nurse assessment Flashcards
look at patient obtain data organize document data
assessing
analyze data, identify health problem give name for problem
diagnosing
prioritize problems/ diagnoses select nursing interventions independent things you can do for yourself, goal setting for patient
planning
put hands on patient what needs to be done supervise delegated care
implementing
collect data outcome, compare data outcomes, see if implementation was successful
evaluating
what is nurse assessment
physical most important head to toe, listen feeling, smelling.
mental, spiritual, economic, cultural status
what are skills for nurse assessment
IPPA- inspection, palpation, percussion, auscultation
seated position
sitting
flat on back-lying position with legs extended
supine
60 degree angle sitting with head up
fowlers
30-40 degree angle sitting with head up
semi-fowlers
laying on back with knees flex
dorsal recumbent
legs open getting pap smear, legs in stirrup
lithotomy
laying on side with top knee toward chest
sims
lies on abdomen with head to the side
prone
linear crack with sharp edges extending into dermis ex: cracks at corners of mouth hand athlete’s foot
fissure
translucent, dry, paper like wrinkled skin, thinning or wasting of skin due to loss of collagen ex: striae, aged skin
atrophy
rough thick hard epidermis ex: chronic dermatitis
lichenification
deep irregular shape area of skin may bleed ex: pressure ulcers, stasis, ulcers chancres
ulcer
elevated irregular darkened area of excess scar tissue ex: keloid from ear piercing or surgery
keloid
Linear erosion ex: scratches some chemical burns
excoriation
