Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
116 Cards in this Set
- Front
- Back
Define nursing assessment, include the four features common to all its definitions |
The systematic Gathering of information related to the physical, mental, spiritual, socio-economic, and cultural status of an individual, group, or community. |
|
Although various definitions exist in the nursing process, all definitions of assessment include the following features: |
Collecting data, categorizing data, recording data, and using a systematic and ongoing process |
|
How does assessment relate to diagnosis in the nursing process? |
Assessment provides the data necessary for identifying the client's health problems and strengths |
|
How does an assessment relate to planning outcomes in the nursing process? |
Data about the patient's motivation, family, and available resources help you formulate realistic goals |
|
How does assessment relate to planning interventions in the nursing process? |
Assessment data can help you choose the interventions most likely to be acceptable to and effective for the client. |
|
How does assessment relate to implementation in the nursing process? |
As you perform nursing actions, you will also gather data by observing the clients responses. |
|
How does assessment relate to evaluation in the nursing process? |
After performing interventions for existing diagnosis, you assess the client's responses. This reassessment provides the basis for changes in the care plan. |
|
State the ANAs position on delegating assessment. |
The registered nurse collects comprehensive data pertinent to the healthcare consumers health and/or situation. |
|
Name the three requirements of The Joint Commission regarding patient assessment |
1. Assessments are written, comprehensive, and used to identify and assign priorities for care. 2. Agency policy designates when each patient is to be reassessed and which disciplines can make which assessments. 3. All patients are assessed for pain |
|
Subjective data |
Information communicated to the nurse by the client, family, or community. Reveals that perspective, thoughts, feelings, beliefs, and sensations of the person giving the data |
|
Objective data |
Gathered through a physical assessment or from a laboratory diagnostic tests, they can be measured or observed by the nurse or other healthcare providers |
|
Primary data |
The subjective and objective data obtained from the client: what the client says or what You observe |
|
Secondary data |
Obtained from the medical record or from another caregiver such as family member |
|
Initial assessment |
Completed when the client first comes to the Health Care Agency. The data related to the person's reason for seeking nursing or medical assistance. |
|
Comprehensive assessment |
Provides holistic information about the client's overall health status. Include subjective and objective data about the client's body systems and functional abilities, emotional status, spiritual health, and psychological situation including the information about the family and community. Enables you to identify client problems and strengths. |
|
Ongoing assessment |
Performed as needed, at any time after the initial database is completed. |
|
Focused assessment |
Perform to obtain data about an actual, potential, or possible problem that has been identified or is suspected. Focuses on a particular topic, body part, or functional ability rather than overall health status |
|
Whether the assessment is initial or ongoing, comprehensive, or focused, you will use these skills of |
Observation, physical assessment,nursing interview |
|
What are the procedures of the physical assessment? |
Inspection, palpation, percussion, auscultation |
|
Observation and visual examination of the client, as well as the use of equipment such as an otoscope or ophthalmoscope |
Inspection |
|
Light touch, progressing to deeper touch, using the pads of the fingers |
Palpation |
|
Striking a body surface with a tip of a finger, produces different vibrations and sounds depending on what's under the area that is tapped. For example air, fluid, or solid. |
Percussion |
|
Listening with the unaided ear for sounds made by the client and listening using the stethoscope for Normal and abnormal sounds within the body |
Auscultation |
|
List special needs assessments |
Functional ability assessment, nutritional assessment, pain assessment, cultural assessment, spiritual health assessment, psychosocial assessment, Wellness assessment, family assessment, Community assessment. |
|
Identify at least four components of a nursing health history and state the purpose of each |
Biographical data, Chief complaint, family health history, medication history and device use |
|
Interview used to obtain factual, easily categorized information, or in an emergency situation. In this type of interview you control the topics and ask mostly closed questions |
Direct interviewing |
|
In this type of interview you will allow the patient and control the subject matter. You want to promote communication, build rapport, or help the patient Express their feelings |
Non-directive interviewing |
|
Examples of closed and open ended questions |
|
|
When should you validate data? In which circumstances? |
Abnormal readings of Vital Signs such as high blood pressure when the patient states they don't have high blood pressure, abnormal temperature, abnormal heart rate |
|
Nursing Frameworks to organize data |
|
|
State four guidelines for documenting data |
Document as soon as possible, write neatly legibly and in Black Ink or record electronically, use acronyms sparingly, record only the most important patient words, record cues not inferences |
|
Difference between cues and inferences |
|
|
What are the purposes of a physical examination? |
.To obtain Baseline data . To identify nursing diagnosis, collaborative problems, and wellness diagnosis . To screen for health problems |
|
Two different approaches to a physical examination |
Head to toe approach Body systems approach |
|
How do you prepare for an examination? |
Prepare yourself, prepare the environment, prepare the client |
|
Position used to assess Vital Signs, head and neck, chest, cardiovascular system, and breast. If your client is Wink he may need assistance to maintain this position |
Sitting position |
|
Position used to assess the abdomen, breast, extremities, impulses. If your client becomes short of breath, raise the head of the bed to Fowler's position |
Supine position |
|
Position used for abdominal assessment if your client has an abdominal or pelvic pain. |
Dorsal recumbent position |
|
Position used for a female pelvic exam, provides maximum exposure of the genitals |
Lithotomy position |
|
Used to examine the rectal area. Use for a female pelvic exam if the patient is unable to assume lithotomy position. Do not use if the client has had a total hip replacement |
Sims position |
|
Position used to examine the musculoskeletal system, especially hip extension, may also be used to examine the back and buttocks. May be difficult to assume by clients with respiratory problems |
Prone position |
|
Position used to evaluate heart murmur or during a thorough cardiovascular assessment. |
Lateral recumbent position |
|
Position provides good visualization for examining the rectal area. However it is not often used because it's embarrassing and uncomfortable for the client |
Knee to chest position |
|
Explain adaptations that may be required when you examine clients of various ages |
Page 486 |
|
The General Survey |
Your overall impression of the clients. Begins at first contact and continues throughout the examination |
|
What are the components of a General survey? |
.appearance and behavior .body type and posture .speech .dress, grooming, and hygiene .metal state .vital signs .height and weight |
|
Components used to perform a skin assessment |
.observe skin color .observe lesions if any .temperature .moisture .texture .skin tie for .edema |
|
Extreme paleness; May be related to poor circulation or low hemoglobin level, anemia. Sites to assess for this include the oral mucous membranes, conjunctiva, nail beds, palms, and soles of feet |
Pallor |
|
Blue gray coloration of the skin, often described as Ashen. If seen on the lips, tongue, mucous membranes, and facial features, is associated with hypoxia. |
Cyanosis |
|
Widespread, diffuse area redness |
Flushing |
|
Reddened area associated with rashes, skin infections, prolonged pressure on skin, or application of heat or cold |
Erythema |
|
Tiny, pinpoint red or reddish purple spots |
Petechiae |
|
Bluish marbling In newborns that can indicate over-stimulation of the autonomic nervous system |
Mottling |
|
Benign, bluish black birthmarks that occur in the lower back and buttocks of black, Hispanic, Native American, and Asian babies |
Mongolian spots |
|
Small, irregular pinkish-red areas that are often seen around the face and nape of the neck in newborns |
Capillary hemangiomas |
|
Light brown birthmarks that can occur anywhere on the body |
Café-au-lait Spots |
|
Disorders that can cause the skin to become coarse, thick, and dry |
Hyperthyroidism and other endocrine disorders. |
|
Leisons that Develop as a result of disease or irritations. |
Primary skin lesions |
|
Lessons that develop from result of continued illness, exposure, injury, or infection. |
Secondary Skin Lesions |
|
Warning signs of malignant skin lesions |
Asymmetry Border irregularity Color variation Diametee greater than 0.5 cm Elevation above skin surface |
|
What can hyperthyroidism do to hair texture? |
Very fine and silky hair |
|
What can hypothyroidism do to the hair? |
Exceptionally Dry and coarse hair |
|
Pediculosis |
Head lice infestation |
|
Hirstuism |
excess facial or trunk hair that may be due to endocrine disorders or steroid use |
|
Cradle Cap |
Scaly white patches over the scalp due to secretion of sebum- is common |
|
Thickened nails may result from |
poor circulation |
|
a thick nail with yellowing is an indication of fungal infection known as |
onchomycosis |
|
brittle nails are seen with which diseases |
hyperthyroidism, malnutrition, calcium and iron deficiency, and repeated use of harsh nail products |
|
soft, boggy nails are seen with |
poor oxygenation |
|
hydrocephalus |
an accumulation of excessive cerebrospinal fluid |
|
a disorder of the head associated with excess growth hormone |
acromegaly |
|
an abnormally small head size, seen in clients with certain times of mental retardation |
microcephaly |
|
a growth or thickening of conjunctiva from the inner canthus toward the iris |
pterygium |
|
an everted eyelid, commonly seen in older adults secondary to loss of skin tone. can lead to excessive dryness of the eyes. |
ectropion |
|
en inverted eyelid, can lead to corneal damage |
entropion |
|
drooping of the lid, may be seen in clients who have experienced a CVA or Bell's palsy |
ptosis |
|
yellow sclera that may be seen with elevated bilirubin (yellow) |
icteric |
|
blood visible in the sclera that may be related to trauma or hypertension |
subconjunctival hemorrhage |
|
Lens opacities frequently seen in older adults that can impair vision |
cataracts |
|
when the pupils constrict and eyes converge (cross) as a person attempts to focus on an object moving toward him. |
accommodation |
|
When pupil accommodation is normal it should be charted as |
PERRLA Pupils Equal Round Reactive to Light and Accommodation |
|
Failure of one or both pupils to accomodate may reflect cranial nerve III problem or bulging eyes: Associated with hyperthyroidism |
Exopthalmos |
|
Enlarged pupils that may be seen with glaucoma, an increase in intraocular pressure |
mydrasis |
|
constricted pupils often seen results from medications to treat glaucoma |
miosis |
|
unequal pupils may be seen with central nervous system disorders such as stroke, head trauma, or cranial nerve injuries |
aniscoria |
|
What chart measures from a distance of 20 feet to assess distance vision? |
The Snellen Chart |
|
diminished distance vision |
myopia |
|
diminished near vision |
hyperopia |
|
What do you use to test for color blindness? |
Ishihara Cards |
|
Cross eye, a condition in which one or both eyes deviate from the object they are looking at |
Strabismus |
|
Which cranial nerve innervates the superior rectus muscle? |
Cranial Nerve III
|
|
Which cranial nerve innervates the lateral rectus muscle? |
Cranial Nerve VI |
|
Which cranial nerve innervates the inferior rectus muscle? |
Cranial Nerve III |
|
Which cranial nerve innervates the inferior oblique muscle |
Cranial Nerve III |
|
Which cranial nerve innervates the medial rectus muscle? |
Cranial Nerve III |
|
What cranial nerve innervates the superior oblique? |
Cranial nerve IV |
|
Which two eye muscles have different nerve innervation than the rest? |
>Lateral rectus (VI) >Superior oblique (IV) |
|
Constant strabismus of one eye may result in "lazy eye" : The eye is not correctable |
amblyopia |
|
The tympanic membrane and cavity, the eustation tube, and the ossicles make up the |
Middle Ear |
|
Hearing involves transmission of sound vibrations and generation of nerve impulses along which cranial nerve? |
CN VIII |
|
Hearing test that assesses sound vibrations and nerve impulses |
The Weber test |
|
Hearing test that tests air conduction and bone conduction. |
Rhinne Test |
|
Which conduction of hearing is susally twice as long as the other? BC or AC? |
Air conduction |
|
What test is used for testing balance? |
Romberg Test |
|
Thick elevated white patches in the mouth or throat that do not scrape off and may be precancerous lesions |
Leukoplakia |
|
Fungal infection in the mouth |
thrush |
|
Vocalization |
phonation |
|
What are reflexes present at birth? |
rooting, sucking, palmar grasp, tonic neck reflex (fencing), and Moro. |
|
What is the first sign of neurological deterioration? |
Decreased level of consciousness |
|
Arousal is based on what type of stimuli? |
Auditory, tactile, or painful (an alert patient responds to auditory stimuli) |
|
Define alert |
follows commands in a timely fashion |
|
define lethargic |
appears drowsy, easily drifts off the sleep |
|
define stuporous |
requires vigorous stimulation before responding |
|
define comatose |
does not respond to verbal or painful stimuli |
|
Refers to the client's awareness of time, place, and person |
Orientation |
|
What do mental status and cognitive function include? |
Behavior Appearance Response to stimuli, speech, memory, communication, and judgement. |