Nur 101 Exam 1 Flashcards
Principals of health
assessment
Assessment - continuous process.
-initiates the first step of the nursing process
- systematic, deliberate, interactive process
Overall process includes
Data collection validation of perception and observation
Diagnosis
Judgment
-focuses on specific functional abilities
The abilities to do (ADL) activities of daily living
- data collected
From several sources
Using various methods
Confidentional
Exam techniques
IPPA
Performed in this order ( except with abs ass. IAPP) Inspection Palpation Percussion Auscultation
Exam techniques
Inspection
Use of the senses of vision, smell, hearing
To observe and detect normal and abnormal findings
Exam techniques
Palpation
Using parts of the hand to touch and feel - texture (rough smooth) - temperature - moisture - mobility( fixed/ moveable, still, vibrating) Consistency ( soft hard fluid filled) Strength of pulse Size Shape Pain or tenderness
Exam techniques
Percussion
Tapping on body parts to produce sound waves/ vibration to assess underlying structures
Percussion for location, size, shape density masses reflexes
Exam techniques
Auscultation
Use of stethoscope to listen for sounds Heart Lung Blood vessels Abdomen
Assessment
1987 Marjory Gordon RN developed Gordon’s Functional Health patterns
A framework for organizing data by 11 areas of health status or function
Focus on a more holistic look at patients
Continuous process that requires skill
Lydia hall
1950s she developed the nursing process APIE
today nursing process is known as ADPIE
ADPIE
Assessment
Diagnosis
Planning
Implementation
NANDA
Developed in 1973 by North American Nursing Association
(ND ) nursing diagnosis is used to
- a problem that can be independently managed by the RN WITHIN THE scope of the nursing practice
- diagnose and treat human response to health problems
- over 200 NDs in use
Clinical problem= medical diagnosis
The health problem , usually a medical diagnosis
- can’t be independently managed by the RN.
- RN has a major role in monitoring and working with the physician and other healthcare providers.
Confidentiality
HIPPA
- Any information a relates will not be made public.
Informed concent
The pt has been informed about the procedure/ treatment etc including the risks involved in order to make decisions
Written informed concent
Protects pt, facility, caregivers
Signature is done in presence of witness who also signs the form
critical thinking
The way a nurse processes the information using: Knowledge Past experience Intuition Cognitive abilities - to formulate conclusion or diagnosis
ESSENTIAL ELEMENTS OF
Critical thinking
Be open minded
Use rational to support opinions/ decisions
Reflect on thoughts before reaching a conclusion
Use past clinical experience to build knowledge
Acquire adequate knowledge base that continues to build
Be aware of : interactions of others/ environment
Nursing assessment
Is a systematic, deliberate and interactive process. It focuses on specific patient characteristics, functional ability to perform activities of daily living (ADL). The nursing assessment includes data collection and validation of pertinent observation.
Evolution of health assessment in nursing
- 1900: public health nursing came about
- 1950: Lydia hall introduced the nursing process (APIE)
- 1960: nurse practitioner emerged
- 1970: expansion of specialities: exam techniques began.
Confidentially
Any info a pt relats will not be made public or available to others HIPPA H- health I- insurance P- probability A-Accountability A- act
Critical thinking
The way a nurse processes information using:
- be open minded
- use rationale to support opinions and decisions
- reflect on thought before reaching conclusion
- use past clinical experiences to build knowledge
- Aquire adequate knowledge base that continues to builds
- be aware of others and the environment
Hand washing procedure
The quickest, easiest, and cheapest way to prevent disease.
Protects patients, healthcare worker and family
1. Rec. 30 sec. Hand washing
2 at least 15 sec between pt
Assessment of vital signs
Include BP, TEMP, PULSE, RESP., AND PAIN ASSESSMENT
SHOULD BE COMPARED TO BASELINE
Prime indicator of body function
Essential in order to detect changes in pt condition
Report changes promptly
Temperature
NORMAL RANGE 98.6F (96.4-99.1) 37.0c (35.8-37.3)
Body temp is controlled by hypothalamus
Brain cells are sensitive to body temp and if greater 106.0 F can die
O2 requirement increase 10% for every 1.0 C in temp.
Measuring temperature
Oral- electronic thermometer in sublingual pocket
Axillary- common for infants and children. Less accurate
Tympanic- in ear with prob cover. Ear tug up for adults and down for children.
Rectal- taken less frequent. Considered safe and accurate for adults. Use lube and gloves.
Influential factors to temp
Age, exercise, infection, time of day, smoking, illness, stress, hemorrhage, emotions, hot/cold liquids.
Temperature Terminology
FEBRILE
Fever, increased/ elevated temperature above normal range
Temperature Terminology
AFEBRILE
No temp, normal range
Temperature Terminology
HYPERTHERMIA
Temperature grater than 102.2 F can lead to brain injury
Temperature Terminology
HYPOTHERMIA
Temperature between 77.0 and 95.0F
Temperature Terminology
Frostbite
Local hypothermia (one area)
Temperature Terminology
Documentation of temp
Must indicate the rout if not taken orally
Pulse
Pulse indicates heart function and is the number of beats per min.
Need arterial site to assess.
Arteries are high pressure vessels
Normal pulse rates
Adult- 60-100 BPM
Child- 80-100BPM
Infant- 100 BPM
Abnormal pulse rates
Tachycardia
-greater than 100 BPM( rapid/ fast)
Abnormal pulse rates
Bradycardia
Less than 60 BPM( slow)
Pulse is influenced by
Autonomic nervous system(ANS)
Parasympathetic nervous system decreases rate(Vagus nerve)
Sympathetic nervous system increases rate (epinephrine )
SA Nod rate is 60-100 BPM
AV node rate is 40-60 BPM
Ventricular rate 30-40 BPM
Other factors influencing pulse
When BP INCREASES P may decrease due to cardiac workload
O2 / Co2 levels
Flu is and electrolyte values
Drugs
Exercise
Acid based status
Emotion
Components of Health assessment
Health history
Subjective data- collected by pt
Symptoms
Components of Health assessment
Physical examination
Objective data
Signs ex BP, lab reports, do testing (measurable )
Gordon’s 11 Functional Health Patterns
- Health perception/ health management
- Nutritional - metabolic
- Elimination
- Activity- exercise
- Cognitive- perceptual
- Sleep rest
- Self-perception / self concept
- Roles and role relationship
- Sexually - reproductive
- Coping- stress tolerance
- Values- beliefs
Gordon’s 11 Functional Health Patterns
Health perception health management
Assessment is focused on the person s perceived level of health and well- being, and on the practices for maintaining health
Gordon’s 11 Functional Health Patterns
Nutritional - metabolic
Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. Actual or potential problems related to fluid metabolic need. Actual or potential problem R/T fluid balance, tissue integrity, and host defenses may be identified.
Includes:
Diate, appetite, N/V, dentition, skin condition , edema, wound drain, IV, etc…
Gordon’s 11 Functional Health Patterns
Elimination
Assessment is focused on excretory patterns (bowl, bladder, skin)
Excretory problems include: incontinence, constipation, diarrhea , and urinary retention may be identified. Includes abdominal assessment, bowel sounds bowel and bladder patterns, I&O, etc…
Gordon’s 11 Functional Health Patterns
Activity - exercise
Assessment is focused on activities of daily living requiring energy expenditure, including self care activities, exercise and leisure activities. The status of major body systems involved with activity and exercise is evaluated including the respiratory, cardiovascular, musculoskeletal systems. Includes: CV data( pulse, cap. Refill, chest pain etc) respiratory data ( resp. Patterns, lung sounds, chest tube, oxygen, ect), musculoskeletal data( activity level, mobility status etc)
Gordon’s 11 Functional Health Patterns
Cognitive perceptual
Assessment is focused on the ability to comprehend and use the information and on sensory function. Sensory experience such as pain and altered sensory input may be identified and further evaluated. Includes: Loc, reflexes, pupil responce, grip, leg strength , numbness, tingling, pain and cognition, etc…
Gordon’s 11 Functional Health Patterns
Sleep- rest
Assessment is focused on the persons sleep, rest and relaxation practices. Dysfunctional sleep patterns, fatigue and response to sleep deprivation may be identified. Includes: sleep patterns, numbers of hours, methods to promote sleep, factors that affect sleep, and aids etc..
Gordon’s 11 Functional Health Patterns
Self perception/ self-concept
Assessment is focused on the persons attitude towards self. Including: identity, body image and self worth. The persons level of self esteem and Response to treat ones self -concept may be identified. Includes: self assessment, non verbals etc…
Gordon’s 11 Functional Health Patterns
Roles and role relationships
Assessment is focused on the persons role in the world and the relationships with others. Satisfaction with roles, role strain or dysfunctional relationships may be further evaluated. Includes marital status, family members, role in family, employment, role changes due to illness, etc…
Gordon’s 11 Functional Health Patterns
Sexuality- reproductive
Assessment is focused on the persons satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may be identified. Includes: female reproductive data( menstrual patterns, birth control, breast exams, etc) male data ( testicular exam, prostate problems etc)
Gordon’s 11 Functional Health Patterns
Coping stress tolerance
Assessment is focused on the persons perception of stress and their coping strategies in terms of stress tolerance may be further evaluated. Includes: stressful situations, how hospitalization affects, stress management, relaxation techniques, support groups, counseling etc..
Gordon’s 11 Functional Health Patterns
Values beliefs
Assessment is focused on the persons values and beliefs including speritul, or the goals That guide their choices or decisions. Includes: religious practices, and affiliation, cultural background, family tradition etc.
Steps of assessment
Preparation
Data collection
Validation
Documentation
