Health Assessment: Nursing Care R/t Clinical Framework

Front 1

Mrs Jones needs a focused pulmonary assessment every 2 hours.

Identify the steps in that assessment.

Back 1

*VS: B/P, heart rate and rhythm, resp rate, temp.
* general: overall comfort/distress level.

Obtain subjective data:
*Ask Mrs Jones how she has been doing in the past 2 hours.
*How does she assess her breathing, cough, SOA, fatigue, and anxiety?
* Ask specifically about color & amount of sputum production and hempotysis.
* If she has been using a sputum cup, be sure to observe amount, color, and consistency.
* Empty cup so that what accumulates in the next 2 hours can also be assessed.

Obtain objective data using:
* Inspection: circumoral color, quality & depth of respirations, chest excursion, intercostal and supraclavicular movement, watching especially for retraction.
* Palpation: check for fremitus.
* Percussion: check for dullness (comparing one level on right side to same level on left side before proceeding down to the next level). Especially note differences in pitch at level of RLL (in Mrs Jones's case).
* Auscultation: any audible wheezing? Auscultate trachea and bronchial areas, then bilaterally side-to-side, comparing one level on right side to same level on the left side before proceeding.

Front 2

How might a focused assessment affect a patient's nursing diagnosis?

Back 2

Diagnoses may remain the same.

Diagnoses may improve: i.e. an ineffective airway clearance may become an actual diagnosis of ineffective airway clearance.

Diagnoses may worsen: i.e. a potential for ineffective airway clearance may become an actual diagnosis of ineffective airway clearance.

New diagnoses may be added: i.e. patient may experience pain upon inspiration.

(Although pain is a nursing diagnosis, pain upon inspiration is a collaborative diagnosis. The physician needs to be notified as pleurisy or pleural effusion may be developing, which are complications of pneumonia.)

Front 3

What are the steps involved in the planning phase of the nursing process?

How does this phase rate to nursing diagnosis?

To interventions?

To evaluation?

Back 3

Planning involves identifying outcomes that are framed within patient goals.

Both the patient goals and the outcomes are specific to the nursing diagnosis under consideration.
Planning also involves identifying interventions designed to achieve the expected outcomes.
The interventions are also diagnosis specific.

Evaluation involves comparing the outcomes attained with the outcomes expected.

Front 4

On what basis would you assign tasks to a NA and to an LPN/LVN?

Back 4

Assign activities of daily living to NAs.

Assign procedures for which the LPN/LVN is educated the LPN/LVN.

Front 5

How do you evaluate outcomes?

Back 5

Compare the expected and attained outcomes.

If the expected outcomes were attained, fine.

If they were not attained, check the accuracy of the measures.

If the measures were accurate, reassess the patient.

Consider the effectiveness of the intervention and change or adjust to obtain the desired outcome.
Individualize for each patient.

Front 6

Identify the types of information that make up a nursing database for a patient.

Back 6

* background.
* presenting problem.
* past health history.
* family history.
* social/environmental history.
* psychological history.
* lifestyle.
* access to health care.

Front 7

Identify the parts of an Initial Nursing Assessment.

Back 7

* nursing history.
* review of systems.
* physical examination.

Front 8

List the parts of the Review of Systems.

Back 8

* general.
* skin, head, face, neck, eyes, ears, nose, throat, mouth/teeth, oropharynx.
* breast.
* respiratory.
* cardiovascular.
* gastrointestinal.
* renal/urinary/reproductive.
* musculoskeletal.
* neurological.
* mental health.
* hospitalizations, surgeries, trauma (head injuries, fractures, etc).

Front 9

Assessments:

Back 9

* are ongoing.
* are supplemented with information from significant others when appropriate.
* need to be updated on the basis of focused assessments performed at regular intervals each day and whenever a change in patient's status is noted.

Front 10

When analyzing assessment data, identity patient _____ , as well as nursing diagnoses.

Back 10

strengths

Front 11

When analyzing assessment data, identity ______ in addition to the patient's actual diagnoses and strengths.

Back 11

potential health problems

Front 12

When analyzing assessment data, identity _____ associated with the diagnoses.

Back 12

risk factors

Front 13

When analyzing assessment data, identity _____ that will play a role in a patient's nursing care.

Back 13

developmental factors

Front 14

When analyzing assessment data, identity problems that require:

Back 14

* collaboration with other health professionals
* implementation of dependent interventions.