Health Assessment #1 - The Nursing Process Flashcards
Which part of the nursing process?
- Collect Data
- Use evidence-based assessment techniques
- Document relevant data
Assessment (of patient needs)
- Collect Data
- Use evidence-based assessment techniques
- Document relevant data
Which part of the nursing process?
- Compare clinical findings with normal and abnormal variation and developmental events
- Interpret data
- Validate diagnoses
- Documents diagnoses
Diagnosis / Analysis (what a nurse can do)
- Compare clinical findings with normal and abnormal variation and developmental events
- Interpret data
- Validate diagnoses
- Documents diagnoses
Which part of the nursing process?
- Establish priorities!!
- Develop outcomes (must be objective and measurable and include a time)
- Identify interventions (the things that YOU as the nurse will do)
- Integrate evidence-based trends and research (always be up to date with the latest and most useful techniques for your patients)
- DOCUMENT plan of care (if you don’t document then you DID NOT do it!)
Planning (of care)
- Establish priorities!!
- Develop outcomes (must be objective and measurable and include a time)
- Identify interventions (the things that YOU as the nurse will do)
- Integrate evidence-based trends and research (always be up to date with the latest and most useful techniques for your patients)
- DOCUMENT plan of care (if you don’t document then you DID NOT do it!)
Which part of the nursing process?
- Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues (don’t be afraid to ask for help)
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- DOCUMENT implementation and any modification
implementation (of care)
- Implement in a safe and timely manner
- Use evidence-based interventions
- Collaborate with colleagues (don’t be afraid to ask for help)
- Use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- DOCUMENT implementation and any modification
Which part of the nursing process?
- Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation
- Include patient and significant others
- Use ongoing assessment to revise diagnosis, outcomes, plans
- Disseminate results to patient and family
Evaluating
- Progress toward outcomes
- Conduct systematic, ongoing, criterion-based evaluation
- Include patient and significant others
- Use ongoing assessment to revise diagnosis, outcomes, plans
- Disseminate results to patient and family
Assessment
Assessment is the point of entry in an ongoing process.
- Two types of data
- ______ : what the person SAYS about
himself or herself during history taking. i.e. pain level, etc. - ______ : what you as the health professional observe by inspecting, palpating, percussing and auscultating during the physical exam.
- ______ : what the person SAYS about
Assessment is the point of entry in an ongoing process.
- Two types of data
-
Subjective data : what the person SAYS about
himself or herself during history taking. i.e. pain level, etc. - Objective data : what you as the health professional observe by inspecting, palpating, percussing and auscultating during the physical exam.
-
Subjective data : what the person SAYS about
Assessment
______ : Finding the best and most updated strategies and techniques to ensure our patients get the care they deserve.
It requires research.
Evidence-based assessment : Finding the best and most updated strategies and techniques to ensure our patients get the care they deserve.
It requires research.
Assessment Techniques
What type of assessment technique?
- Concentrated watching; close, careful scrutiny, first of the individual as a whole and then of each body system.
- It always comes first!
- Compare the left and right sides of the body
inspection
- Concentrated watching; close, careful scrutiny, first of the individual as a whole and then of each body system.
- It always comes first!
- Compare the left and right sides of the body
Assessment Techniques
What type of assessment technique?
- Follows and often confirms points you noted during the previous step.
- Applies your sense of touch to assess these factors: texture, temperature, moisture, organ location, and size, as well as swelling, vibration or pulsation, rigidity or spasticity, ______ (sounds like rice crispies cereal, usually indicates air or gas in an area it should not be), presence of lumps or masses, and presence of tenderness or pain.
- How should you check for temp?
Palpation
- Follows and often confirms points you noted during the previous step.
- Applies your sense of touch to assess these factors: texture, temperature, moisture, organ location, and size, as well as swelling, vibration or pulsation, rigidity or spasticity, ______ (sounds like rice crispies cereal, usually indicates air or gas in an area it should not be), presence of lumps or masses, and presence of tenderness or pain.
- How should you check for temp? Bilaterally
Assessment Techniques
What type of assessment technique?
- Tapping the person’s skin with short, sharp strokes to assess underlying structures.
- Used to map out the location and size of an organ by exploring where the percussion note changes; signaling the density (air, fluid or solid); detecting an abnormal mass.
Percussion
- Tapping the person’s skin with short, sharp strokes to assess underlying structures.
- Used to map out the location and size of an organ by exploring where the percussion note changes; signaling the density (air, fluid or solid); detecting an abnormal mass.
Assessment Techniques - Sound
______ : intensity, how soft or loud
______ : frequency, the number of vibrations per second. Rapid vibrations = high pitch, slow vibrations = high pitch.
______ : or timbre, a subjective difference due to the sounds of distinctive overtones.
______ : the length of time the note lingers.
Amplitude : intensity, how soft or loud
Frequency : frequency, the number of vibrations per second. Rapid vibrations = high pitch, slow vibrations = high pitch.
Pitch : or timbre, a subjective difference due to the sounds of distinctive overtones.
Wavelength : the length of time the note lingers.
Assessment Techniques
- Listening to sounds produced by the body, such as the heart and blood vessels, and the lungs and the abdomen
- Use a stethoscope to listen:
- Use diaphragm for ______-pitched sounds, use it more often.
- Use the bell for ______-pitched sounds usually for murmurs.
Auscultation
- Listening to sounds produced by the body, such as the heart and blood vessels, and the lungs and the abdomen
- Use a stethoscope to listen:
- Use diaphragm for high-pitched sounds, use it more often.
- Use the bell for low-pitched sounds usually for murmurs.
What is the classification of sound?
Amplitude: Medium-loud
Pitch: low
Quality: clear, hollow
Duration: moderate
Sample Location: over normal lung tissue
Resonance
Amplitude: Medium-loud
Pitch: low
Quality: clear, hollow
Duration: moderate
Sample Location: over normal lung tissue
What is the classification of sound?
Amplitude: Louder
Pitch: lower
Quality: booming
Duration: longer
Sample Location: normal over child’s lung; abnormal in the adult, over lungs with increased amount of air (i.e. emphysema)
Hyper Resonance
Amplitude: Louder
Pitch: lower
Quality: booming
Duration: longer
Sample Location: normal over child’s lung; abnormal in the adult, over lungs with increased amount of air (i.e. emphysema)
What is the classification of sound?
Amplitude: loud
Pitch: high
Quality: musical
Duration: sustained longest
Sample Location: stomach, small intestine
Tympany
Amplitude: loud
Pitch: high
Quality: musical
Duration: sustained longest
Sample Location: stomach, small intestine
