Assessment Techniques & Safety in the Clinical Setting: Ch. 8

Question 1

What is the Nursing Process?

Answer 1

AAPIE
-Assessment: collection of subjective (1st) and objective data (2nd)

• Analyze: interpret and analyze data by comparing clinical findings with normal and identifying clusters that are associated (form a hypothesis)
• Planning: identify expected outcomes (goals); prioritize (level 1 - 3)
• Implementation: Implement evidence based interventions (EBI), collaborate with providers, health teaching, coordinate delivery of care, documentation
• Evaluate: Compare actual outcomes with goals; identify reasons for failure to achieve goals and take corrective action to modify plan of care.

Question 2

What are the critical thinking priorities during the planning phase of the nursing process?

Answer 2

1st Level: ABC + Vitals
Airway, Breathing, Cardiovascular + abnormal vitals and labs

2nd Level: Everything else physical
Pain, elimination

3rd Level: Psychosocial, coping, education

Question 3

What is the magic nursing question?

Answer 3

“can you tell me more about how you are feeling?”

Question 4

What 7 items are included in the Complete Health History?

what type of data is obtained?

Answer 4

Subjective Data!
-Biographical: name, contact info. DOB, birthplace, gender, marital status, race, occupation, primary language

• Chief complaint
• History of present illness (HPI): PQRSTU
• Past Medical History (PMH): illness, hospitalization, immunizations, operations, last exam, allergies, medications
• Family History of disease
• Review of Symptoms: HTTA, abnormal symptoms for each body system, health promotion activities
• Functional Assessment (preception of health): education level, activity and exercise, ability to preform ADLs, sleep & rest, nutrition and elimination, personal habits (smoking, drinking, drugs), intimate partner violence, occupation health

Question 5

What is the nursing assessment?

Answer 5

IPPA = “I’ll Properly Preform Assessment”

• Inspection: visual exam of the body
• Palpitation: using hands to feel
• Percussion: using hands to determine density & organ location
• Auscultation: listening to sounds in the body using a stethoscope

Question 6

Stethoscope: diaphragm vs bell

Answer 6

-Diaphragm: high-pitched sound, normal heart sounds, bowel, breath
Used most of the time

-Bell: soft, high-pitched sound, extra heart sounds, murmurs, bruits (abnormal murmur heard through a stethoscope).
Press lightly when using

Question 7

Moro Effect

what it is, and when to do it during the exam

Answer 7

The “startle” reflex measured in infants. Do at the end of the exam as it may cause the baby to cry.

Question 8

Emphysema

what will it sound like during percussion

Answer 8

A lung condition that causes shortness of breath. The air sacs in the lungs (alveoli) are damaged resulting in an accumulation of air in the alveoler spaces

-During percussion will sound hyperresonate

Question 9

Things to be mindful of when assessing an adolescent

Answer 9

• Work around clothing as much as possible
• Give constant feedback while assessing
• Provide privacy by ensuring the parent is not in the room
• Use the HTTA
• Do not treat them like a child, but do not overestimate and treat them like an adult either
• Positive attitudes developed now may last through adult life. Focus your health teaching on ways the adolescent can promote wellness