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32 Cards in this Set
- Front
- Back
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What is an assessment? |
Collection of data which identifies a patient's current and past health status; functional health status; present and past coping. Provides a baseline against which future changes can be evaluated. Enables nurse to make clinical judgments and obtain necessary resources. |
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How do you get people to tell you personal things and allow you to asses them? |
Establish a rapport! Be open, responsive, and non-judgmental. |
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What is involved in psychosocial comfort? |
Privacy, smiling, therapeutic communication, personal questions in a professional way, and organization (have a plan)! |
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What is the difference between medical history vs. nursing history? |
Medical history is information gathered by all team members. Nursing history is data collected about a patient's level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness. Underlining rationale is different. |
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Where do you start the baseline assessment? |
With the patient's primary problem. |
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What does the PQRSTU pseudonym mean? |
P = Provoke + Palliative Q = Quality + Quantity R = Region + Radiation S = Severity T = Time U = Understand (patient's perception) |
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What kind of questions to ask with Provoke + Palliative? |
What makes your pain better? What makes it worse? |
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What kind of questions to ask with Region + Radiation? |
Show me where your pain is. Does the pain radiate? |
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What kind of questions to ask with Quality + Quantity? |
Tell me what your pain feels like. Describe the pain. |
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What kind of questions to ask with Severity? |
On a scale of 0-10, 0 being no pain and 10 being the worst pain possible, what does your pain feel like? |
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What kind of questions to ask with Timing? |
Is the pain constant or intermittent? Does the pain increase during specific times of the day, or during certain activities? |
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What equipment do you need for an assessment? |
Penlight, stethoscope, and vital signs. |
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What causes inaccurate data? |
Disorganization, irrelevant data, unaccepted abbreviations that are not common. |
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When you palpate radial pulse, what can you learn? |
Is it regular or irregular? Is their skin dry, clammy, moist, or diaphoretic (sweaty)? Is their pulse regular, weak, or bounding? |
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What is auscultation? |
Involves listening to sounds the body makes to detect variations from normal. |
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If you smell fruity breath, what does that mean? |
Diabetes. |
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If you smell sulfur, what does that mean? |
UTI. |
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If you smell horrible diarrhea, what does that mean? |
C-diff. |
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Why do you auscultate before palpation? |
Palpation may stimulate bowel activity and falsely increase bowel sounds. |
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What does GCS stand for? |
Glasglow coma scale. Eye opening, best verbal response, and best motor response. |
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What is the A-H inspection? |
Airway, Breathing, Circulation, Deficit (neuro), Expose, Fahrenheit, Get vital signs and Give comfort, and Head-to-Toe focused assessment. |
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What is a clinical manifestation? |
The way a disease presents itself to the patient: it can be something he or she feels, or a symptom that manifests itself (objective vs. subjective) |
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What is involved in physical comfort during a PA? |
Warmth, addressing basic human needs, pain management. |
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What is the most used technique during a physical assessment? |
Inspection; you need to look for normal and abnormal findings |
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Bradypnea respiratory pattern |
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Trachypnea respiratory pattern |
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Cheyne-Stokes respiratory pattern |
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If a patient has less than 8 on the GCS, what are you going to do? |
Get ready to intubate. More occuring in coma patients. |
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During acute care, what do you need to do? |
Regulate temperature, maintain neurological function, maintain fluid and electrolyte imbalance, promote bowel elimination and nutrition, promote urinary elimination, and promote wound healing. |
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What is the order of head-to-toe assessment? |
Neurological, Respiratory, Cardiovascular, Gastrointestinal, Gastrourinary, Musculoskeletal, Integumentary. |
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What are the valves located when auscultating for sounds? |
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Where is the apical pulse? |
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