Assessment Flashcards
What are the two main areas of assessment?
Health history and physical assessment
What begins the nursing process?
Assessment
What are the four major assessment activities?
Collection
Organization
Validation
Documentation
What is a collection or store of information?
Data base
Clients description of the problem
Subjective Data
Detectable by an observer. Something seen, heard, smelled, or felt.
Objective Data
Who states Administer assessment done to determine each persons need for nursing care?
Joint Commission
What is the purpose of assessment?
To enable the nurse to make a judgment or diagnosis about the patients health state.
What is identified as the purpose of assessment?
- The deviations from normal
- The clients health beliefs and patterns of health illness
- The presence of risk factors for physical and behavior health problems
- The patients resources for support and adaption
Is a continuous process carried out during all phases of the nursing process
Assessment
What are the 5 components of the nursing process?
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
What is collected so problems are identified?
Initial data
What are the 4 types of assessments?
- Initial
- Problem-focused
- Emergency
- Time-lapsed
All the information about a client including past history and current problems
Baseline data or database
What is the purpose of data collection?
To provide information or identify patient needs. It need to be continuous and symptomatic without omission.
Who is the primary source of data?
Client and they are the best source
Who is the secondary source of data?
Support people, medical charts, client records, diagnostic studies, record of therapies etc
What is the pupils normal size?
3-5mm
What does PERRLA stand for?
Pupils round reactive to light accommodation
Skin springs back
Elastic
Skin is slow to return
Tenting
20 - 30 seconds of skin tenting indicates what?
Dehydration
Decreased skin turgor is a late sign of what?
Dehydration
What is anosmia?
Unable to smell
Normal breath sounds are?
Soft and breezy
What is the major breath sound?
Vesicular: best at the base of the lungs. Soft intensity. Low pitched.
What are abnormal breath sounds?
Adventitous breath sounds
Musical or constant pitch?
Continuous adventitous breath sounds
Intermittent, cracking, bubbling
Discontinuous adventitous breath sounds
Where does the heart lie?
Behind and to the left of the sternum
PMI is found where?
At the apex of the heart
Area of the chest above the heart is?
Precordial
Aortic valve can hear?
S1
Mitral valve can hear?
S2
Which valves are responsible for LUB?
Atrioventricular (atrial, tricuspid)
Which valves are responsible for DUB?
Semilunar (aortic and pulmonary)
Systole
Ventricles contract
Diastole
Ventricle relax
What percentage is the atrial kick?
30% or more
Bruit or thrill indicates what?
Turbulent blood flow
You can ______ the bruit and ______ the thrill
Hear, feel
Decrease or absent pulse and hair, pallor with elevation, nails thick, skin cool, shiny, and dry, ulcerations on bony points.
Arterial insufficiency
Edema, ulcers, brownish color, warm, scaling eczema, pulse unaffected.
Venous insufficiency
Inspect external jugular vein and interior jugular vein for JVD at what angle?
45 degree
The abdomen is divided by:
A vertical line from Xiphoid process to Symphysis pubis and a horizontal line across the umbilicus
High pitch and air-filled indicates
Tympany
Dull and solid or fluid filled
Resonance
Awake and responsive
Alert
Sleepy but arousable
Lethargic
Obtunded
Needs to be shaken
Arouses with difficulty
Stuporous
Not arousable
Comatose
What is the babinski sign?
Toes bend = negative
Toes flair = positive (but is normal in a baby)
What is validation of data?
Double checking
SLIDE
Single line initial date error
A head to toe assessment is called?
Cephalocaudal
