Ch. 13: Physical Assessment Flashcards
The patient’s well-being relies heavily on an
accurate nursing assessment
In a nursing assessment, signs are
objective data as perceived by the examiner, can be measured with observation and measurement
Exudate
refers to fluid, cells, or other substances that are slowly exuded or discharged
-perspiration, pus, and serum
Symptoms
subjective indications of illness that the patient perceives
Subjective data collection
the interviewer encourages a full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it
Disease
a pathological condition of the body, any disturbance of a structure or function of the body
The nurse relies on assessment of
signs and symptoms to formulate a patient problem statement
The patient problem statement recognizes
holistic needs of the patient that will be treated with nursing interventions
Origins of disease
congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental, or a combination of some
Autoimmmune disease have an unknown
etiology
Contributing factors to congenital diseases
inadequate oxygen, maternal infection, drugs, alcohol, malnutrition, and radiation
Inflammatory diseases
caused by either microorganisms or can be manifestations of an allergic reaction
Degenerative disease
can be caused by the aging process
Metabolic disease
loss of metabolic control of homeostasis in the body
Neoplastic disease
abnormal growth of new tissues
Traumatic conditions
result from physical and emotional trauma
Environmental diseases
a group of conditions that develop from exposure to a harmful substance in the environment
Autoimmune responses
immunoglobulins that attack its own tissues or substances
Risk factors
any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the vulnerability of an individual or group to illness or accident
The nurse assesses the patient’s risk factors and uses them to help formulate a
nursing diagnosis
Four categories of risk factors
genetic and physiologic, age, environment, and lifestyle
Types of disease
chronic, remission, acute, organic disease, functional disease,
Signs of infection
erythema, edema, heat, pain, purulent drainage (pus), and loss of function
Purulent exudate
is the accumulation of neutrophils, dead cells, bacteria, and other debris from the infectious process
A complete health assessment
is an evaluation or appraisal of the patient’s condition, involves orderly collection of information concerning the patient’s health status
Assessment involves
taking a medical history and performing a physical examination, the data collected establishes a baseline
A baseline
allows the health care provider or the nurse to identify problems and plan care
Perform an assessment to determine the actual or potential
patient problems that will require nursing interventions for the safety and well-being of the patient
The nursing assessment comprises of
gathering, verifying, and communicating of data about the patient
Data collected during the nursing assessment includes
the nursing health history, examination findings, results of laboratory and diagnostic tests, and information from health care team members and the patient’s family or significant others
