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Health Assessment > Ch 1 > Flashcards

Ch 1 Flashcards

1
Q

What are nurses in relation to healthcare

A

The backbone of healthcare

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2
Q

Why must a health history be complete and accurate

A

For decision making in an accurate nursing diagnosis

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3
Q

What is the American nurses association (ANA) and what does it promote? What does it give and guide

A

A professional nursing organization that promotes:

  • optimal function
  • wellness of body, mind, spirit

The American nurses association gives and guides nursing goals

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4
Q

What are the four broad nursing goals

A

-To promote health
(through teaching)

  • to prevent illness and injury
    (through teaching)
  • to treat human responses to health or illness
    Holistically

-to advocate for individuals, families, communities, populations
Nurses aka guardians of health

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5
Q

What is known as advocating for underserved populations to decrease disparities

A

Known as promoting social justice

(ensuring equal treatment for all)

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6
Q

Define social justice

A

Ensuring equal treatment for all

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7
Q

What are 3 roles of nurses for protection

what three areas do they protect and take responsibility of

A
  1. Ethical (patient)
  2. Legal
  3. Safety
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8
Q

List the legal responsibilities a nurse must protect from

A
  • Assault (threat)
  • Battery (laying hands)
  • Defamation
  • Negligence
  • Malpractice
  • Breach of confidentiality (HIPPA)

 -False imprisonment (restraining for convenience)

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9
Q

What does a scope and standards of practice and code of ethics for nurses address

A

It addresses nursing values “behavior”



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10
Q

Give the nursing values in the code of ethics and briefly describe

(5)

A

Altruism
: concerned for welfare of othersHuman dignity
: showing respect ensuring privacy and confidenceAutonomy
: right to make decisionsIntegrity
: always providing honest infoSocial justice
: equal treatment for all

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11
Q

Define altruism as a nursing value

A

Concern for welfare of others

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12
Q

Define human dignity as a nursing value

A

Showing respect and ensuring privacy and confidence

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13
Q

Define autonomy as a nursing value

A

The right to make decisions

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14
Q

Define integrity as a nursing value

A

Always providing honest information

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15
Q

Define social justice as a nursing value

A

Equal treatment for all

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16
Q

Give the different types of nursing interventions (4) and a description of each

A
  1. Dependent nursing interventions
    • requires doctors orders
  2. Independent nursing interventions
    -done alone
    • teachings, vitals, monitoring
  3. Collaborative interventions
    • help from others
      • ambulating , turning
  4. Inter-dependent interventions
    • progression of treatment
      • clear to bland diet
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17
Q

What are care responsibilities of a nurse for a patient

A

Patient teachings, therapeutic communication, and physical procedures

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18
Q

Define what it means to be a member of the profession

A

To be a lifelong learner and continuing education

Being an advocate for your patient and profession and upholding values ( altruism, human dignity, autonomy, integrity, social justice)

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19
Q

Who is considered a professional nurse

A

A nurse with a bachelors in the science of nursing

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20
Q

What are unique things that advanced practice nurse may do within their scope of practice for patients

A

Advanced practice registered nurses may prescribe and write orders some can even work independently

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21
Q

Give the verbatim definition of health assessment

A

Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes

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22
Q

What is complete and accurate data in relation to patient outcomes

A

Complete and accurate data = accurate diagnosis= Wanted outcomes

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23
Q

Give the two components of health assessment (equation)

A

Health assessment = health history (interview) + physical assessment

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24
Q

What are other components of a health assessment that are not commonly described

A

Psychological, socio cultural, spiritual, economic, lifestyle

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25
Q

How does the nursing process begin

A

With a complete and accurate health assessment

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26
Q

What is wellness oriented towards

A

Maximizing the potential function of ADL

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27
Q

Define Healthy People*

A

A National model for health promotion, risk reduction that aims to increase length and quality of life and eliminating Health disparities

28
Q

How often are healthy people goals reevaluated and revised

A

Every 10 years

29
Q

Give the healthy people 20 2010 goals

A 
Physical activity
Overweight/obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and violence
Environmental quality
Immunization
Access to healthcare
30
Q

What are outcomes associated with in the nursing process

A

Outcomes are associated with teachings

31
Q

What is primary prevention And examples

A

Primary prevention is preventing and educating

  • immunizations
  • Health teachings
  • Safety
32
Q

What is secondary prevention and examples

A

SS secondary = screenings for early diagnosis and treatment

  • mammo/ Pap smears/ colonoscopy
  • vision/hearing/scoliosis
  • TB
33
Q

What is tertiary prevention and examples

A

Tertiary is preventing complications of disease and promoting highest level of health

  • diet teachings
  • Exercise
  • Administration of pain medications*
34
Q

ADPIE: A

Give all related info

A

Assessment: collect data

S: says ( subjective)
O: observe (Objective

Prioritize
ABC/CAB
Maslow‘s
Acute v chronic
Actual (now) v potential (risk)

P-roblem
E- tology (R/T)
S- S&s (AEB)

35
Q

ADPIE: D

Give all related info

A

Diagnosis : data clustering

NANDA

P-roblem
E- tology (R/T) >actual
S- S&s (AEB)

E- tology (R/T) > potential
S- S&s (AEB)

36
Q

ADPIE: P

Give all related info

A

PLANNING

Long term/ short term

S- pacific 
M-easurable (#)
A- attainable
R- esult oriented 
T- ime framed (time and date)
37
Q

ADPIE: I

A

Implementation/intervention: treatment

Collaborative
-dependent
-independent

38
Q

ADPIE: E

A

Evaluation

Met/ unmet/ partially met
After evaluation go back to planning

39
Q

Define ADPIE (book definition)

A

A scientistic systematic problem solving approach

40
Q

Is ADPIE linear

A

No, it’s overlaps

41
Q

Define critical thinking

A

Critical thinking= clinical reasoning/ clinical judgement

: that ability to understand and act on what you know about the nursing content

42
Q

Define diagnostic reasoning

A

Proposing a diagnosis

Gathering and clustering data to draw interference and propose diagnosis

43
Q

Give the 7 step process of diagnostic reasoning

A
  1. id ab/norm +strengths and weaknesses
  2. Cluster data
  3. draw inferences
  4. propose nursing diagnosis
  5. check for defining characteristics
  6. Confirm and rule out nursing diagnosis
  7. Document
44
Q

Describe and Give requirements for emergency assessment

Is there anything done simultaneously?

What is it based on?

A

Done in life-threatening and unstable situations

  • perform intervention simultaneously in emergency assessment

Based on A, B, C, D, E

45
Q

give meanings of ABCDE

A

A-irway (protects C spine)

B- reathing (rate/ depth)

C- irculation (rate/ rhythm, color)

D - isability (loc)

E - exposure

46
Q

Describe and Give requirements for comprehensive assessment

When is A comprehensive Assessment usually done in the hospital and long term care facility

A

Comprehensive = head to toe

A complete health history and physical assessment

During admission In hospitals in long-term care settings

47
Q

Describe and Give requirements for focused assessment

A

FOCUSED = SPECIFIC

A focused assessment is smaller in scope but assess body systems SPECIFIC to signs and symptoms

48
Q

What is the most important skill in nursing based on critical thinking and clinical reasoning

A

Priority setting

49
Q

What situation is of the upmost priority and what do you use to prioritize pt care during the situation

A

Life-threatening situations are top priority, look at what will save lives

Based on ABC DE & CAB

50
Q

What is acuity, what is high acuity and what is low acuity

A

Acuity is level of severity of illness

High acuity is very severe

Low acuity is moderately severe

51
Q

What determines the frequency of assessment

A

Mainly pt need but it varies based on the standard of care by the facility (how often they choose)

52
Q

How often do you do a comprehensive assessment in a long-term care facility (I.e. nursing home) v icu

A

Once a month
V
Q shift

53
Q

How often do you do it focused assessment post treatment

A

About 30 minutes after meds

54
Q

When are times in life when will visit assessments are most frequently done
(2 answers)

A

Birth -10: for g&d

65+: for treatment of illnesses

55
Q

Why is it important to know normal development V delayed development

A

To identify if development is appropriate for age

56
Q

What are cultural considerations for those of the same culture

A

Traits that a group of people share where they learn how to be healthy and how to be ill

I.E: Hispanics have home remedies when ill

57
Q

What is cultural competence

A

Cultural competence is having cultural sensitivity considering the total context of a patient situation across cultural boundaries

58
Q

How do I use cultural competence in healthcare to deliver care

A

We assess how their culture affects the care we can give and the patient’s health as well as treating the patient to what they practice

59
Q

What is Stereotyping and how do you avoid it?

A

Stereotyping is assuming of cultures and to avoid it you should ask your patient directly what their culture is and what they practice

60
Q

When giving a Health Assessment with another person in the room what should you as a nurse do to maintain confidentiality

A

Obtain patient permission for others to be present by asking “ is it OK for them to be here for the assessment”

61
Q

During a health assessment who do you get subjective data from and what is it used to to build between the pt and the nurse

How do you document subjective data

A

You get subjective data from the patient (primary source) and it’s used to build rapport and a relationship

Use quotation marks

62
Q

Give an example of objective data

A

Vital signs, anything observable visually

63
Q

When documenting what are DONTS

When documenting what are DOs

A

Don’t use white out
Don’t erase

Do correct mistakes by drawing 1 line and putting initials

64
Q

When documenting using SBAR what does it stand for

A

Situation (why)
Background (circumstance)
Assessment (subj/obj)
Recommendation suggestion

65
Q

Name the three major frameworks for health assessment

A
  1. functional assessment
    • ADL and functional patterns
  2. head to toe assessment
    • comprehensive
    • most organized*

3.body systems approach
- promotes critical thinking
-clusters similar data together


66
Q

What does evidence-based Practice rely on

A

Research findings and scientific support

Health Assessment (20 decks)

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