• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/116

Click to flip

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.