Nursing Assessment Chpt 1,3 & 8

Front 1

Assessment

Back 1

Collection of dadta about the individual's health state

Front 2

Evidence Based Assessment

Back 2

using assessment techniques based on evidence based care

Front 3

Objective Data

Back 3

Information obtained by performing a physical exam, or from lab values/ diagnostic tests by reading the pt's old chart

Front 4

Subjective

Back 4

Info provided by pt. How many surgeries etc.

Front 5

Database

Back 5

Contains both subjective & objective data. Nurse must modify the approach to data collection based upon presenting clinical situation

Front 6

Complete Total Health Database

Back 6

A complete health hx & full physical Exam. Includes present, past and family hx, health maintenance, ADL's

Front 7

Focused or Problem Centered
database

Back 7

"mini database Limited to one problem or concern. Dr. sick visit.

Front 8

Follow Up database

Back 8

Evaluation of previously identified problem. Seeks info on the status or problem (better or worse)

Front 9

Emergency database

Back 9

Calls for rapid collection of data. Usually done simultaneously with life saving assessments and interventions

Front 10

Evidence based practice

Back 10

"systematic approach to practice that emphasizes the use of best evidence in combination with the clinician's experience as well as the pt preferences and values to make decisions about care and tx,

Front 11

Cue

Back 11

is a piece of pt info that the pt told you or diagnostic testing (lab radiology, ABG)

Front 12

Nursing Diagnosis

Back 12

clinical judgement about a person's response to an actual or potential health state

Front 13

Diagnostic reasoning

Back 13

analyzing cues and health data to come up with a nurse diagnosis

Front 14

Critical Thinking

Back 14

how we take in info, process the info and then act on it in a critical manner. Affected by education and experience. 17 Critical thinking skills

Front 15

Biomedical model

Back 15

traditional medicine views as the absence of disease
Disease identification ans treatment

Front 16

Holistic Health

Back 16

emphasize body, mind & spirit Whole person and the environment they live in. Culture, family, values, stress

Front 17

Environment

Back 17

can be physical, social, or ecological

Front 18

Wellness

Back 18

move toward optimal functioning. Wellness a direction of progress and not the absence of disease

Front 19

Health promotion & disease prevention

Back 19

intervention directed at the link between health and personal behavior. Smoking, alcohol abuse, lack of exercise

Front 20

Nursing Process

Back 20

Assessment
Nursing Diagnosis
Outcome identification
Planning
Implementation
Evaluation

Front 21

Scientific Method

Back 21

1. Look at clues
2. Make hypothesis
3. Gather more data to support or refute hypothesis
4. Evaluating the hypothesis and make final dx.

Front 22

Why nursing dx?

Back 22

Tells us the pt response to the problem or interventions

Front 23

Framework to guide assessment

Back 23

Biomedical Model
Holistic Model
Health Promotion and Disease Prevention: vaccinations, smoking cessation, diet counseling

Front 24

Why do you need excellent interview skills

Back 24

RN at bedside most
Pt's are sicker
Need to intervene quicker
Discharge sooner
More liability for not having good assessment skills

Front 25

Interview

Back 25

collection of subjective data. used to elicit a health hx

Front 26

Who has the burden of effective communication?

Back 26

care provider/ nurse

Front 27

Goal of interview

Back 27

what needs to be accomplished

Front 28

External factors or important considerations during an interview

Back 28

Physical environment
Keep note taking during the interview to a minimum
Use non-verbal communication techniques advantageously

Front 29

Open ended ?'s

Back 29

Pt free to answer any way

Front 30

Closed or direct questions

Back 30

Requires a short answer, yes or no

Front 31

Physical environment

Back 31

Arrange equal status seating
Avoid standing
position 4 to 5 ft apart
Ensure privacy
Comfortable room temp & lighting
Avoid interruptions
Face to face when in bed.
Do not use computer monitor as barrier

Front 32

Therapeutic Communication techniques
Pt perspective

Back 32

Facilitation- encourage talking
Silence- allow time to collect thoughts
Reflection - Repeating what the person just said
Empathy- recognize feelin put in words
Clarification- Confirm perception of RN when pt communication is confusing

Front 33

Therapeutic Communication techniques
Nurse perspective

Back 33

Confrontation- honest feedback about what you see or feel based on discrepancy
Interpretation- pulls cues together presents back to pt.
Provide explanation- give factual info
Summarize- condense facts and present for validation purposes.

Front 34

Non therapeutic Communication

Back 34

Provide false reassurance
Give advice
Use authority
Use avoidance language
Use distancing
Use Professional Jargon
Use leading biased questions
Talk too much
Interrupt
Use "why " question

Front 35

Avoidance language

Back 35

"passed on" instead of death
"put to death" instead of put to sleep

Front 36

Distancing

Back 36

use of impersonal speech to space between pt and nurse

Front 37

leading biased questions

Back 37

implies one answer is better than another

Front 38

Non verbal skills

Back 38

Physical appearance
Posture
Gesture
Facial expressions
eye contact
tone of voice
Touch

Front 39

Customize interview based on

Back 39

Developmental level and age
Special needs(hearing impaired)
Cultural/ language
Sexual orientaion
Acutely ill
Angry or threatened
Anxiety
Crying
Personal questions
Sexually aggressive

Front 40

What percent of info gathered during the hx and physical comes from the assessment

Back 40

5-10%

90% comes from verbal hx

Front 41

Assessment confirms

Back 41

your judgment or diagnosis from the health hx

Front 42

Benefits in addition to gather data from interview

Back 42

Establish a rapport with pt and family
Teaching opportunities

Front 43

Must have a high degree of __________ and be ____________

Back 43

suspicion
systematic

Front 44

Assessment techniques are used during the physical examination to

Back 44

gather objective data.

Front 45

Skills required for physical exam include:

Back 45

inspection, palpation, percussion, auscultation

Front 46

Inspection

Back 46

by looking

Front 47

Palpation

Back 47

use touch, temp, texture, moisture, swelling, crepitation, lumps,

Front 48

Percussion

Back 48

assess density direct/indirect

Front 49

Auscultation

Back 49

Listen

Front 50

Inspection instruments

Back 50

otoscope, opthalmoscope, pnlight speculums

Front 51

Palpation different parts of hands best for different assessments
Fingertips

Back 51

fine tactile discrimination

Front 52

Palpation different parts of hands best for different assessments
Thumb and forefinger grasping action

Back 52

assessing size of lumps and masses

Front 53

Palpation different parts of hands best for different assessments
Dorsa (back of) hand

Back 53

temperature

Front 54

Palpation different parts of hands best for different assessments
base of fingers or ulna surface

Back 54

best for vibrations

Front 55

Direct Percussion

Back 55

striking hand directly contacts the body. for example percussing the sinus area

Front 56

Indirect Percussion

Back 56

striking hands contacts the examiner's fixed hand on skin

Front 57

Vibrations penetrate about ___ cm deep

Back 57

5

Front 58

Do not percuss over _________.

Back 58

bone

Front 59

Use percussion hammer for determining ____________.

Back 59

Deep Tendon Reflexes

Front 60

Percussion uses

Back 60

Deep Tendon Reflexes
Find location and size of an organ
Density of a structure
Detect abnormal mass

Front 61

structures with increased air produce

Back 61

louder deeper longer sound due to freer vibration

Front 62

Dense structures with less air produce

Back 62

less vibration and sound is higher softer and shorter

Front 63

resonant

Back 63

clear hollow (lung sounds)

Front 64

Hyperresonant

Back 64

booming emphysema

Front 65

Tympany

Back 65

musical drum like
Stomach

Front 66

Dull

Back 66

muffled thud dense organ - liver

Front 67

Flat

Back 67

dead stop of sound no air muscle bone

Front 68

Auscultation

Back 68

listening to sound produced by body such as heart, blood vessels, lungs and abdomen

Front 69

Stethoscope description

Back 69

earbuds angled towards nose
tubing 14 to 18 "
Diaphragm- high pitched sounds firm pressure
bell- low sounds light pressure (abnormal heart sounds

Front 70

Development Considerations
Infant

Back 70

auscultate first (heart lung and abd.) then invasive (eye, ear, nose, throat) 1- 2 hours after feeding. Leave diaper on

Front 71

Development Considerations
Toddler

Back 71

Sit in parent lap. Demonstrate on parent. Undress one body part at a time

Front 72

Development Considerations
Preschool

Back 72

likes to assist, use games

Front 73

Development Considerations
School age

Back 73

understanding does not match speech, explain likes small talk

Front 74

Development Considerations
Adolescent

Back 74

without parent, privacy important

Front 75

Development Considerations
Older adult

Back 75

takes time may need rest periods

Front 76

Development Considerations
Ill person

Back 76

break up into small sections and position of comfort