NUR2092 Health Assessment Exam 1 Complete Study Guide 2023/2024

What are the 6 steps of the nursing process? 1. Assessment 2. Diagnosis 3. Outcome 4. Planning 5. Implementation 6. Evaluation Assessment Definition (nursing process) 1. Collect data 2. Use evidence-based assessment techniques 3. Document relevant data Diagnosis Definition (nursing process) 1. Compare clinical findings with normal and abnormal variation and developmental events 2. Interpret data-- make & test hypotheses 3. Validate diagnoses 4. document diagnoses Outcome Identification Definition (nursing process) 1. Identify expected outcomes 2. Individualize to the person 3. Culturally appropriate 4. realistic and measurable 5. include a timeline Planning Definition (nursing process) 1. ESTABLISH PRIORITIES 2. Develop Outcomes 3. Set timelines for outcomes 4. IDENTIFY interventions 5. Integrate evidence-based trends and research 6. Document plan of care Implementation Definition (nursing process) 1. Implement in a safe and timely manner 2. Use evidence-based interventions 3. Collaborate with colleagues 4. use community resources 5. coordinate care delivery 6. provide health teaching and health promotion 7. document implementation and any modifications. Evaluation Definition (nursing process) 1. Progress toward outcomes 2. conduct systematic, ongoing, criterion-based evaluation. 3. Include patient and significant others 4. use ongoing assessment to revise diagnoses, outcomes, plan 5. distribute results to patient and family Acute pain 1. Is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. 2. Self-protective purpose; it warns the individual of actual or threatened tissue damage. Chronic Pain 1. Over 6 months in duration 2. Adaptive responses Phantom pain 1. Pain where limb used to exist Malignant pain Vs nonmalignant pain 1. Malignant pain is cancer-related and is caused by tumor cells that cause necrosis or stretching. 2. Nonmalignant pain is often associated with musculoskeletal conditions. Visceral pain Originates from internal organs. Somatic pain and deep somatic pain 1. Somatic pain originates from musculoskeletal tissues or the body surface. 2. Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone. Referred pain Pain that is felt at a particular site but originates from another location. Nociceptive pain 1. Develops when functioning and intact nerve fibers in CNS are stimulated. 2. They are triggered by events outside nervous system from actual or potential tissue damage. 3.Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation Neuropathic pain 1. Pain caused by a lesion or disease of the somatosensory nervous system. 2. This implies an abnormal processing of pain message from an INJURY to the NERVE FIBERS. 3. This pain is very difficult to treat and assess. Subjective Data Pain is always subjective. What the patient is complaining of; SYMPTOM Objective data What the nurse observes ; SIGN Nutritional Status o This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors Nutritional Assessment  Food intake o 24 hour recall o Food diary o Food frequency o Direct observation  Anthropometric measurements  Swallowing assessment prn  Lab tests Pain assessment tools 1. Brief pain inventory 2. McGill Pain Questionnaire 3. Initial Pain assessment 4. Pain rating scales 5. Wong-Baker Faces pain rating scale Pain Assessment • Posture/behavior • Facial expression • Sounds • Skin inspection/palpation • BP/pulse/respirations • Pupil size How to assess domestic violence "Abuse assessment screen" is a tool used by many healthcare providers. Pulse Oximetry • Noninvasive • Estimate arterial oxygen saturation in blood Normal Resp. Rate for adult 10-20 Normal BP for Adult 120/80 BMI requirements for being underweight, normal weight, overweight, obese. Underweight = 18.5 BMI Normal weight = 18.5- 24.9 BMI Overweight= 25-29.9 BMI Obese= 30+ BMI How to document pulse 0=absent 1+= weak 2+= normal 3+= bounding Definition of Eupnea Normal/good breathing Definition of Apnea Breathing has stopped What does the acronym PQRSTU stand for? P= Precipitating/palliative/provocative, What brings it on ? what were you doing when you noticed it? Q= Quality or Quantity, how does it feel, sound? How intense/severe is it? R=Region or Radiation, Where is it? Does it spread anywhere? S= Severity Scale, Scale of 1-10. Is it getting better/worse? T= Timing/ onset. When did it first occur? Duration? How long did it last? Frequency? U= Understand patient's perception of the problem. What do you think it means? Vital Signs Influences ► Blood Pressure o Age o Gender o Race o Diurnal variations o Emotions o Pain o Personal habits o Weight ► Respiratory Rate o Exercise and anxiety ► Heart Rate (Pulse) o exercise, age, gender, anxiety, pain ► Temperature o Diurnal variations - Lowest early AM, highest late afternoon/early evening o Exercise – rises o Menstrual cycle – increase mid cycle ovulation to menses o Age – very young wider variation; older typically lower o Drinks hot or cold Normal pulse rate for adult 50-90 What happens to BP if cuff is too small or big? If too small it will increase BP If too big it will lower BP Normal Oral temp + range 98.6. range off 96.4 to 99.1 Is it normal for new born infants rectal temps to be higher? Yes, average is 100 How do you measure BP cuff size With of bladder should equal 40% of circumference of persons arm. Length of bladder should equal 80% of circumference. What is the working phase of the interview? The working phase is the data-gathering phase. What are the steps to the "Tools of a physical Assessment", 4 Steps 1. Inspection—Visual examination of body 2.Palpation—texture, temp., rigidity, lumps, masses 3. Percussion— To evaluate size, borders, consistency, tenderness, extent of fluid 4. Auscultation—listening to sounds body produces; pitch, loud or soft, duration, and quality Delirium Vs Dementia 1. Delirium is an ACUTE confusion state 2. Dementia is a CHRONIC progressive loss of cognitive & intellectual functions. Disorientation, judgment loss, memory loss, impaired.  Complete total health database  Includes complete health history and full physical examination  Describes current and past health state and forms baseline to measure all future changes  Yields first diagnoses  Episodic or problem-centered database  For limited or short-term problems  Concerns mainly one problem, one cue complex, or one body system  History and examination follow direction of presenting concern ► Follow-up database  Status of all identified problems should be evaluated at regular and appropriate intervals  Note changes that have occurred  Evaluate whether problem is getting better or worse  Identify coping strategies being used