Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
52 Cards in this Set
- Front
- Back
|
Assessment covers what, why do we do it |
age, gender, culture, ethnicity, physical, psychological, socioeconomic status. collection of data from patient to compare info with ideal state of health |
|
|
components of the nursing process: |
assess (conduct health history, perform physical exam, document findings) diagnosis plan implement evaluation (ADPIE) |
|
|
documentation |
a legal document. permanent record use medical terms for documentation but laymen's terms with client) DO NOT INCLUDE BIAS OR OPINION |
|
|
Types of health assessments |
comprehensive focused episodic screening |
|
|
what is a clinical judgement |
an interpretation or conclusion about a patient's needs, concerns, or health probs and or the decision to take action (noticing, interpreting, responding, reflecting) |
|
|
difference between health promotion and protection |
promotion: increase well-being, actualize human health potential protection: avoid illness, catch it early, maintain function withing constraints of illness |
|
|
3 levels of health promotion |
primary (prevent a disease) secondary (screening for early detection) tertiary (minimizing disability from condition) |
|
|
2 primary components of health assessment |
health history, subjective physical exam- objective |
|
|
general rules about health history |
don't startle or surprise don't use first name except with adolescents or children you direct convo as client-centered open questions to get talking closed ended to get more detailed responses or for clarification dont use inflammatory words |
|
|
allergies |
if they state they have an allergy, ask what type of reaction and how long ago they had it. is it a side effect or allergic rxn
|
|
|
personal habitss |
tobacco use, EtOH- excessive intake of alcohol use of illicit street drugs. don't say illegal. |
|
|
4 basic techniques of physical assessment |
inspection palpation percussion auscultation |
|
|
inspection |
adequate lighting is a concern includes posture, body movement, mood |
|
|
palpation |
ensure hands are warm, touch is gentle, nails are short always tell the client the purpose of the touch gloves are worn when palpating mucous membranes or when body fluid contact |
|
|
percussion 2 types |
performed to evaluate size and location and borders of organs, detects tenderness, extent of bodily fluids direct: strike finger or hand on body indirect: both hands, different |
|
|
5 types of percussion sounds |
tympany: loud, high pitched over abdomen resonance: over normal lung tissue hyper-resonance: overinflated lungs dullnesss: over liver flat: over bones and muscle |
|
|
auscultation, 4 sounds to listen for |
pitch intensity duration quality |
|
|
parts of stethoscope |
earpieces binaurals (angle toward nose) tubing head (diaphragm (high pitched) and bell for low pitched sounds) |
|
|
when does the general inspection begin |
the moment you meet: physical appearance, hygeine, body structure and movement, emotional, mental health, behaviour |
|
|
5 elements of vital signs (4 true) |
temp, heart rate, respiratory rate, blood pressure, 5th is pain |
|
|
what do you have to tell them when you take temperature |
where it was taken: tympanic, oral, rectal, axillary, temporal |
|
|
what s the difference between rhythm and rate for the heart rate |
rate: # of times in a minute rhythm: time between each beat is consistent |
|
|
how do you report blood pressure |
systole/diastole systole: ventricles contract diastole: ventricles relax upper arm slightly flexed and at heart level. palm up. inflate 20 to 30 mm above where you no longer hear pulse. |
|
|
when do you reasses pain |
15 min after meds given |
|
|
whats purpose of genogram study |
to trace diseases with genetic traits |
|
|
what do you record |
age, sex, health problems, occupation, dates of relationships, interaction paterns, dates of death |
|
|
define culture |
shared beliefs, values, behaviours, define right and wrong, abnormal, inappropriate. |
|
|
what is cultural assessment |
systematic aseesment of individuals, families, and communities regarding health beliefs and values. |
|
|
ethnicity |
small group within a cultural and social system that shares common cultural and social heritage including language history, lifestyle, religion, geographic origin, race. |
|
|
race |
genetic in origin. not culture. skin color, bone structure, eye and hair color. |
|
|
national standards to ensure equitable care: who are the organizatins and what are the 3 themes |
dept of health and human services, office of minority Health. culturally competent care language access organizational supports for cultural competence |
|
|
what do you ask to become culturally competent: |
language, personal beliefs about health, illness, religous or spiritual influences, roles of individuals in family, dietary |
|
|
purpose of nutritional assessment |
id individuals at risk for malnourishment (failure to thrive) provide data for baseline provide data for designing a diet plan to prevent malnutrition |
|
|
what is symptom analysis |
OLD CARTS onset, location, duration, characteristics, aggravating and alleviating, related symptoms, treatment by the patient, severity |
|
|
what effects present health status what do you need to ask about |
chronic illness, meds, changes in weight, food intolerance or allergies, problems obtaining or preparing or eating food, street drugs and alcohol. surgery, family history of obesity, diabetes, eating disorders |
|
|
what are the measurements: |
anthropometric- height and weight skin, hair, nails eyes inspection and palpation of extremities bilaterally |
|
|
diff between triceps skin fold and mid arm muscle circumfrence |
skin fold: estimate subcutaneous fat stores other to evaluate muscle reserve |
|
|
BMI |
[wt in lbs/ " x " ] x 703
or
wt in kg / m x m |
|
|
what s normal and whats not |
18.5 - 24.9 normal 25 - 29.9 overweight 30 - 34.9 obese in classes 1 -3 in 5 point intervals |
|
|
considerations |
BMI not accurate for people under 5 ft tall results innaccurate for body builders, people who are retaining fluid, elderly naturally lose muscle tissue |
|
|
obesity stats in US |
65% overweight or obese 1% going into category every year adults 20 -40 gain 1.8 to 2 lbs / yr
|
|
|
clinical signs and symptoms of malnutrtion often confused with other diseases |
anemia, hyper/hypo thyroidism, cancer, liver disease, depression |
|
|
reasons for malnutrition |
chronic disease, meds, acute illness or injury, no adequate safe food, lack of knowledge/skills, chronic dieting, food or religious beliefs, eating disorders, alcohol, depression, poor dental/oral health, erratic work hours, poverty, extreme age, disability, over - nutrition: excess intake of fat, sugar, calories, nutrients, sedentary lifestyle, acute illness or injurty, lack of knowledeg, poverty, meds like steroids |
|
|
increased BMI risk factors, these all feed off of each other |
diabetes, cancer, sleep apnea, respiratory distress, heart disease, stroke, hyper thyroidism, osteoarthritis, gout, impaired wound healing, high risk for death in surgery |
|
|
good nutrition signs |
alert, energetic, good posture , firm, well-developed muscles, good turgor and elasticity in skin, eyes bright and clear, mucous membranes pink and moist, tounge smooth |
|
|
bad nutrition signs |
withdrawn, agitated, stooped, over or under weight, flaccid muscles, paresthesis (numbness or tingling), skin dull or pasty, scaly, dry, bruised, eyes dull, conjunctiva pale, hair brittle and dull, mucous membranes pale, gums boggy, bleed, tounge dark red and swollen |
|
|
changes in elderly |
more salt sensitive loss of muscle tone and mass loss of subcutaneous fat fat is redistributed from face and neck to abdomen , arms, hips |
|
|
abdominal vs. visceral fat |
visceral fat in abdomen increases health risk vs. subcutaneous fat and may be an independent predictor of health risks even when BMI falls within normal. |
|
|
how do you assess hydration status |
weight (% changes), skin turgor, pitting edema, skin for moisture, tongue, lung sounds, blood pressure |
|
|
fluid overload: signs |
weight gain 6-10 lbs in a week pitting edema, visible neck veins/jugular vein distension, bounding pulsatings crackling lung sounds, elevated pulse rate and blood pressure, difficulty breathing |
|
|
dehydration, signs |
weight loss 6-10 lbs in a week tenting of skin tounge is dry, fissures, sunken eyeballs, dark circles blood pressure decreased w elevated pulse rate decreased or absent tears, dry mucous membranes |
|
|
nutritional clinical exam |
height and weight for BMI calculate desirable body weight % change in weight waist to hip ratio: apple or pear assess general appearance and level or orientation skin, hair, nails, eyes, oral cavity, palpate extremities for shape |
