Summary Flashcards
6 steps to an assessment
-Health History
-Subjective data
-Physcial exam
-Objective data
-Documentation
-Analys data
Assessment
Collect data: review clinical record, healthh history, physical exam, functional assessment, risk assessment, review literature
-Evidence based, document
Diagnos
-Compare clinical findings with normal and abnormal variation and development event
-Interpret clusters, hypothesis, test, derive
-validate
-document
Outcome identification
-Identify expected outcome
-individualize to the person
-culturally appropriate
-realistic
-timeline
Planning
-Establish priority
-develop outcome
-set timeline for outcome
-ID interventions
-Integrate evidence based trends
-document plan of care
Implement
-Safe and timely
-Use evidence based interventions
-collaborate with colleagues
-use community resources
-coordinate care delivery
-rpovide health teaching and health promotion
- document implementation and any modification
Evaluate
progress toward outcome
-conduct systematic on going
-include patient and significant others
-Iuse ongoing assessment to revise diagnosis, outcomes and plan
-disseminate results to patient and family
Types of health assessments
emergency, focused on issue and condition, comprehensive assessment broad and wide ranging
Emergency Assessment
carries out in life threatening situations
-follows ABCD (airway breathing circulation disability)
Comprehensive assessment
includes complete health history subjective and physical examianation
-various settings
-inpatient admission
-head to tow
Focused assessment
based on patients presenting health issues
-less extensive than comprehensive 1-2 body systems involved
-in depth info solicited is entered on presenting health problems
Preparation for assessment
-Explain
-gather equipment
-HH
-Promotes comfort, dignity and safety
-head to toes
Subjective data
Biographical data
Reason for seeking care
Present health or history of present illness
Past history (medical, surgical, medications)
Family history
Review of systems
Functional assessment or activities of daily living (ADLs)
first thing to do in head to tow
60 sec and general survey
What to do after 60 sec and general survey
take vitals, weight, height, BMI, snellen, use bathroom (patent is still clothed)
When patient is seated perform
skin, head and face, ear, nose, mouth and through, neck, chest, upper extremities
when supine
check breast, heat, abdomen, inguinal area, lower extremities
What is subjective data?
Data that is told to us by our patients
What is objective data?
Data that is collected by observation
in pain assessment O stands for
onset (when did the pain start what were you doing)
In pain assessment what does the P stand for
provocative/pallative (does this pain increase or decrease when doing specific things)
What does the R stand for in the pain assessment
region (where is it hurting)
What does the S stand for in Pain assessment
Severity of the pain (1-10)
what does the T stand for in Pain assessment
Treatment/timing (what has worked for you, is it consistent or is there specific times it flares)
What does U stand for in pain assessment
Understanding pain (What do you believe is causing the pain)
What does V stand for in Pain assessment
Values (what is your acceptable level for this pain, what else would you like to say about its effects)
What is in the general survey
- Physical appearance: healthy, well groomed, alert, skin color, even toned, facial features
- Body structure: Posture, stature, position, nutritional
- Mobility: Gait, Arm swing symmetrical, any involuntary movements
- Behavior: Facial expression, speech, mood, dress and hygiene
What is the purpose of the 60 second
The purpose is to assist you in the development of situational awareness. In the patient care area, situational awareness focuses on the art of patient observation. This includes routine use of a general survey (observation) of the patient, family and environment during every incidental encounter and periodically at planned intervals throughout the day. Situational awareness promotes a safer patient care environment and helps the nurse develop care priorities and attention to clinical detai
Normal vital signs
Temp:35.8-37.3 degrees oral
Radial pulse: 60-100
Resp: 10-20
SP02: 95-100
BP: 120/80
What part of the brain regulates temp
hypothalamus
What is referred to as the main pacemaker of the heart and located in the wall of the right atrium?
sinus node
5) The patient states he has shortness of breath which occurs when lying flat. The term for this is?
Orthopnea
After one reading of high blood pressure would they patient be diagnosed with hypertension?
-no you would test again at another time, or re test and see if there was something you did wrong (ex. Not lined up, arm above heart, feet not on floor) patient also may just be stressed out.
9) What assessing for hydration what skin assessing is done when looking for tenting?
turgor
Ecchymosis is what?
bruise
11) A flat, circumscribed, color change in the skin < 1cm is referred to as what?
patch
13) Flakey, scaly (shredding of keratin cells), type of dermatitis – autoimmune?
actinic keratosis
12) An elevated, solid, circumscribed < 1cm is referred to what?
nodule
ABCDE moles
A: asymmetry
B:border
C: colour
D: diameter
E: elevation/enlargement/evolving
15) Clubbing of the nails is seen with which health conditions?
Cardiac or low oxygen
Name the 4 valves and locations of the heart
-Right atrium, left atrium, right ventricle, left ventricle
Systole
relaxation of the heart
diastole
contraction of the heart
S1 is
systole (when the heart contracts it pushed blood into the large blood vessels of the circulatory system from here the blood goes all of the organs
S2 is
diasolic (This is when the heart relaxeds and the chambers fill with blood
What is a bruit? Is it a normal sound to hear?
turbulent blood flow no you should not hear this
What is a Thrill? Is it a normal sound to hear?
-A vibratory sensation felt on the skin overlying the heart which indicates turbulence (felt when palpating)
What is the difference between Kyphosis and Lordosis?
Kyphosis is when the upper part of your back curves
Lordosis is when the lower part of your back curves
What are the locations and names of the 5 places we auscultate the heart?
Aortic: Right sternal border S2 louder then S1, second intercostal space
-Pulmonic valve: Left sternal border, S1 louder then S2, Second intercostal space
-Erbs point: =, 3rd intersotal space, left sternal border
-Tricuspid: 5th intercostal space, left sternal border S1 louder then S2
-Mitral: 5th intercostal space, left midclavicular line, S1 louder then S 2
Cardinal sign of Musculoskeletal Disease
pain, swelling, erythema (redness), warmth, and stiffness.
What function does the lymph nodes as part of the immune system?
monitor the lymph flowing into them and produce cells and antibodies which protect our body from infection and disease.
The 3 normal breath sounds are?
vesicular breath sounds, and bronchial breath sound, bronchovesicular
Enlarged lymph nodes are called?
Lymphadenitis
venous stasis
If you have venous stasis, your veins can’t send the blood from your legs back to your heart.
Pallor
red to pink toneoxygeznated hemoglobin in the blood are lost, the skin takes on the colour of CT. Can be observed in the tips, nail bed, mucous membrane
Erythmea
redness, excess blood. Can indicate a fever or excess blood flow
