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75 Cards in this Set

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Guidelines for conducting a health assessment
Establish rapport
Encourage honest communication
Make eye contact
Listen carefully
Be aware of your own nonverbal communication
Avoid technical terms - communicate in a way that is easily understood
Consider educational & cultural background and any disabilities pt may have
The Assessment Database (data collection) includes:
The initial interview
Nursing health history
Physical examination
Results of lab/diagnostic tests
FIRST step on the beginning of data collection is:
Client's interview
Definition of Interview
Organized conversation with client to obtain client's health history and info about current illness
Phases of Interview
Orientation Phase
Work Phase
Termination Phase
Interview's opportunities
1. To be introduced to client, explain role, and the role of others during care
2. To establish sense of caring for pt
3. To establish therapeutic relationship
4. To gain insight about pt's concerns/worries
5. To determine client's goals/expectations of healthcare system
6. To obtain cues of data collection needing further in-depth investigation
Orientation Phase
Begins with nurse's introduction (name, position, explanation of purpose of interview: e.g., for nursing history or focused assessment)
State confidentiality of info obtained
Establish trust and confidence with client (allows pt to feel more comfortable)
Lays groundwork for nurse to know pt's needs
Assure pt that interviews are confidential
Be professional and convey competence
Set interview time with pt
Working phase
Gather information about client's health status
Use interview techniques to gather comprehensive/complete database
Initial interview usually most extensive
Termination phase
Ideally client should be given a clue that interview is coming to an end
Example "There are just two more questions." or "We'll be finished in 5 to 6 minutes."
Four(4) Interview Techniques (in order)
Open-ended questions
Back Channeling
Closed-ended questions
Open-ended questions
Prompts clients to describe situation in more than one or two words
Back Channeling
(active listening technique) Indicates nurse has heard what pt says and encourages even further elaboration. "all-right" "go on" "uh-huh"
Focus on the symptoms that the client mentions to fully describe/identify specific problems
Closed-ended questions
Limit client's answers to one or two words: "yes" or "no" or a number or frequency of a symptom
Example: "How often does the diarrhea occur?"
Components of Health History
Biographical data (pt profile and cultural considerations)
Chief complaint
Present health concern (or present illness)
Past history
Family history
Environmental history
Psychosocial history
Spiritual environment
Review of systems
Review of systems (Textbook, pg. 292, Box 15-4)
1) general presentation of symptoms: fever, chills, malaise, pain, sleep patterns, fatigability
2) diet: appetite, likes/dislikes, restrictions, written diary of food intake
3) skin, hair, nails
4) musculoskeletal
5) head and neck
6) endocrine and genital/reproductive
7) chest and lungs
8) heart and blood vessels
9) gastrointestinal
10) genitourinary
11) neurological
12) psychiatric
Ethical/Legal use of History or Physical Exam Data
Data are recorded in a clear, concise manner using appropriate terminology
Functional Assessment

Functional Assessment (continued)
Cognitive function
Nutrition and Metabolism
Activity and Exercise
Sleep and Rest
Coping and Stress Tolerance
Interpersonal relationships and resources
Areas of Concern (Functional Assessment)
Physiologic function
Cognitive function
Psychosocial needs
Sleep and Rest
Activity and exercise
Meeting developmental tasks
Physiologic function
Nursing action:
-Maintain physiologic reserves
-Maintain ongoing assessments for early detection of problems
-Review perceptions of current health status,problems, and prescribed or over-the-counter meds
-Include nursing care that maintains physical status (e.g., skin care, planned rest and activity)
Cognitive function
Nursing Action: Slow pace of activity and wait for responses.
Be sure eyeglasses and hearing aids are used.
Psychosocial needs
Nursing Action: Be aware that illness, hospitalization, or changes in living arrangements are major stressors.
Assess and support sources of strength, incl. cultural and spiritual values and rituals.
Encourage use of support system.
Set mutual goals and encourage pt's role in making decisions about care.
encourage life review and reminiscence.
Encourage self-care.
Consider pt's background, interests, capabilities, values, culture, and lifestyle when planning care.
Nursing Action: Assess for lost or damage teeth; ensure dentures fit properly.
Assess ht,wt,eating patterns, food choices.
If wt is being lost, assess income, storage, and transportation.
Assess swallowing ability.
Sleep and Rest
Nursing Action: Discourage excessive napping.
Assess normal bedtime, time for rising,bedtime rituals, effects of pain, medications, anxiety, and depression.
Nursing Action: Assess frequency of bladder elimination (incontinence).
Assess normal times for bowel movements.
ensure floor is uncluttered, toilet is accessible, lighting is adequate,and privacy is provided.
Review diet for necessary fluid and fiber content.
Activity and exercise
Nursing Action: Assess ability to walk.
Consider effects of illness, surgery, medications, and changes in diet and fluid intake on strength and motor function.
Ensure uncluttered environment with good lighting.
Slow pace of care, allowing extra time to carry out activities
Nursing Action: Assist as necessary with hygiene, hair care, oral care, clean clothing and bedding, makeup, and shaving.
Maintain clean, odor-free environment.
Demonstrate genuine caring (e.g., ask preferred name)
Discuss safer sex, if appropriate.
Discuss water-soluble lubricants with women; refer men for evaluation if erectile dysfunction is a concern.
Meeting developmental tasks
Nursing Action: Promote continued development and maintenance of functional health by identifying unmet tasks, feelings of isolation, and physical or sensory limitations.
Assist in finding creative solutions to developmental tasks.
Collaborate with other healthcare providers to provide info and referral to community resources for the pt and family.
Topic: Infection Control
Topic: Infection Control
Chain of infection (definition)
infectious agent (bacteria, viruses, fungi, protozoa)
Reservoir (definition)
place where pathogen can survive (but doesn't "stay"); Survival based on food, oxygen, water, temperature, light
Portal of Exit (definition)
how pathogen gets out of initial host: skin, respiratory tract, urinary tract, gastrointestinal tract, reproductive tract, blood
Six(6) Modes of Transmission (definition)
How organism gets from one host to another.
1. Direct contact
2. Indirect contact
3. Droplet
4. Air
5. Vehicles
6. Vectors
Direct contact (definition)
person to person, blood and body fluids, touch
Indirect contact (definition)
needle sticks, surfaces (depends, blood pressure machine)
Droplet (definition)
sneezing, coughing
Air (definition)
carried on dust particles or suspended in air
Vehicles (definition)
contaminated items, water, drugs, solutions, blood, food.
Vectors (definition)
External (flies).
Internal (mosquito, louse, flea, tick)
Portal of Entry (definition)
how organisms enter human body, same as portal of exit
Susceptible Host (definition)
very old, very young, depends on nutritional status, disease process, functioniung immune system, mental and physical overall
Infection control measures to reduce reservoirs of infection (pg. 789 of textbook)
Dressing changes.
Contaminated Articles in proper disposal.
Contaminated needles in puncture-proof container.
DO NOT RECAP contaminated NEEDLES.
Bedside Unit: Keep table surfaces clean and dry.
Bottled solutions: do not leave open for prolonged periods, keep tightly capped, date bottles when opened and discard according to policy.
Surgical wounds: Keep drainage tubes and collection bags patent to prevent accumulation of serous fluid under skin surface.
Drainage Bottles and Bags: empty and dispose of drainage suction bottles, empty all drainage systems each shift (unless otherwise ordered by MD). Never raise a drainage system (e.g., urine bag) above level of the site being drained, unless it is clamped off.
How we defend against infections (3 ways)
1- Inflammatory response
2- Normal flora
3- cellular response defenses
Inflammatory response
Protective reaction that neutralizes pathogens and repairs body cells.
Vascular and cellular.
Formation of inflammatory exudate.
Tissue repair.
Normal Flora
-does not cause disease, we all have normal flora
-does not like to mix with non-normal flora
-everywhere, from head-to-toe, but can be disrupted easily
Defenses: cellular response
-dilation through inflammatory response which allows more circulation
-chemical mediators allow more fluid to flow, leads to localized edema (this is protective during injury only)
-White Blood Cells (WBCs) arrive at injured site, leads to process that eats and destroys microorganisms (Phagocytosis)
-Inflammation becomes systemic which leads to more WBCs being produced and circulating
White Blood Cells (WBCs) NORMAL (adult) RANGE

-Increased in acute infection.
-Decreased in certain viral or overwhelming infections.
Success Against Infections
Know when something is CLEAN, DIRTY, STERILE
PUTTING ON protective wear (page 799 in textbook):
In this order:
TAKING OFF protective wear:
In this order:
Assessment of LAB VALUES
-WBCs: 5000-10,000
-Erythrocyte sedimentation rate (ESR): 20 mm/hr (women), 15 mm/hr (men)
-Differential count
-Neutrophils: 55-70%
-Lymphocytes: 20-40%
-Monocytes: 2-8%
-Eosinophils: 1-4%
-Basophils: 0.5-1%
-Iron level: 60-90 g/100 ml
Infection - Nursing Diagnosis
Decide/Critical Thinking Exercise
Nursing Diagnosis: Risk of Infection for complaint of "HOPELESSNESS" not for "Activity Intolerance"
Infection - Nursing Diagnosis
Decide/Critical Thinking Exercise
Nursing Diagnosis: Risk of Infection for "TOTAL INCONTINENCE" not for "risk for trauma"
Infection - Nursing Diagnosis
Decide/Critical Thinking Exercise
Nursing Diagnosis: Risk of Infection for both "TISSUE PERFUSION" and "TISSUE INTEGRITY"
Nursing diagnoses that may apply to Infection (pg. 783 of textbook):
- Disturbed body image
- Risk for infection
- Risk for injury
- Imbalanced nutrition: less than body requirements
- Impaired oral mucous membrane
- Risk for impaired skin integrity
- social isolation
- Impaired tissue integrity
Infection - Planning
-goals directed towards prevention and controlling or eliminating risks
-goals directed towards actual treatment
-realistic, measurable, take home lessons for patient. Upon discharge: make sure pt has supplies and knows how to clean wound.
Infection - Implementation
-Interventions for healthcare personnel (not just nurses) make sure promotes infection control.
-Make sure gets body able to fight and internally prevent infection (nutrition, control immunosuppression through stress reduction)
-Be mindful of what's clean, dirty, and sterile
Infection control measures:
asepsis, sterilization, disinfection, OSHA and CDC guidelines, gowning, gloving
Asepsis (medical asepsis):
(page 786 of textbook)
Absence of pathogens. Medical asepsis is also called "clean technique".
Principles of medical asepsis are commonly followed in the home, as in washing hands before preparing food.
complete elimination or destruction of ALL microorganisms
think Purell
Infection Control Measures
-Hand hygiene: friction, friction, friction
-Isolation measures (airborne, droplet, contact)
-wound care
-sterile dressing change
-sterile gloving
Infection - Evaluation
-Prevention of "frequent flyers"
-Follow-up phone calls
Example of Test Question:
When is environment: clean?
Clean: use of standard precautions (hand washing, using clean gloves to prevent direct contact with blood or bodily fluids, cleaning the environment routinely)
Example of Test Question:
When is environment: dirty?

Example of Test Question:
When is environment: dirty?
Dirty: anything that is contaminated by bodily fluids or suspected of containing pathogens
Example of Test Question:
When is environment: sterile?

Example of Test Question:
When is environment: sterile?
Sterile: (pg.802) during procedures requiring perforation of client's skin (insertion of IV catheters or administration of injections)
When skin integrity is broken as a result of a trauma surgical incision or burns.
During procedures that involve insertion of catheters or surgical instruments into sterile body cavities.
Example of Test Question:
Contamination: What is it? and What do you do about it?
(Page 786): After an object becomes unsterile or unclean, it is considered contaminated.

(pg.787): if object is disposable, usually it is discarded unless policy/procedure is in place to reprocess the object. Reusable objects must be cleaned thoroughly before reuse and then either disinfected or sterilized according to manufacturer's recommendations.
Purposes of Teaching & Learning
To help patients & families develop the self-care abilities (knowledge, attitude, & skills) that enable them to maximize their functioning and quality of life (or dignified death)
Promote health
Prevent illness
Restore health
Facilitate coping
Informal- Unplanned teaching
Immediate learning needs
May lead to planned teaching
Formal - Planned teaching done to fulfill learner objectives
Differences in Children vs. Adults
Concept of self: Dependent
Previous Experience: Not a resource / Building a body
Readiness to learn: Uniform by age
Orientation to learning: Subject centered;Use later
Motivation: External rewards
Differences in Children vs. Adults
Concept of self: Independent
Previous Experience: Serves as a resource
Readiness to learn: From life tasks, roles, problems
Orientation to learning: Task centered; Use immediately
Motivation: Internal incentives & curiosity
Psychomotor Learning
When a physical skill has been acquired
Example objective:
The patient demonstrates how to change dressings using clean technique.
Affective Learning
Involves changes in attitudes, values, and feelings
Example objective:
The patient expresses renewed self-confidence following physical therapy
Verbs that can be used when writing Learner Objectives (Cognitive Domain):
Cognitive Domain:
--Compares -- Prepares
Defines -- Plans
Describes -- Solves
Designs -- States
Differentiates -- Summarizes
Gives examples
Verbs that can be used when writing Learner Objectives (Affective Domain):
Affective Domain:
Chooses -- Shares
Defends -- Uses
Displays -- Values