NU 305 final exam Flashcards
When would you use a focused assessment?
occurs in settings that need a smaller scope, but with increased depth. Example: before treatment, postop.
-focused on one system or one problem
-usually used in the ER
When would you use a comprehensive assessment?
Complete health and physical assessment is performed.
Used on things such as
- yearly check-ups
-admissions
used to check for cognitive development, emotional development, and physical growth
What is subjective data?
-what the patient tells you.
-things that only the patient can feel
What is objective data?
-what you can see as the nurse
-how the skin looks
-what you hear when auscultating
-visual appearance
-measurable info (V/S)
How do you state a chief complaint?
-In the patients own words
-their statement about what they are feeling
- “My head feels like its going to explode”
What is a review of systems?
-a way to assess the whole body
-helps to determine which systems need more focus than others
-involves critical thinking
Opening and closing interview :
Pre-interaction phase
-collecting information from their medical record
-previous hx of medical procedures, illness, allergies, and surgeries
- current medication list
- used to help detect medical patterns of illness
Opening and closing interview :
Opening phase
-beginning phase
-introducing yourself
-basic hellos
Opening and closing interview :
Working phase
-collecting data by asking questions about the pt.
- asking open ended questions
-can use close ended questions to help pt identify pain
Opening and closing interview :
Closing phase
-summarizing what the pt is there for
-letting pt know plan or next steps
- asking pt if they need anything else
-reviewing completeness of notes and letting the pt know they have been heard
When does discharge planning begin?
nurse starts planning discharge on admission
Use of an interpreter
-look at pt, not the interpreter
-provide written material in their language
- DON’T use family members as interpreter
What are some examples of therapeutic communication?
-interaction focuses on the pt
- caring
-empathy and connection with the pt
- self concept; being aware of self biases
How do you check for skin abnormalities on different ethnicities?
check the eyes, mucous membranes, palm of hands for darker ethnicities; this is checking for cyanosis
What is flushing of the skin?
increased permeability of the peripheral capillaries as with a fever
What is pallor of the skin?
decreased arterial blood flow of arterial insufficiency
What is Rubor or Brawny skin?
decreased venous return in venous insufficiency
What is the cause of fingernail clubbing?
long periods of hypoxia
what is jaundice?
Yellow discolouration of the skin or sclera
- liver disease
what would you expect with perfusion arterial issues?
White
What would you expect with arterial issues?
-ulcers on distal extremities
-cool to touch
-red
-Wound edges are DEFINED
What would you expect with venous issues?
-blue
- warm to touch
-brownish discoloration of lower leg
-edges of wounds are IRREGULAR
Common nursing diagnosis associated with the integumentary system?
-Impaired skin integrity
-impaired tissue integrity
-pain
-risk for infection
what are symptoms of dehydration?
-poor skin turgor
-dry mucous membranes
- decreased urinary output
-low BP
What is a pressure ulcer?
localized damage to the skin or underlying soft tissue usually over a bony prominence or related to medical or other device
Stage 1 Pressure ulcer
-skin may appear darker
-non blanch-able redness
Stage 2 Pressure ulcer
-partial thickness loss of skin with exposed dermis
-wound bed is viable
Stage 3 Pressure ulcer
-full thickness skin loss
-tunnelling may occur
- bone and cartilage is NOT exposed
Stage 4 Pressure ulcer
-full thickness and tissue loss
- rolled edge
- tunneling
Stage 5 Pressure ulcer
-unstageable
-extent of damage cannot be confirmed because it is obscured by slough or eschar
Normal findings of the lungs:
Inspection
-AP diameter ratio 1:2
-chest expansion is symmetrical
-no accessory muscle use
-retractions are absent
Normal findings of the lungs:
Palpitation
-thorax is non tender without any lesion
-tactile remits is equal bilaterally (say 99)
Normal findings of the lungs:
Auscultation
-breath sounds are louder and coarser in larger airways
- smaller airways are softer and finer
-no adventitious sounds (crackles, wheezes, and rhon
chi)
