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47 Cards in this Set

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The registered nurse collects comprehensive data pertinent to the patient's health or the situation.
Assessment
The RN analyzes the assessment data to determine the diagnoses or issues.
Diagnosis
The RN identifies expected outcomes for a plan individualized to the patient or the situation.
Outcome Identification
The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes.
Planning
The RN implements the identified plan through coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment.
Implementation
The RN evaluates progress toward attainment of outcomes.
Evaluation
Information provided by clients when asked to describe their current state of health, previous illnesses and surgeries, and their family background.
History (subjective data)
Subjective data acquired by another individual (such as a family member)
Secondary source of history data
Collection of observable data by the nurse. Data obtained using techniques of inspection, palpation, percussion, and auscultation.
Objective Data - Examination
Data observed, felt, heard, or measured by the nurse. Include fever, rash, enlarged lymph nodes, and swelling.
Signs
Data that the client or family tells the nurse. Pain, itching, nausea.
Symptoms
Detailed history and physical examination performed at the onset of care. Encompasses health problems of the client as well as health promotion, disease prevention, and assessment for problems with known risk factors.
Comprehensive assessment
History and examination that is limited in scope to a specific problem or complaint (ie sprained ankle).
Problem based/focused assessment.
Usually done when client is seeking additional care with a provider after a previous visit. 2 weeks after antibiotics, etc.
Follow-up/Episodic assessment
Short, usually inexpensive exam focused on disease detection.
Screening assessment
5 data sources
Client, Significant Others, Records, Consultations, Lab/Diagnostic studies
Data collection methods
observation
health history interview
physical exam
Health History Interview 4 components
Purpose, Preparation, Plan-Skills, Parts
Health History Purpose
I - involve client
C - collect subjective data
E - establish a baseline
Health History Preparation
S - self (build trust, skills, knowledge, appearance)
S - setting (privacy, quiet, comfort)
Health History Plan
Interpersonal
Communication
Health History Parts
Bio
Reason
Present
Past
Family Hx
Psycho/Social
ROS
Health History Physical Examination
Purpose
Preparation
Plan-Skills
Physical Exam Purpose
V - validate subjective data
C - collect objective data
E - establish a baseline
Physical Exam Preparation
Hands, equipment, client positioning
Physical Exam Plan - Skill
KNOW IN ORDER:
Inspection
Palpation
Percussion
Auscultation

Except abdominal exam, out of order - auscultation before palpation/percussion
Diagnosis - Purpose
Direct plan of care
PPM - predict, prevent, manage
decrease costs, increase efficiency
Diagnosis - Process
Analyze - normal, risk, impaired
Synthesize - signs/symp, evidence
Normal Temperature
96.4-99.1
Normal Oral Temperature
97.6-99.6
Normal axillary temperature
96.6-98.6
Normal rectal temperature
98.6-100.6
Normal Heart rate
60-100 BPM
Normal respirations
12-20 RPM
Normal Blood Pressure
Systolic 110-140/
Diastolic 60-90
Risk potential diagnosis
2 parts -
Risk of "x"
r/t "x"
Actual diagnosis
3 parts -
diagnosis
r/t "x"
AEB (as evidenced by) "x"
Symptom Analysis
O - onset
L - location
D - duration
C - characteristics
A - aggravating and alleviating factors
R - related symptoms
T - treatment
S - severity
Onset
When did symptoms begin?
Location
Where are the symptoms?
Duration
How long do the symptoms last?
Characteristics
Describe the characteristics of the symptom
Aggravating and Alleviating Factors
What affects the symptoms?
Related Symptoms
What other symptoms are present?
Treatment
Describe self treatment tried before seeking care
Severity
Describe the severity of the symptom
older adult vital sign changes
97.2 F average temp
arteriosclerosis - higher BP