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nurs 222: funds > week 8 > Flashcards

week 8 Flashcards

1
Q

what is the purpose of the head to toe assessment?

A

covering all of the aspects (all systems) in order to identify any pathology

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2
Q

should our head to toe assessment always be organized the same?

A

yes!

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3
Q

is it okay to link together sections/systems like eye exam with head and neck?

A

yes!

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4
Q

how can we be efficient in our HTT assessment?

A

limit the amount of times you need to use a particular instrument

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5
Q

should we be talking to our patients through each step?

A

yes, it decreases patient anxiety!

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6
Q

attire for HTT assessment

A

what you wear to clinicals

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7
Q

what equipment is needed for a HTT assessment?

A

-stethoscope
-pen light
-pen/paper for notes
-hand sanitizer
-alcohol wipes
-gloves

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8
Q

what are the introduction steps of a HTT assessment

A

-assemble equipment prior to entering room
-knock on door
-provide privacy
-hand hygiene
-safety scan
-introduce self
-describe procedure

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9
Q

when assessing a general survey of our patient, what emotional behaviors should we be looking for?

A

general appearance, mood, and signs of distress or comfort

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10
Q

what are the elements of a HTT assessment?

A

-cognition
-neurological exam
-mouth
-skin
-lungs
-heart
-abdomen
-bowel & urinary function
-peripheral vascular

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11
Q

when we assess for cognition what kinds of questions will we ask?

A

odd questions like the mini-cog

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12
Q

when we assess for neuro what test do we perform?

A

PERRL or PERLA

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13
Q

when assessing for oral cavity (mouth), what 3 areas are we looking at?

A

lips, teeth, and tongue

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14
Q

when INSPECTING the skin what should we look for?

A

color/tone, integrity, lesions, & boney prominences

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15
Q

when PALPATING skin what should we look for?

A

temperature, moisture, texture, thickness, & boney prominences

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16
Q

when assessing the lungs what questions should we ask prior to auscultating lung sounds?

A

any coughing, SOB, any breathing difficulties, and any phlegm?

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17
Q

what are normal auscultated breath sounds

A

clear visceral breath sounds

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18
Q

when assessing lungs sound posteriorly what areas should we avoid?

A

scapula & spine

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18
Q

when assessing the heart what two sounds are we looking for?

A

S1 & S2

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19
Q

what flow should we follow when auscultating hearts sounds?

A

aortic valve, pulmonary valve, erb’s point, tricuspid valve, and mitral valve

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20
Q

when assessing the abdomen for bowel function what questions should we ask?

A

-if pt has had any bowel movements and if yes what was the color, consistency, & frequency
&
-passing any gas

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21
Q

when inspecting the abdomen what are we looking for?

A

contour, symmetry, distention, & massess

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22
Q

when assessing urinary elimination what should we be looking for?

A

color, clarity, bladder control problems, burning, blood or pain when urinating

23
Q

normal urine color

A

pale yellow

24
Q

when inspecting urine what characteristics do we look for?

A

color, clarity, & odor

25
Q

when assessing peripheral vascular what are we looking for?

A

-edema
-pulses (radial, dorsalis pedis, & posterior tibial)
-capillary refill

26
Q

proper palpation order for neuro & motor function

A

-radial pulses
-capillary refill: fingers
-arm strength
-inspect & palpate for edema
-dorsalis pedis & posterior tibial pulse
-capillary refill: toes
-lower extremity strength

27
Q

when we end a HTT assessment what should we do?

A

closing remarks, any questions, call light, safety scan, hand hygiene, and exit room

28
Q

what is critical thinking?

A

the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process

29
Q

what is the nursing process?

A

process where you reflect on and analyze your thoughts, action, and knowledge

30
Q

what are the functions of the nursing process?

A

-analyze complex data
-make decisions
-decide
-evaluate

31
Q

nursing process: ADPIE

A

assess, diagnose, plan, implement, evaluate

32
Q

who in the medical field interprets data?

A

RNs

33
Q

what is clinical decision making?

A

-problem solving activity
-considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients

34
Q

assessment definition of the nursing process and examples

A

the deliberate and systematic collection and analysis of data to determine a patient’s current and past health status and their response to their health problems.
-nursing history
-vital signs, lab work, diagnostic tests
-review of pt record

35
Q

nursing diagnosis of the nursing process

A

involves a clinical judgment about the patient’s response to an actual or potential health condition or needs

36
Q

nursing diagnosis vs medical diagnosis

A

-medical diagnosis = pain arm, x-ray reveals fracture
-nursing diagnosis = how pt responds to health problem, ex: arm mobility affects daily activities

37
Q

what is NANDA

A

North American Nursing Diagnosis Association (NANDA), developed to standardize nursing diagnosis

38
Q

what is problem-focused nursing diagnose?

A

a patient problem (s/Sx) present at time of nursing assessment

39
Q

what is a risk nursing diagnosis?

A

patient has risk factors that require nursing interventions prior to development of a real problem
-involves the word “risk”

40
Q

what is a health promotion nursing diagnosis?

A

a clinical judgment about a patient’s motivation or desire to increase well being
-involves the word “readiness”

41
Q

PFND: problem statement definition

A

a concise term or phrase that represents a pattern of related cues

42
Q

PFND: problem statement, what 2 things it includes and examples

A

“qualifier” and “focus of diagnosis”
-decreased cardiac output
-impaired oral mucus membrane
-ineffective breathing pattern
-delayed surgical recovery

43
Q

PFND: etiology/related factors definition

A

what causes the pt to have this problem, or in other words factors that appear to show some type of patterned relationship with the nursing diagnosis

44
Q

PFND: defining characteristics definition (aeb)

A

clusters of signs or symptoms (2 or more) at least 2* identified in the assessment that indicate the presence of a particular diagnostic label

45
Q

3rd phase of nursing process: planning/outcomes definition

A

nursing interventions to achieve the expected outcomes (must have a timeframe) →evidence based
-how to manage problem

46
Q

3rd phase of nursing process: goal definition

A

a broad statement that describes the desired change in a patient’s condition, perceptions, or behavior

47
Q

3rd phase of nursing process: expected outcome

A

measurable change that must be achieved to reach a goal
FOR THE PT NOT THE NURSE

48
Q

3rd phase of nursing process: how to write goals & expected outcomes

A

-the nurse is never the subject
-“the patient will…”
-address the identified problem

49
Q

3rd phase of nursing process: SMART acronym for expected outcomes

A

S: specific →for the pt only
M: measurable →measurable verb
A: attainable →achievable for pt
R: realistic →for pt
T: timed →include a timeframe

50
Q

3rd phase of nursing process: expected outcome example

A

the patient will not develop any blanchable redness throughout hospitalization

51
Q

planning: what is nursing intervention

A

treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes
-whats best for the pt?

52
Q

4th phase of nursing process: what is implementation

A

-putting the plan into action
-you perform the interventions that you have individualized to your patient

53
Q

5th phase of nursing process: what is evaluation

A

-did the plan work?
-examine results
-compare achieved effect with goals and expected outcomes
-revise care plan
﹡for both nurse & patient*

54
Q

writing a nursing care plan overview

A

-assessment
-nursing diagnosis
-expected outcome
-interventions
-evaluation

nurs 222: funds (15 decks)

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