Term
| The role of assessment in relation to the nursing process is..... |
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Definition
| To focus on the human response to the disease state of pathophysiology (Fear, body image, pain) |
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Term
| The process of analyzing data and drawing conclusions to identify is? |
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Definition
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Term
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Definition
| The initial available cue |
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Definition
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Definition
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Definition
| data related to the hypothesis |
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Definition
Assessment
Diagnosis
Planning
Implementation
Evaluation |
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Term
| Priority ___ is Immediate and Life Threatening |
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Definition
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Term
| Priority __ is acute pain, urinary |
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Definition
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Term
| Priority __ is knowledge problems |
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Definition
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Term
| Complete (total health) Database |
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Definition
| health history and full physical exam |
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Term
| Episodic or problem centered Database |
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Definition
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Definition
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Definition
| rapidly collecting data, often life saving |
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Term
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Definition
| How to think vs. What to think |
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Term
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Definition
identify your assumptions
organized approach - head to toe
validation
normal vs. abnormal
inferences - drawing conclusions
clustering
relevance
inconsistencies
patterns
missing information
health promotion |
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Term
| Validating data entails... |
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Definition
A. Distinguishing normal from abnormal
B. Making inferences
C. Using an organized and comprehensive approach
D. Checking the accuracy and reliability of the data
D |
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Term
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Definition
A. Useless because it isn't based on evidence
B. Something that generally happens late in the nursing process
C. Helpful because it clusters and organizes cues
D. The most important type of critical thinking
C |
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Term
| The four physical assessment skills are |
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Definition
Inspection
palpation
percussion
auscultation |
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Term
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Definition
Look, do not rush.
Compare pt.'s right side to left side
Concentrated watching
PERRLA |
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Term
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Definition
Pupil
equally
react
regularly
to light
and Accommodation |
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Term
| Tools used with Inspection are |
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Definition
otoscope/ophthalmoscope
specula - vaginal/ nasal
penlight |
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Term
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Definition
Feel
use different parts of hand
Light Vs. Deep palpation |
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Term
| In __________ you follow up on things noticed during inspection. |
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Definition
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Term
| you use _______ palpation for pulses, and go ________ deep |
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Definition
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Term
| You use ________ palpation for organ size and go ________ deep |
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Definition
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Term
| you use ________ for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining the presence of a lump |
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Definition
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Term
| you use _________ for determining temperature because_________ |
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Definition
| the dorsa of the hands and fingers, because the skin is thinner than that of the palm |
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Term
| _________ is when you tap body parts to produce sounds waves. This helps to assess underlying structures |
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Definition
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Term
| _______ is the most common form of percussion, where you use a stationary hand and a striking hand |
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Definition
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Term
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Definition
resonant - part air part solid (normal lung tissue)
hyperresonant - mostly air (emphysema pt.)
Tympany - air (stomach)
Dull - Solid (liver)
Flat - dense tissue (bone- clavicle) |
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Term
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Definition
Listening
use stethoscope
Diaphragm and Bell pieces |
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Term
| Your physical assessment should begin with the hands because |
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Definition
A. They are easy to reach from any position
B. They reveal a great deal about the pt.
C. They will always be clean and dry
D. They are a place people are accustomed to being touched by strangers.
D |
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Term
| Which of the following characteristics is not evaluated via palpation? |
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Definition
A. Temperature
B. Resilience
C. Density
D. Crepitation
C |
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Term
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Definition
Clean the equipment
clean vs. used area for handling equipment
nosocomial infections - hospital born/spread
Hand washing or alcohol based hand rub
Wear gloves
Standard Precautions
Transmission - based precautions |
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Term
| Optimal nutritional status is |
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Definition
| a balance between intake and requirements. A person is active, has fewer illnesses, and will live longer. |
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Definition
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Definition
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Term
| Nutritional requirements differ at different ages |
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Definition
Infants and Children - increase need
Adolescence - increase need
Pregnancy and lactation - increase need
Adulthood - stabilize
The Aging adult - decrease need |
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Term
| The components of nutritional status are... |
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Definition
| identify pt with over or under nutrition/hydration |
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Term
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Definition
admission nutrition screening tool
24-hour diet recall
feed frequency questionnaire
food diaries
direct observation |
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Term
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Definition
Eating patterns - # of meals and snacks daily
usual weight
changes in appetite, fast, smell, chewing and swallowing
recent surgeries, trauma, burn, infection
chronic illness
vomiting, diarrhea, constipation
food allergies, or intolerance
medications and/or nutritional supplements
self-care behaviors
alcohol or illegal drug use
exercise and activity patterns
family history - diabetes, cancer, HTN |
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Term
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Definition
skinfold calipers - lange or harpenden - estimates body fat
Measurement tape - waist line
Dangerous waist measurements
male - 40<
Female - 35 <
anthropometer
pen or pencil
nutritional assessment data form |
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Term
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Definition
Hemoglobin - RBC (lack = anemia)
Hematocrit - cell volume
Cholesterol - <200
Triglycerides <150
Total lymphocyte count - infection immune response
Skin Testing - adequate immunity
Serum proteins
serum albumin
serum transferrin
pre albumin
Nitrogen balance
Creatinine - height index |
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Term
| Erikson's developmental stages |
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Definition
infant - 18 months
18 months - 3 years
3 - 5 years
5 - 13 years
13 - 21 years
21 - 40 years
41 - 65 years
65 and on |
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Term
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Definition
Virtue: hope
Trust vs. Mistrust
Mother
Can I trust the World |
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Definition
virtue: will
Autonomy vs. shame & doubt
Parents
Is it ok to be me? |
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Definition
Virtue: Purpose
Initiative vs. guilt
Family
Is it ok for me to do, move and act? |
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Definition
Virtue: competence
Industry vs. inferiority
Neighbors, school
Can I make it in the world of people and things |
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Definition
Virtue: Fidelity
Identity vs. Role confusion
Peers, role model
Who am I? What can I be? |
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Definition
Virtue: Love
Intimacy vs. isolation
Friends, partners
Can I love? |
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Definition
Virtue: Care
Generativety vs. stagnation
Household, workmates
Can I make my life count? |
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Definition
Virtue: Wisdom
Ego Integrity vs. Despair
Mankind, my kind
Is it ok to have been me? |
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Term
ADL
Activities of Daily living |
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Definition
Toileting
Hygiene
transferring
dressing upper or lower
Eating
walking |
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Term
IADL
Instrumental activities of Daily Living |
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Definition
Taking meds by self
Shopping
financials
telephone use
meal preparation
house keeping
laundry
use of transportation |
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Term
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Definition
| To score ability to do ADL and IADL |
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