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NUR 121 Final Assessment and Health History
Nursing Health Assessment and health history
57
Nursing
Undergraduate 1
04/28/2012

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Term
The role of assessment in relation to the nursing process is.....
Definition
To focus on the human response to the disease state of pathophysiology (Fear, body image, pain)
Term
The process of analyzing data and drawing conclusions to identify is?
Definition
Diagnostic reasoning
Term
Attending
Definition
The initial available cue
Term
Cue
Definition
Sign/symptom, Lab value
Term
Formulating-hypothesis
Definition
explanation of the cue
Term
Gathering
Definition
data related to the hypothesis
Term
Evaluating
Definition
Does it make sense?
Term
Nursing Process: ADPIE
Definition
Assessment
Diagnosis
Planning
Implementation
Evaluation
Term
Priority ___ is Immediate and Life Threatening
Definition
1
Term
Priority __ is acute pain, urinary
Definition
2
Term
Priority __ is knowledge problems
Definition
3
Term
Complete (total health) Database
Definition
health history and full physical exam
Term
Episodic or problem centered Database
Definition
Related to the problem
Term
Follow Up Database
Definition
Short Term
Term
Emergency Database
Definition
rapidly collecting data, often life saving
Term
Critical Thinking
Definition
How to think vs. What to think
Term
Critical thinking
Definition
identify your assumptions
organized approach - head to toe
validation
normal vs. abnormal
inferences - drawing conclusions
clustering
relevance
inconsistencies
patterns
missing information
health promotion
Term
Validating data entails...
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
Term
To a nurse a "hunch" is
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
Term
The four physical assessment skills are
Definition
Inspection
palpation
percussion
auscultation
Term
Inspection
Definition
Look, do not rush.
Compare pt.'s right side to left side
Concentrated watching
PERRLA
Term
PERRLA stands for
Definition
Pupil
equally
react
regularly
to light
and Accommodation
Term
Tools used with Inspection are
Definition
otoscope/ophthalmoscope
specula - vaginal/ nasal
penlight
Term
Palpation
Definition
Feel
use different parts of hand
Light Vs. Deep palpation
Term
In __________ you follow up on things noticed during inspection.
Definition
Palpation
Term
you use _______ palpation for pulses, and go ________ deep
Definition
light, less than 1 cm.
Term
You use ________ palpation for organ size and go ________ deep
Definition
deep, 1-2 inches
Term
you use ________ for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining the presence of a lump
Definition
fingertips
Term
you use _________ for determining temperature because_________
Definition
the dorsa of the hands and fingers, because the skin is thinner than that of the palm
Term
_________ is when you tap body parts to produce sounds waves. This helps to assess underlying structures
Definition
Percussion.
Term
_______ is the most common form of percussion, where you use a stationary hand and a striking hand
Definition
indirect percussion
Term
Percussion notes
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)
Term
Auscultation
Definition
Listening
use stethoscope
Diaphragm and Bell pieces
Term
Your physical assessment should begin with the hands because
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
Term
Which of the following characteristics is not evaluated via palpation?
Definition
A. Temperature
B. Resilience
C. Density
D. Crepitation
C
Term
Infection Control
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
Term
Optimal nutritional status is
Definition
a balance between intake and requirements. A person is active, has fewer illnesses, and will live longer.
Term
Undernutrition
Definition
inadequate intake
Term
Over nutrition
Definition
over consumption
Term
Nutritional requirements differ at different ages
Definition
Infants and Children - increase need
Adolescence - increase need
Pregnancy and lactation - increase need
Adulthood - stabilize
The Aging adult - decrease need
Term
The components of nutritional status are...
Definition
identify pt with over or under nutrition/hydration
Term
Nutritional Screenings
Definition
admission nutrition screening tool
24-hour diet recall
feed frequency questionnaire
food diaries
direct observation
Term
Subjective data
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
Term
Objective Data equipment
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
Term
Nutritional Lab studies
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
Term
Erikson's developmental stages
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
Term
Infant - 18 months
Definition
Virtue: hope
Trust vs. Mistrust
Mother
Can I trust the World
Term
18 months - 3 years
Definition
virtue: will
Autonomy vs. shame & doubt
Parents
Is it ok to be me?
Term
3 - 5 years
Definition
Virtue: Purpose
Initiative vs. guilt
Family
Is it ok for me to do, move and act?
Term
5 - 13 years
Definition
Virtue: competence
Industry vs. inferiority
Neighbors, school
Can I make it in the world of people and things
Term
13 - 21 years
Definition
Virtue: Fidelity
Identity vs. Role confusion
Peers, role model
Who am I? What can I be?
Term
21 - 40
Definition
Virtue: Love
Intimacy vs. isolation
Friends, partners
Can I love?
Term
41 - 65
Definition
Virtue: Care
Generativety vs. stagnation
Household, workmates
Can I make my life count?
Term
65 and on
Definition
Virtue: Wisdom
Ego Integrity vs. Despair
Mankind, my kind
Is it ok to have been me?
Term
ADL
Activities of Daily living
Definition
Toileting
Hygiene
transferring
dressing upper or lower
Eating
walking
Term
IADL
Instrumental activities of Daily Living
Definition
Taking meds by self
Shopping
financials
telephone use
meal preparation
house keeping
laundry
use of transportation
Term
Katz scale
Definition
To score ability to do ADL and IADL
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