NUR 220 - Quiz 1 Flashcards
What is a health assessment?
systematic method of collecting + analyzing data
what is a health assessment used to create?
plan-of-care
5 primary components of a health assessment:
- History
- Physical exam
- Documentation of Data
- Analyze + interpret data
- Develope plan-of-care
ANA 6 Standards of Practice:
- Assessment
- Diagnosis
- Outcome identification
- Planning
- Implementation
- Evaluation
Benefit of clustering data:
problems more clearly apparent
what is the body system format?
organizing data based on body system ex. cardiovascular
what is conceptual format?
organize based on concept ex. oxygen, perfusion, mmobility
difference between health promotion vs. protection?
promotion is when patient already has illness so we try to increase well-being vs. protection is when we try to avoid illness altogether
what is primary health promotion?
preventing disease through healthy lifestyle
what is secondary health promotion?
screening for early detection
what is tertiary health promotion?
already have illness but prevent further diabilities
what areas are assessed in lateral recumbant position?
heart, rectum, vagina
what areas are assessed in prone position?
musculoskeletal system
what areas are assessed in dorsal recumbant position?
head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen
what areas are assessed in supine position?
head and neck, anterior thorax and lungs, breasts, axillae, heart, abdoment, extremities, pulses
what areas are assessed in sitting?
head and neck, back, thorax and lungs, breasts, axillae, heart, vital signs, upper extremities
what is included in the palpation part of assessment?
touching, light pressing- feeling for consistency, size, shape, tender/painful areas
what is palmar used to feel?
vibrations
what is dorsal hand used to feel?
temperature
light palpation depth
1/2 inch
deep palpation depth
2 inches
what is assessed in percussion?
light tapping, sound is what is being observed
how would you do percussion for obese patients?
stronger percussion
how many times should you tap in one area?
2-3x before moving onto next area
tymphany
lound, high pitched - abdomen
resonance
normal lung sound
hyperesonance
overinflated lungs - higher pitched
dullness
liver
flatness
bones + muscle
what is auscultation?
stethescope usage to assess pitch, intensity, duration, and quality
whats the most common type of stethoscope?
acoustin
what are the binurals?
metal parts that connect stethoscope
whats the diaphragm (stethoscope)?
big side - high pitched sounds
whats the bell?
small side of stethoscope - low pitch or soft sounds
term for blood pressure machine
sphygmanometer
if the cuff size is too small what will happen to the blood pressure?
too high
if the cuff size is too large what will happen to the blood pressure?
too low
what is a limitation of using an automated blood pressure machine?
cannot asses quality or strength of brachial pulse
what is the advantage of an automated blood pressure machine?
can take blood pressure in time intervals
chart used in dr. office to test vision
snellen chart
what is the top number of a snellen chart reading?
distance away from chart (20)
who is the E snellen chart used for?
kids + non-english speakers
common tool for nurses that is used during inspection of skin or eyes of a patient
penlight
what do nurses use a ruler or tape measure for?
to measure wounds or to take circumfrance of infants heads
purpose of physical exam
- gather baseline data
- confirm or refute subjective data
- identift + confirm nursing diagnosis
- make clinical decisions
- evaluate outcomes
