BN4 The Nursing Process Flashcards
What term describes the act of listening for sounds within the body?
Auscultation
What term describes information that you obtain through the use of the senses?
Cue
What position is a patient in when lying on their back in the supine position, with the knee flexed, used for assessing the head, neck, anterior thorax, lungs, axillae, heart, abdomen and extremites?
Dorsal Recumbent
What term describes judgement or interpretation based off cues?
Inference
What is a technique used in physical examination to carefully and critically examine the body using the sense of sight?
Inspection
What position is a patient in when lying supine with hips and knees flexed and the thighs abducted and rotated externally?
Lithotomy position
What examination technique is being used when assessing texture, size, consistency and location of certain parts of the body with the hands?
Palpation
What technique of physical exam consist of tapping the body with fingertips to evaluate the size, boarders and consistency of some internal organs and to discover the presence and evaluate the amount of fluid in a cavity of the body?
Percussion
What term describes using the sense of small during a physical examination?
Olfaction
What position is a patient in who is in a side lying position on either side, with the top leg flexed toward the abdomen?
Sim’s Position
What occurs when the nursing process is done in order and with good communication?
Nursing care is organized and has a purpose, Nursing team members have the same goals for the patient, Patient feels safe and secure
What are the five steps in the nursing process?
Assessment, nursing diagnosis, planning, implementation and evaluation
What part of the nursing process is described by the deliberate and systematic collection of data to determine a patient’s current and past health status?
Assessment
What term describes a clinical judgement about an individual, family or community response to actual and potential health problems and life processes?
Nursing diagnosis
What is the difference between a nursing and a medical diagnosis?
Medical Dx describes a disease or condition, nursing Dx is formulated based on patients needs because of the medical Dx
What is considered when developing a nursing Dx?
Physcial Needs
Emotional needs,
Social needs,
Spiritual needs
In what part of the nursing process are diagnoses prioritized to meet the patients immediate needs?
Planning
What part of the nursing process is performing or carrying out the nursing measures using interventions developed during planning?
Implementation
What part of the nursing diagnosis would you determine whether the patient’s condition or well being has improved?
Evaluation
What is a patient medial Hx used for?
Establish rapport, provide a focal point for the physical assessment, Aid in ordering appropriate tests, institute appropriate treatment
What information should you obtain in the past medial Hx?
Allergies, Pertinent treatment, Hospitalizations, surgeries, Illnesses, risk factors, medications, alcohol or tobacco use, sleep hygiene, diet
What does the examiner uses physical assessments for?
Gather baseline data regarding the patients health, Supplement, confirm, or refute previously gathered data, confirm and identify diagnosis, make clinical judgements about the patients health status, evaluate the physiological outcomes of care
what are the basic guidelines when obtaining a medical Hx?
Maintain patient confidentiality, Prepare the environment, Conduct the interview
What guideline for obtaining a medical hx are you following when you ask a patient “what brings you to see us today?”
Conduct the interview
What information should you ask in environmental Hx?
Do you live alone? Do you have Transportation? What is your work environment?
What questions should you ask when obtaining a psychosocial Hx?
Do you have a support system? How do you cope with stress?
what piece of examination equipment assess automatic responses to a given stimulus?
Percussion/reflex hammer
What can a mouth mirror be used for?
Reflects light, retracts tongue and tissue, protects oral mucosa from injury
What can an Explorer be used for?
Detect breaks in the enamel, check severity of decay, locate popcorn husks, tooth pick fragments
What dental instrument has a long blunt working end calibrated from one to ten mm and is used to check the periodontal pockets?
Peridontal probe
What is a tweezer like instrument used to transport small items to and from the mouth?
Cotton Forceps
What are the five basic skill involved in physical examination?
Inspection, palpation, percussion, auscultation, smell
What part of the hands are best for feeling texture, moisture and shape?
Fingertips
What part of the hands are best for feeling vibration?
Palmar
What part of the hand is best for feeling temperature?
Back of the hand
What should you allow your patient to do before examination?
allow them to relieve their bowel or bladder, provide collection cups if needed
What can you do to help alleviate a patient’s anxiety about a physical exam?
Educate the patient on the procedures and the purpose of the examination. As you complete each body system give detailed explanation to the patient. convey open, receptive approach, allow and encourage questions
