Health Ass

Front 1

is a dynamic process that uses information in a meaningful way through problem-solving strategies to place the patient, family, or community in an optimal state

Back 1

Nursing process

Front 2

SIX PHASES OF THE NURSING PROCESS:

Back 2

ASSESSMENT

DIAGNOSIS

OUTCOME IDENTIFICATION

PLANNING

IMPLEMENTATION

EVALUATION

Front 3

it is the orderly collection of information concerning the patient’s health status

Back 3

Assessment

Front 4

*gathering SUBJECTIVE data, usually from the patient. Includes what the patient says and thinks. (attitudes/ beliefs)*some cannot be verified; while others can be confirmed through PHYSICAL ASSESSMENT .

Back 4

Health History

Health History

Front 5

Physical assessment

Back 5

*this includes OBJECTIVE DATA or information that is observable & measurable, can be verified by more than one person using the senses; this describes the systematic and comprehensive physical examination techniques that will elicit data.

*Data can be obtained in a BODY SYSTEM or HEAD TO TOE approach.

Front 6

*is a clinical judgment about individual, family or community responses to actual or potential health problems/ life processes

*provides a basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable by NANDA-I

Back 6

Nursing Diagnosis

Front 7

Descriptor / QUALIFIER

Back 7

describes or qualifies the human response – IMPAIRED, INEFFECTIVE, READINESS FOR ENHANCED

Front 8

Label or human response

Back 8

actual or potential health problem or wellness factors

Front 9

Related factors

Back 9

origin of the patient’s health problem and can be changed with nursing interventions “RELATED TO”

Front 10

Defining characteristics

Back 10

signs, symptoms, & statements made by the patient that validate the existence of the nursing actual or wellness nursing diagnosis. “ AS EVIDENCED BY”

Front 11

Goal

Back 11

-directed toward the removal of related factors or patient response to an adverse condition

-broad statement; not measurable

Front 12

Expected change in patient behavior demoting progress toward resolution f the altered human response over specified period of time. With time frame – short term and long term

Back 12

Outcome

Front 13

Planning

Back 13

PRIORITIZATION of nursing diagnoses and care and the selection of nursing interventions.

___________ determination of problems which are most vital to the patient’s well being at that particular time

Front 14

executes the interventions to meet the predetermined outcomes

Back 14

Implementation

Front 15

patient’s progress in achieving the outcomes is determined. (continual and a dynamic process)- MET or UNMET.

Back 15

Evaluation

Front 16

Assessment of a comprehensive information about the total patient (holistic), which includes P, M, E, D, S, C aspects. Patient’s past and present states of health, family status & relationships, cultural background, developmental level. Other factors: self concept, religious affiliation, social supports, sexuality, and reproductive processes.

Back 16

Nursing interview

Front 17

establish TRUST and get to know each other; define the relationship

Back 17

Stage 1-joining/intro

Front 18

bulk of the patient data is collected; includes refocusing and redefining the goals established in the 1st stage

Back 18

Stage II working

Front 19

information is summarized & validated; allow opportunity to give additional information & make comments or statements

Back 19

Stage III termination

Front 20

act of perceiving what is said verbally and nonverbally; primary goal is to decode patient messages in order to understand the situation or problem as the other persons sees it.

Back 20

Listening

Front 21

Factors affecting com

Back 21

Listening

NONVERBAL cues

Distance

Front 22

message without words

Back 22

Nonverbal cues

Front 23

Distances

Back 23

Intimate Distance - approx. 1.5ft

Personal Distance

Social Distance

Public Distance

Front 24

provides general rather than focused information; provides the patient a sense of control

Back 24

Open ended questions

Front 25

which regulate or restrict patient’s response; answered by YES or NO; can pinpoint specific areas of concern, elicit valuable information quickly & efficiently

Back 25

Closed question

Front 26

verbal and nonverbal means to encourage patients to continue talking

Back 26

Facilitating /facilitation

Front 27

can help structure & pace the interview; convey respect & acceptance

Back 27

Silence

Front 28

verbalize perceptions about the patient’s behavior—to validate

ex. “Speaking about these symptoms seems to make you tense.”

Back 28

Making observations

Front 29

involves repeating or rephrasing the main idea expressed by the patient; provides the patient with an opportunity to explain or elaborate on an issue/ concern

P: “I don’t sleep well anymore. I find myself waking up frequently at night.”

N: “You’re having difficulty sleeping?”

Back 29

Restating

Front 30

it focuses on the content of the patient’s message as well as the patient’s feelings, & ideas back to the patient & provides opportunity for the patient to reconsider or expand on what was just said

P: “I told the doctor that I had problems with this medication and he just didn’t listen.”

N: “Sounds as if you are angry with him.”

Back 30

Reflecting

Front 31

to make clear or to pinpoint the message when the patient’s words & nonverbal behavior do not agree.

P: “I have an awful pain in my back.”

N: “Tell me what you mean by awful.”

“I’m not sure that I follow you…when does this pain occur?”

Back 31

Clarifying

Front 32

RN has the opportunity to share inferences or conclusions gathered from the patient’s interview.

Back 32

Interpreting

Front 33

knowledge of time frame which symptoms/ problems developed or occurred; proper sequence of events; patterns of behavior

N: “Did this sharp pain occur each time you had sexual intercourse or only when you didn’t empty your bladder first?”

Back 33

Sequencing

Front 34

deal more effectively with unfamiliar situations in a context of something else familiar

N:”Have you had similar experiences?”

Back 34

Encouraging comparison

Front 35

a brief concise review of the important points covered helps the patient identify anything that has been left out; opportunity to make sure that what he understood the patient to say is actually what was said.

N: “During the past hour, you shared with me several health concerns of which is most disturbing to you is your difficulty in losing weight, is that correct?”

Back 35

Summarizing

Front 36

4 types of health history

Back 36

Complete

EPISODIC

Interval/ follow up

EMERGENCY

Front 37

comprehensive history of the pt’s past & present health status

Back 37

Complete

Front 38

shorter / specific to pt’s current reason for seeking health care

Back 38

Episodic

Front 39

shows progress from a prior visit, preceding visit to a healthcare facility

Back 39

Interval /follow up

Front 40

only information required immediately to treat the emergent need; life-threatening

Back 40

Emergency

Front 41

(History of the present illness)Signs and symptoms

Record as direct quote from the patient.

“What concern(s) brings you here today?”

“How long has this condition been concerning you?”

Back 41

Chief complaint

Front 42

PQRSTU

Back 42

Pqrstu

Front 43

1st & 5 minutes of life

Back 43

Apgar

Front 44

Apgar

Back 44

A - ctivity (muscle tone)

P – ulse (heart rate)

G – rimace (reflex irritability)

A – ppearance (skin color)

R – espiration (breathing & effort)

Front 45

Shows what a child can do at a particular age, not an intelligence test

Back 45

Denver I developmental screening test

Front 46

Is the most appropriate instrument to assess functional status as a measurement of patient’s ability to perform ADLs INDEPENDENTLY

Back 46

Katz index of independence in ADLs

Front 47

Katz index

Back 47

6 – full function4 – moderate impairment2 - severe functional impairment

Front 48

consists of 10 items that measure a person's daily functioning specifically the activities of daily living and mobility. The items include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on level surface, going up and down stairs, dressing, continence of bowels and bladder.

0= dependent, 5- needs some assistance 10= independent

Back 48

Barthel index

Front 49

assume every person is potentially infected; can transmit microorganism

- to prevent exchange of blood & body fluid

Back 49

Standard/universal precautions

Front 50

PPEs – Personal Protective Equipment

Back 50

gloves

-gowns

-masks

-eye protection

Front 51

maximum pressure exerted on the arterial wall at the peak of left ventricular contraction.

Back 51

Systolic

Front 52

30mmHg above the stopped pulse

Back 52

**Korotkoff sounds

Front 53

= 20 (distance from chart to patient)/20 (distance from which the person with normal vision could read the line)

Back 53

Snellen Chart – N

Front 54

to observe the eye’s internal structure. Green with positive number to focus on near objects such as cornea and lens.

Red with negative number to focus on distant objects such as retina.

Back 54

Ophthalmoscope

Front 55

used for examination of the patient’s auditory canal, tympanic membrane and malleus.

Below 3 years old – pull down

3 above – pull up the auricle

Back 55

Otoscope

Front 56

NOSE, MOUTH, LESIONS, PUPILLARY REACTIONS

Back 56

Penlight

Front 57

determining DTR

0 = absent impulses

+1 = diminished

+2 = normal

+3 = increased (maybe normal)

+4 = hyperactive

Back 57

Reflex hammer

Front 58

record the measurement at the nearest millimeter

- Used to measure the skin-fold thickness.

Back 58

Caliper

Front 59

-commonly used.

If has intact hymen, never given birth – use Pederson speculum (narrow blades)

Back 59

Speculum – “Graves’ speculum

Front 60

– to check for color, patency and examine the nostrils and inner nose.

Back 60

Nasal speculum (with the use of penlight)

Front 61

use to assess the conduction of hearing loss, impaired sound transmission to the inner ear, sensorineural hearing loss and impaired auditory nerve conduction

Back 61

Tuning fork

Front 62

most accurate atm

Back 62

Otoscopic Thermometer

Front 63

SOME TEAMS

Back 63

Symmetry – face & body

Old – appearance

Mental acuity – LOC

Expression – ill, in pain, anxious

Trunk – lean, obese, barrel-chested

Extremities – fingers clubbed, joint abnormalities

Appearance – clean, appropriately dressed

Movement – posture, gait (smooth & effortless, controlled, purposeful)

Speech – understandable, clear, slurred, respond to questions & commands easily

Front 64

Major componets ABCT

Back 64

Remember ABCT

(Appearance – body movements,

Behaviour – LOC/facial expression,

Cognition – orientation/memory,

Thought Process – perception/suicidal tendencies)

Front 65

normal) – awake; readily aroused

Back 65

Alert

Front 66

somnolent) – not fully alert; drifts of to sleep when not stimulated (name in normal voice, drowsy)

Back 66

Lethargic

Front 67

sleeps most of the time; needs to shout or vigorous shake

Back 67

Obtunted

Front 68

spontaneously unconscious; only to vigorous shake or pain

Back 68

Stupor /semi-coma

Front 69

completely unconscious; no response to pain or stimuli

Back 69

Coma

Front 70

transitional state between Lethargy and Stupor

Back 70

Obtunted

Front 71

* Measure height for patients in wheelchair or has scoliosis. –

Back 71

“Wingspan Technique”

Front 72

Pain scale for children

Back 72

Wong Baker’s pain scale

Front 73

ongoing process-vision

color, size, location, movement

symmetry-smell

- odor-hearing

- ex. Wheezing

Back 73

Inspection

Front 74

act of touching

short finger nails, warm hands

if with pain  palpate tender areas last

Use standard precaution

Back 74

Palpation

Front 75

best for fine tactile discrimination (texture, lumps)

Back 75

Fingertips

Front 76

– position, shape and consistency of organ and masses

Back 76

Grasping action of fingers and thumb

Front 77

temperature due to the skin is thinner than on palms

Back 77

Back of hands and fingers –

Front 78

Vibration

Back 78

Base of fingers (metacarpophalangeal)/ ulnar surface

Front 79

assess for surface abnormalities, texture, tenderness, temperature, pulsations, and masses

Back 79

Light Palpation

Front 80

= feel internal organs and masses (4 to 5 cm deep)

Back 80

Deep Palpation

Front 81

involves striking of finger/ hands against a body part to cause vibration to produce sound

Most frequent site: Thorax & Abdomen

Intensity, duration, pitch, quality, & location

Back 81

Percussion

Front 82

loudness/softness of sound

Back 82

Intensity

Front 83

time period over which a sound is heard when elicited

Back 83

Duration

Front 84

highness/lowness of sound (relative to frequency), measure as ‘cps’ (cycles per second) or vibrations per second

Back 84

Pitch

Front 85

– how one perceive it

Back 85

Quality

Front 86

index and middle fingers (for sinuses)

Back 86

Direct Percussion

Front 87

are a group of four paired air-filled spaces that surround the nasal cavity.

The maxillary sinuses are located under the eyes;

the frontal sinuses are above the eyes;

the ethmoidal sinuses are between the eyes

the sphenoidal sinuses are behind the eyes.

Back 87

Paranasal sinuses

Front 88

**extend the middle finger of nondominant hand (“pleximeter”), middle finger of the dominant hand as the striking hand (“plexor”)

Back 88

Indirect Percussion

Front 89

use of stethoscope (breath sounds, heart sounds, bowel sounds)

note the intensity and location

Back 89

Auscultation