Chapters 1-3 Flashcards
Name the 5 phases of the nursing process.
Assessment, Diagnosis, Planning, Intervention/ Implementation, Evaluation (ADPIE)
Assessment
The collection of subjective and objective data
Diagnosis
The analysis of subjective and objective data to make a professional nursing judgment
Planning
Determination of outcomes/ goals and intervention plan
Implementation
Carrying out the plan
Evaluation
Assess whether outcomes/ goals have been met; revising plan as necessary
Name 4 basic types of nursing assessment
1) Initial comprehensive, 2) Ongoing or Partial, 3) Focus/ Problem-Oriented, 4) Emergency
Initial Comprehensive
Collection of subjective data about the client’s perception of health of all body systems, PMH, family history, lifestyle and health practices.
Ongoing, Partial
Data collection that occurs after comprehensive database is established, or transfer to another unit
Focused/ Problem Oriented
Full assessment of a particular problem, not inclusive of other systems
Emergency
Rapid assessment in a life threatening event/ situation
2 assessment types essential for complete patient care
Holistic nursing assessment and physical medical assessment
Holistic nursing assessment
Includes holistic subjective and objective data to determine overall level of functioning
Physical medical assessment
Focuses primarily on physiologic development status
6 components of subjective data assessment
1) Biographical
2) HPI (and CC)
3) PMH
4) family history
5) health & lifestyle practices
6) review of systems (ROS)
5 components of objective data assessment
1) Measurements (height, weight, BMI)
2) Vital signs (Temperature, HR, BP, RR)
3) General survey (appearance, behavior)
4) Physical findings, characteristics (inspection, palpation, percussion, auscultation; head-to-toe)
5) Results from lab, radiology, procedure testing
3 phases of subjective interviewing
1) Introduction
2) Working
3) Summary/ Closing
The 6 components of subjective data assessment occur during which phase of subjective interviewing?
2, working
List 4 objective physical exam techniques
1) Inspection
2) Palpation
3) Percussion
4) Auscultation
What is the general order of body system review?
General survey; skin, hair, nails; head, neck; eyes; ears; mouth, throat, nose, sinuses; thorax, lungs; breasts, lymph; heart, neck vessels; peripheral vascular; abdomen; genitalia; anus, rectum, prostate; musculoskeletal; neurologic
Which part of the hand should you use when you’re palpating for pulse, texture, size, consistency, shape?
Fingerpads
Which part of the hand should you use when you’re palpating for vibrations, thrills, fremitus?
Ulnar or palmar surface
Which part of the hand should you use when you’re palpating for temperature?
Dorsal (back) surface
Define percussion
Directly tapping an area or body part with one or two fingers to elicit possible sounds, size/ shape, vibrations or tenderness
Define palpation
Using parts of the hand to touch/ feel for various characteristics, including texture, temperature, moisture, mobility, consistency, pulse strength, size, shape, tenderness
Define auscultation
Listening for heart sounds, movement of blood through the cardiovascular system movement of the bowel, and movement of air through respiratory tract
Define diaphragm
High-pitched sounds (breath sounds)
Define bell
Light pressure for low-pitched sounds (bruits)
