Term
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Definition
| systematic and continuous collection, validation and communication of client data |
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Term
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Definition
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Term
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Definition
| information percieved and verified only by the person experiencing it. |
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Term
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Definition
| observation that can be observed, measured or percieved by another person |
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Term
- purposeful - comprehensive, focused, emergency
- complete - collect all data (head to toe)
- factual - is information reliable?
- relevant - how much data should you collect?
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Definition
| characteristics of organized data |
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Term
- initial assesment
- focused assesment
- emergency assesment
- time-lapsed assesment
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Definition
| Types of Nursing Assesments |
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Term
| health perception/health management |
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Definition
| focus on how the patient manages his health |
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Term
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Definition
| focus on the patient's dietary habits, skin, oral mucous membrane, hair, nails, teeth, metabolic needs and allergic response |
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Term
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Definition
| bowel and bladder routines, drainages & fluid |
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Term
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Definition
| exercise patterns, ability for ADL's, VS, musculoskeletal & cardiopulmonary system |
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Term
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Definition
| sleep habits and adequacy of rest |
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Term
cognitive/perceptual
winky-winky :) |
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Definition
| awareness and judgement, expression, perception, memory, 5 senses neurological |
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Term
| self perception/self concept |
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Definition
| identify development stage |
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Term
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Definition
| identification of own role |
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Term
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Definition
| sexual identity/ reproductive Hx |
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Term
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Definition
| current stressors/methods of coping |
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Term
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Definition
| values, beliefs, goals and cultural orientation that are influential in decision making |
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Term
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Definition
-
preparatory phase
-
introduction
-
working
-
termination
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Term
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Definition
| type of assessment performed shortly after pt is admitted to a health care facility |
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Term
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Definition
| type of assessment that focuses on specific problem that has already been identified |
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Term
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Definition
| type of assessment that identify life threatening conditions |
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Term
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Definition
| type of assessment that compares current status to baseline data |
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Term
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Definition
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Term
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Definition
| act of confirming or verifying |
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Term
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Definition
| what is the 5th vital sign besides temp, pulse, respiration and BP? |
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Term
- general survey
- vital signs
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Definition
| components of a physical assessment |
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Term
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Definition
| primary source of heat in body temperature |
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Term
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Definition
| primary source of heat loss |
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Term
35.9 C to 37.4 C
96.6 F to 99.3 F
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Definition
| normal range for body temperature |
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Term
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Definition
| control center of body temperature |
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Term
- convention
- conduction
- radiation
- evaporation
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Definition
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Term
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Definition
| dissemination of heat by motion |
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Term
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Definition
| transfer of heat (ice pack, cold bed pan) |
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Term
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Definition
diffusion of heat by electronic waves
(bath blanket) |
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Term
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Definition
conversion of liquid to vapor
(sweating) |
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Term
- circadian rhythm
- age
- gender
- stress
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Definition
factors affecting body temp.
winky - winky :) |
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Term
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Definition
| true or false.....elders can have infection with no fever |
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Term
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Definition
| increased production of epinephrine and noripinephrine will cause..... |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| abnormal elevation of body temp |
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Term
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Definition
| an agent that reduces fever |
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Term
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Definition
| indefinite feeling of debility or lack of health |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| true or false............pulse increases 5-10 beats every degree of fever |
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Term
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Definition
type of body temp assessment that can cause the vagal nerve to be stimulated resulting to bradycardia
winky winky :) |
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Term
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Definition
| throbbing sensation that can be palpated over peripheral artery |
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Term
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Definition
| normal range ofr respiration |
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Term
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Definition
| regulated by ANS through sinoatrial (SA) node often called pacemaker |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| apical pulse less the radial pulse |
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Term
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Definition
| measures force of blood against arterial walls |
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Term
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Definition
| left ventricle pushing blood thru aortic valve |
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Term
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Definition
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Term
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Definition
| difference between systolic and diastolic |
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Term
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Definition
| typical range for pulse pressure |
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Term
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Definition
| heart rate X stroke volume |
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Term
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Definition
- one of the main factors affecting BP
- state of arterioles being in partial contraction
- provides constant level of restraint to blood flow
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Term
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Definition
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Term
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Definition
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Term
orthostatic hypotension
(postural hypotension) |
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Definition
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Term
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Definition
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Term
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Definition
| ability to breathe easier sitting up |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| alternating deep rapid breathing followed by periods of apnea |
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Term
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Definition
| varying depth and rate followed by periods of apnea |
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Term
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Definition
| increased rate and depth of respiration |
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Term
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Definition
| harsh high pitched sound on inspiration |
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Term
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Definition
| noisy strenous respirations |
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Term
- establish nurse-pt relationship
- gather data about the pt's general health status
- identify pt's strength
- identify actual & potential health problems
- establish a base of nursing process
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Definition
| goals of a health assessment |
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Term
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Definition
| the act of using the sense of touch |
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Term
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Definition
| the act of striking one object against another to produce a sound |
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Term
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Definition
| the act of listening with a stethoscope to sounds within the body |
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Term
- color
- symmetry
- distribution of facial hair
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Definition
| what do we check for physical assessment in the face |
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Term
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Definition
| what do we check for PA in the eyes |
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Term
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Definition
| what do we check when we move an object towards pt's nose |
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Term
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Definition
| what do we check for PA on distant to near point |
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Term
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Definition
| we check for this using a penlight towards the eyes |
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Term
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Definition
| what do we assess on heart tones |
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Term
- pulse
- edema
- capillary refill
- skin color
- temperature
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Definition
| what do we check for circulation |
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Term
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Definition
light popping sounds like milk on rice krispies or rubbing between fingers
adventitious breath sounds |
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Term
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Definition
may be a gurgling sound
adventitious breath sounds |
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Term
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Definition
rubbing, grating. asucultated on lateral, anterior chest surface
adventitious breath sounds |
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Term
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Definition
decreased air exchange
adventitious breath sounds |
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Term
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Definition
squeaking, high pitched sounds
adventitious breath sounds |
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Term
- auscultate bowel sounds
- inspect the abdomen
- percussion
- palpate abdomen
- assess bowel movements
- assess urinary function
- history
- medication
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Definition
| what to check during abdominal assessments |
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Term
- LOC
- orientation - time, place & person
- memory
- abstract reasoning
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Definition
| what to check during mental assessments |
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Term
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Definition
| understands written and spoken language but unable to speak |
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Term
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Definition
| cannot understand written and spoken language |
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Term
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Definition
| loss or impairment of the power to use or comprehend words usually resulting from brain damage |
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Term
- peripheral pulses
- edema
- capillary refill
- color
- temperature
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Definition
| what do we check for circulation |
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Term
- inspection
- auscultation
- percussion
- palpation
rationale: auscultation follows inspection because percussion and palpation stimulate bowel sounds |
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Definition
| sequence for assessing abdomen |
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Term
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Definition
| ability to move about freely |
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Term
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Definition
| the efficient use of the body as a machine and means of locomotion |
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Term
-
venous thrombosis
-
orthostatic hypotension
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Definition
| hazards of immobility towards cardiovascular system |
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Term
- decreased ventilatory effort
- increased respiration
- hypostatic pneumonia
- poor exchange of co2 an 02
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Definition
| hazards of immobility towards respiratory system |
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Term
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Definition
| incomplete expansion or collapse of lung tissue |
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Term
- bone de-mineralization
- muscle atrphy & muscle contractures
- ankylosis
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Definition
| hazards of immobility towards musculoskeletal system |
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Term
- decreased metabolic rate
- fluid and electrolyte imbalances
- alterations in the exchange of nutrients and gasses
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Definition
| hazards of immobility towards metabolic system |
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Term
- decreased apppetite
- poor digestion
- constipation
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Definition
| hazards of immobility towards GI system |
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Term
- cardiovascular
- pulmonary
- gastrointestinal
- urinary
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Definition
body systems primarily affected by fluid stasis
winky winky :) |
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Term
Rest
Ice
Compression
Elevation |
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Definition
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Term
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Definition
| impaired muscle contraction |
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Term
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Definition
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Term
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Definition
| weakness of one half of the body |
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Term
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Definition
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Term
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Definition
| paralysis of the arms and legs |
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Term
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Definition
| promotes muscle mass and strength |
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Term
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Definition
| improves mobility and helps prevent fluid stasis |
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Term
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Definition
defined by ANA
the diagnosis and treatment of human responses to actual and potential health problems |
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Term
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Definition
- main ingredient for nursing practice
- tool nurses use to provide quality nursing care
- organized, systemic method of providing individualized plan of care
- client centered focus
winky winky :)
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Term
- assesment
- diagnosis
- planning
- implementing
- evaluating
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Definition
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Term
|
Definition
| systematic continuous collection, validation and communication of client data |
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Term
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Definition
| analysis of client data to identify actual or potential health problems |
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Term
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Definition
| establish plan of care that specifies desired goals, outcomes and nursing interventions most likely to meet expected outcomes |
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Term
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Definition
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Term
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Definition
| evaluate the effectiveness of plan of care |
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Term
| scientific problem solving |
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Definition
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Term
| intuitive problem solving |
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Definition
| based on similarity to other situations |
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