Term
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Definition
| Objective examination of pt on system-by-system basis. Differs from health assessment in that it does not attempt to rank the severity of the pt's illness(es) |
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Term
| 3 preliminary considerations before starting any assessment |
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Definition
1. Hand hygiene
2. Latex and like allergy precautions
3. Positioning |
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Term
| Name 6 Positions the pt may be asked to assume before a physical assessment |
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Definition
There are 9:
seated (vitals), supine (abdominal), prone, fowlers/semi-fowlers, trendelenberg, dorsal recumbent, lateral recumbent, lithotomy (GU), & sims |
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Term
| Define the 4 methods of physical assessment |
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Definition
IPAP:
inspection (observation)
palpation (use of touch to gather information)
auscultation (listening for sounds produced by body)
percussion (striking to produce sound waves in order to assess size, shape, location, and density of tissues) |
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Term
| 3 considerations upon inspection |
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Definition
| ensure proper lighting, maintain the dignity of the pt, and note what you can before the official assessment begins (gait, balance, speech patterns, etc.) |
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Term
| The part of the hand used for palpation |
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Definition
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Term
| The depth in cm of the three types of palpation |
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Definition
light: <1cm
moderate: 1-2cm
depth: 2-4cm |
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Term
| 3 things a nurse can do on their side to make palpation more comfortable for the pt |
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Definition
warm hands
keep nails well manicured
be gentle |
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Term
| Order of methods for assessment, and rationale |
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Definition
| IPAP: inspection, palpation, auscultation, and percussion; least invasive to most invasive, promotes comfort and prevents muscle guarding. With children ears and throat should be done last as this can be painful. During an abdominal assessment, auscultation should be performed prior to palpation to avoid stimulation of peristalsis |
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Term
| 5 characteristics of sounds to be documented(auscultation) |
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Definition
1.presence (whether there's a sound or not)
2. intensity (loud, soft)
3. pitch (high, low)
4. quality (whooshing, crackling, etc.)
5. Duration (time)
PIP from DQ |
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Term
| List 3 tones of percussion |
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Definition
| there are five: tympany, dullness, resonance, hyperresonance, and flatness |
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Term
| How does one decide where to percuss? |
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Definition
| Tap areas of tympany/resonance and areas of dullness/flatness, documenting the location it changes |
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Term
| What are the three aspects of the 3 minute assessment? |
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Definition
| Patient inspection, and environment inspection, followed by specific assessment |
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Term
| Initial points of interest for pt inspection portion of the 3 minute assessment |
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Definition
Vitals-check if on monitor
airway-breathing, color
orientation and other obvious concerns
Comfort/pain scale
family members |
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Term
| Medical equipment consideration for pt inspection portion of the 3 minute assessment |
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Definition
IV-site & dressing
feeding tube-formula level, site & dressing
oxygen-type, amount, humidifier
foley-urine, drainage, amt
compare all with chart |
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Term
| Environment Inspection: Bed |
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Definition
low position, pt in comfortable position
side rails
call light |
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Term
| Environment Inspection: Precautions |
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Definition
-Signs to indicate all precautions
-medications: should they be there, when do they expire
-needle box |
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Term
| Environment Inspection: Tubes |
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Definition
-suction drainage canister
-feeding, rate
-IV: site, rate, exp. date
-check against chart |
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Term
| Steps of the Nursing Process |
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Definition
Assess, Diagnose (nursing diagnosis), ID Outcome & Plan, Implement, Evaluate
ADOIE! (face-palm) |
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Term
| Assessment, step 1 of the nursing process |
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Definition
| continuous and systematic collection of patient data |
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Term
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Definition
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Term
| Nursing vs. Medical Assessment |
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Definition
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Term
| Data Collection Methods for Assessment |
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Definition
Nursing History (subjective)
Nursing Phys. Assessment (objective)
-Focus on non-verbal |
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Term
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Definition
| actual or potential health problems based on conclusions formed from assessment |
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Term
| 4 types of nursing diagnoses |
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Definition
SWAP:
1. Syndrome: cluster of risk/actual
2. Wellness: desire for higher level of health
3. Actual/Risk: actual problem or risk therefore as defined by specific characteristics
4. Possible: needs further follow-up |
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Term
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Definition
| Plan of care to achieve a beneficial outcome based on diagnosis |
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Term
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Definition
PACS
1. Psychomotor: motor skills/action
2. Affective: changes in mood, attitude, etc.
3. Cognitive: teaching-learning
4. Short/Long Term: now vs. life habits |
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Term
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Definition
| Putting care plan into action after reassessing pt and applying necessary changes to care plan |
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Term
| True or False: You are the nurse and the patient advocate, therefore you are fully responsible for your pt's outcome. |
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Definition
False.
You are responsible for promoting self-care of the patient, and keeping them involved in the care plan. |
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Term
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Definition
Compare planned outcome with actual outcome
achieved: conclude plan of care
unachieved: modify plan
not achieved, but improving: elongate plan of care |
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