his situation related to sexuality * How have the person's plans and experiences matched regarding having children? * Any disease/dysfunction of the reproductive system

Sexuality - Reproductive Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Person's means/actions of coping with problems * If coping actions help or make things worse * Any treatment for emotional distress

Coping - Stress Tolerance Pattern

BASIC COMPONENTS OF HEALTH HISTORY **Under Functional Assessment** The FF are referring to what? * Principles that the person learn as a child which are still important to him * Person's identification with any cultural, ethnic, religious, regional or other groups * Support systems that the person has

Value - Belief Pattern

Under BASIC COMPONENTS OF HEALTH HISTORY The FF are referring to what? * Subjective responses to a series of body system - related questions * Head - to - toe approach * Include sign or symptom - related and disease - related questions

Review of Systems

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Usual weight * Recent weight changes * Weakness * Fatigue * Fever * Sweats

General Survey

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Rashes * Lumps * Sores * Itching * Dryness * Color change * Changes in hair or nails

Skin/Integument

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Headache * Head injury * Dizziness

Head

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Vision * Glasses or contact lenses * Last eye examination * Pain and redness * Excessive tearing * Double vision * Spots * Flashing lights * Glaucoma and cataracts

Eyes

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Tinnitus * Vertigo * Earaches * Infection * Discharge * Use of hearing aids

Hearing

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Frequent colds * Nasal stuffiness * Discharge or itching * Nosebleeds * Sinus trouble

Nose and Sinuses

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Condition of teeth and gums * Bleeding gums * Dentures if any and how they fit * Last dental examination * Sore tongue * Dry mouth * Frequent sore throat * Hoarseness

Mouth and Throat

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Lumps * Swollen glands * Goiter * Pain or stiffness in the neck * Limitation of motion

Neck

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Lumps * Pain or discomfort * Nipple discharge * History of breast disease * Any surgery of the breast * BSE including frequency and method

Breast

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Cough * Sputum (color, quantity) * Hemoptysis * Wheezing * Asthma * Dyspnea * History of respiratory diseases * Toxin or pollution exposure * Last x-ray film

Thorax and Lungs (Respiratory)

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Precordial or retrosternal pain * Heart trouble * High blood pressure * Rheumatic fever * Heart murmurs * Chest pain or discomfort * Palpitations * Dyspnea * Orthopnea * Edema * Past ECG or other heart test results

Heart (Cardiac)

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Dysphagia * Heartburn * Appetite * Nausea * Vomiting * Regurgitation * Vomiting of blood * Indigestion * Frequency of BM * Color and size of stools * Change in bowel habits * Rectal bleeding or black tarry stools * Hemorrhoids * Constipation * Diarrhea * Abdominal pain * Food intolerance * Excessive belching or passing of gas * Jaundice * Liver or gallbladder trouble

Gastrointestinal

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Frequency of urination * Polyuria * Nocturia * Burning or pain on urination * Hematuria * Urgency * Reduced force of the urinary stream * Hesitancy, dribbling, incontinence * Urinary infections * Stones

Urinary

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Hernias * Discharge from or sores on the penis * Testicular pain or masses * History of sexually transmitted infections and their treatments * Sexual preference, interest, function, satisfaction and problems

Male genitalia

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Age @ menarche * Regularity * Frequency and durations of periods * Amount of bleeding * Bleeding between periods or after intercourse * Last menstrual period * Dysmenorrhea * Premenstrual tension * Age of menopause * Menopausal symptoms * Discharge, itching * Sores, lumps * Number of pregnancies * # of deliveries * Complications of pregnancy * Birth control methods (for married women) * Sexual preference, interest, function, satisfaction, any problems

Female genitalia

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Coldness, numbness and tingling * Swelling of legs * Discoloration of hands or feet * Varicose veins or complications * Intermittent claudication, thrombophlebitis, ulcers * Does the occupation of the client involve long-term sitting or standing? * Does the client avoid crossing legs at the knees? * Does the client wear support hose?

Peripheral Vascular

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * **Joints**: Pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion. * **Muscles**: Pain, cramps, weakness, gait problems or problems with coordinated activities * **Back**: Pain (location and radiation to extremities) stiffness, limitation of motion, or history of back pain or disease

Musculoskeletal

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * History of seizure disorder and stroke * **Sensory function:** Memory disorders (recent or distant, disorientation) * **Motor function:** tics or tremors, paresis — weakness, fainting, blackouts

Neurologic

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Anemia * Easy bruising or bleeding * Past transfusion

Hematologic

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Thyroid trouble * Heat or cold intolerance * Excessive sweating * Diabetes * Excessive thirst/hunger * Polyuria

Endocrine

BASIC COMPONENTS OF HEALTH HISTORY **Under REVIEW OF SYSTEMS** The FF are referring to what? * Nervousness * Tension * Mood including depression * Hx of mental dysfunction or hallucination

Psychiatric

In collecting Data, What are the **2 Type of Sources of data**?

Primary and Secondary

What type of Sources of Data is this? * The client

Primary

What type of Sources of Data is this? * All sources other than the client

Secondary

Who is the **best source** of information?

The client

FAMILIARIZE ONLY! **"Basic Categories of Diagnostic Tests"**

1️⃣ **Tests that Measure Body Function & Performance** * Evaluate how well an organ or system is working. Examples: → **Heart Rate Monitoring** – ECG, pulse oximetry → **Lung Function Tests** – Spirometry → **Vision Tests** – Visual acuity, color blindness test 2️⃣ **Tests that Use Hollow Tubes & Fiber Optics to View Inside the Body** * Uses cameras to examine internal structures directly. Example: → **Endoscopy** – Gastroscopy, colonoscopy, bronchoscopy 3️⃣ **Tests that Use Imaging (Film or Sound) to Look at the Body** * Provides internal views without invasive procedures. Examples: → **X-rays** – Chest X-ray, bone fracture imaging → **Scans** – CT scan, MRI → **Ultrasound (UTZ)** – Obstetric UTZ, Doppler UTZ 4️⃣ **Tests that Collect & Analyze Specimens from the Body** * Requires bodily fluids or tissues for laboratory analysis. Examples: → **Blood Tests** – CBC, blood glucose test → **Urinalysis** – Checks kidney function, infections → **Fecalysis** – Detects parasites, GI infections → **CSF Analysis** – Diagnoses meningitis, neurological conditions

WHAT IS THIS? * A test that examines **urine** to detect infections, kidney disease, diabetes, or other medical conditions. * **Common Parameters:** Color, pH, glucose, protein, ketones, WBC, RBC, bacteria.

Urinalysis

WHAT IS THIS? * The process of **drawing blood** from a vein using a needle for laboratory testing. * **Common Blood Tests:** CBC, blood glucose, cholesterol levels, electrolyte panel.

Venipuncture

WHAT IS THIS? * A **small sample of tissue** is removed from the body for microscopic examination. * **Purpose:** Diagnose cancer, infections, or other abnormal tissue growth.

Biopsy

WHAT IS THIS? * Uses **radiation (X-rays)** to capture images of bones and internal structures. * **Common Uses:** Bone fractures, pneumonia, lung diseases, dental imaging.

Radiography (X-ray)

WHAT IS THIS? * Uses **high-frequency sound waves** to create real-time images of organs and tissues. * **Common Uses:** Pregnancy monitoring, heart (echocardiography), abdominal organs.

Ultrasonography (UTZ)

WHAT IS THIS? * Uses **powerful magnets and radio waves** to generate detailed images of organs, soft tissues, and joints. * **Common Uses:** Brain scans, spinal cord injuries, ligament tears, tumors.

Magnetic Resonance Imaging (MRI)

WHAT IS THIS? * Records the **electrical activity of the heart** to assess heart rhythm and function. * **Common Uses:** Detects arrhythmias, heart attacks, heart enlargement.

Electrocardiogram (ECG/EKG)

NURSING PROCESS ASSESSMENT Flashcards

(81 cards)