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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
when inspecting urine what characteristics do we look for?
color, clarity, & odor
25
when assessing peripheral vascular what are we looking for?
-edema -pulses (radial, dorsalis pedis, & posterior tibial) -capillary refill
26
proper palpation order for neuro & motor function
-radial pulses -capillary refill: fingers -arm strength -inspect & palpate for edema -dorsalis pedis & posterior tibial pulse -capillary refill: toes -lower extremity strength
27
when we end a HTT assessment what should we do?
closing remarks, any questions, call light, safety scan, hand hygiene, and exit room
28
what is critical thinking?
the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process
29
what is the nursing process?
process where you reflect on and analyze your thoughts, action, and knowledge
30
what are the functions of the nursing process?
-analyze complex data -make decisions -decide -evaluate
31
nursing process: ADPIE
assess, diagnose, plan, implement, evaluate
32
who in the medical field interprets data?
RNs
33
what is clinical decision making?
-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
assessment definition of the nursing process and examples
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
nursing diagnosis of the nursing process
involves a clinical judgment about the patient’s response to an actual or potential health condition or needs
36
nursing diagnosis vs medical diagnosis
-medical diagnosis = pain arm, x-ray reveals fracture -nursing diagnosis = how pt responds to health problem, ex: arm mobility affects daily activities
37
what is NANDA
North American Nursing Diagnosis Association (NANDA), developed to standardize nursing diagnosis
38
what is problem-focused nursing diagnose?
a patient problem (s/Sx) present at time of nursing assessment
39
what is a risk nursing diagnosis?
patient has risk factors that require nursing interventions prior to development of a real problem -involves the word "risk"
40
what is a health promotion nursing diagnosis?
a clinical judgment about a patient's motivation or desire to increase well being -involves the word "readiness"
41
PFND: problem statement definition
a concise term or phrase that represents a pattern of related cues
42
PFND: problem statement, what 2 things it includes and examples
"qualifier" and "focus of diagnosis" -decreased cardiac output -impaired oral mucus membrane -ineffective breathing pattern -delayed surgical recovery
43
PFND: etiology/related factors definition
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
PFND: defining characteristics definition (aeb)
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
3rd phase of nursing process: planning/outcomes definition
nursing interventions to achieve the expected outcomes (*must have a timeframe*) →evidence based -how to manage problem
46
3rd phase of nursing process: goal definition
a broad statement that describes the desired change in a patient’s condition, perceptions, or behavior
47
3rd phase of nursing process: expected outcome
measurable change that must be achieved to reach a goal *FOR THE PT NOT THE NURSE*
48
3rd phase of nursing process: how to write goals & expected outcomes
-the nurse is never the subject -"the patient will..." -address the identified problem
49
3rd phase of nursing process: SMART acronym for expected outcomes
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
3rd phase of nursing process: expected outcome example
the patient will not develop any blanchable redness throughout hospitalization
51
planning: what is nursing intervention
treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes -whats best for the pt?
52
4th phase of nursing process: what is implementation
-putting the plan into action -you perform the interventions that you have individualized to your patient
53
5th phase of nursing process: what is evaluation
-did the plan work? -examine results -compare achieved effect with goals and expected outcomes -revise care plan ﹡for both nurse & patient*
54
writing a nursing care plan overview
-assessment -nursing diagnosis -expected outcome -interventions -evaluation

nurs 222: funds (15 decks)

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