fundamentals- chapter 5

Question 1

who initiates the plan of care?

Answer 1

the RN

• LPNs may collect data to contribute to the assessment

Question 2

approaches to assessment

Answer 2

• functional health patterns assessment (Mary Gordon)
• focused assessment (focuses on a specific problem)
• basic needs assessment based on Maslow’s hierarchy

Question 3

Gordon’s 11 health patterns

Answer 3

1. health perception - health management pattern
2. nutritional-metabolic pattern
3. elimination pattern
4. activity-exercise pattern
5. cognitive-perceptual pattern
6. sleep-rest pattern
7. self-perception-self-concept pattern
8. role-relationship pattern
9. sexuality-reproductive pattern
10. coping-stress tolerance pattern
11. value-belief pattern

Question 4

for each pattern, the following are assessed:

Answer 4

functional:
- present function
- personal habits
- lifestyle and cultural factors
- age-related factors

dysfunctional:
- history of dysfunction
- diagnostic test abnormalities
- risk factors related to medical treatment plan

Question 5

the interview

Answer 5

• based on gathering data
• not a social interaction
• find out patient’s major complaints, perform a physical exam, and determine the patient’s overall health
• good communication essential (verbal and nonverbal)
• your posture, facial expressions, attitude, and movement are important

Question 6

interview stages

Answer 6

1. the opening: rapport is established with the patient
2. the body: necessary questions are presented
3. the closing: information is summarized

Question 7

medical records (chart) review

Answer 7

should include:
- face sheet and physician’s orders
- nurses notes (at least past 24 hours)
- physician’s progress notes, history, physical exam
- medication administration record
- Surgery operative report and pathology report
- Diagnostic tests
- Nursing admission history and assessment
- Fall risk assessment and skin assessment
- Nursing care plan or problem list

Question 8

physical assessment

Answer 8

• use techniques of inspection, auscultation, palpation, and percussion
• head-to-toe assessment
• Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem

Question 8

physical assessment

Answer 8

• use techniques of inspection, auscultation, palpation, and percussion
• head-to-toe assessment
• Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem

Question 9

head-to-toe assessment

Answer 9

initial observation:
- breathing
- how the patient is feeling
- general appearance
- skin color
- affect (expression)

Question 10

head-to-toe assessment pt. 2

Answer 10

head:
- level of consciousness (awake, alert, and oriented)
- ability to communicate (language spoken, any communication deficits)
- mentation status (able to comprehend, form thoughts)
- appearance of the eyes (pupil size, light reaction)

Question 11

obtunded

Question 12

stuporous

Question 13

head-to-toe assessment pt. 3

Answer 13

vital signs:
1. temperature
2. pulse rate (rhythm, strength, apical, radial)
3. respirations (rate, pattern, depth; oxygen saturation)
 Blood pressure
• Within normal limits
• Compare with
previous readings
5. pain

Question 14

head-to-toe pt. 4

Question 15

adventitious

Question 16

head-to-toe pt. 5

Question 17

head-to-toe pt. 6

Question 18

assessment in long-term care

Answer 18

• Extensive initial assessment performed when patient enters long-term care facility
• Reassessment at fixed intervals and as the patient’s condition changes
• Physical assessment, health history, medication history, and a functional assessment performed
• skilled facilities may require different charting
• “medicare charting”

Question 19

assessment in home health care

Answer 19

• initial patient assessment in the home is usually performed by the RN
• the LPN/LVN will need to perform daily assessments and maintain necessary documentation
• changes found on assessment should be reported to the RN supervisor or physician

Question 20

analysis

Question 21

nursing diagnosis/ problem identification

Answer 21

indicates the patient’s actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms)

Question 22

etiologic factors

Answer 22

• causes of the problem
• signs are abnormalities that can be verified by repeat examination (objective data)
• symptoms are data the patient has said are occurring that cannot be verified by examination (subjective data)

Question 23

defining characteristics

Answer 23

• characteristics (signs and symptoms) that must be present for a particular problem statement to be appropriate for that patient
• supply the evidence that the problem statement is valid

Question 24

prioritization of problems

Answer 24

• problems ranked according to their importance
• physiological needs for basic survival take precedence (airway, circulation, etc)
• after physiological needs are met, safety problems take priority
• every nurse must look at the patient holistically, keeping psychosocial needs in mind

Question 25

problem statements in long-term and home health care

Question 26

planning: expected outcomes

Question 27

interventions (nursing orders)

Question 28

documentation