Light palpation
Give this one a try later!
There should be very little or no depression (less than 1 cm). Feel the
surface structure using a circular motion.
Use this technique to feel for pulses, tenderness, surface skin texture,
temperature, and moisture.
SAD PERSONS Suicide Assessment
Give this one a try later!
, Sex
Age
Depression
Previous Attempt
Ethanol (Alcohol) Abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness
Percussive Sounds: Flatness
Give this one a try later!
FLATNESS: Soft/High/Short/Flat: heard over very dense tissue: bone,
muscle, thigh, sternum
When assessing older adults
Give this one a try later!
during the interview always convey there is something positive that the
older person is doing & acknowledge the older clients accomplishments
that made their life meaningful.
The complete health history is performed to collect as much subjective data about a
client as possible. It consists of eight sections:
Give this one a try later!
, 1. Biographic data (name, address, phone, gender, who provided the info—
the client or significant others. birth date, Social Security, medical record
number, or similar identifying data may be included) NOT occupation.
2. Reasons for seeking health care ("What is your major health problem or
concerns at this time?" & "How do you feel about having to seek health
care?")
3. History of present health concern (use COLDSPA)
4. Personal health history (illnesses, immunizations, allergies, etc)
5. Family health history,
6. Review of body systems (ROS) for current health problems (skin, hair
nails, head, neck, etc)
7. Lifestyle and health practices (social history: Description of Typical Day,
Nutrition and Weight Management, Activity Level and Exercise, Sleep and
Rest, Substance Use)
8. Developmental level.
Auscultation ca be used to detect:
Give this one a try later!
normal heart sounds, breath sounds, and bowel sounds
Process of data analysis
Give this one a try later!
, 1. Identify abnormal data and strengths.
2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those diagnoses. 6. Confirm or rule
out nursing diagnoses.
7. Document conclusions.
7 Steps for Diagnostic Reasoning/Critical Thinking for Diagnosis
Give this one a try later!
1. Identify abnormal data and strengths.
2. Cluster data.
3. Draw inferences.
4. Propose possible nursing diagnoses
5. Check for presence of defining characteristics.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions.
Early signs of sepsis include:
Give this one a try later!
changes in vital signs such as an
elevated temperature (fever)
increased heart rate (tachycardia)
HYPOtension
Hypertension and bradycardia are not associated with sepsis.
Give this one a try later!
There should be very little or no depression (less than 1 cm). Feel the
surface structure using a circular motion.
Use this technique to feel for pulses, tenderness, surface skin texture,
temperature, and moisture.
SAD PERSONS Suicide Assessment
Give this one a try later!
, Sex
Age
Depression
Previous Attempt
Ethanol (Alcohol) Abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness
Percussive Sounds: Flatness
Give this one a try later!
FLATNESS: Soft/High/Short/Flat: heard over very dense tissue: bone,
muscle, thigh, sternum
When assessing older adults
Give this one a try later!
during the interview always convey there is something positive that the
older person is doing & acknowledge the older clients accomplishments
that made their life meaningful.
The complete health history is performed to collect as much subjective data about a
client as possible. It consists of eight sections:
Give this one a try later!
, 1. Biographic data (name, address, phone, gender, who provided the info—
the client or significant others. birth date, Social Security, medical record
number, or similar identifying data may be included) NOT occupation.
2. Reasons for seeking health care ("What is your major health problem or
concerns at this time?" & "How do you feel about having to seek health
care?")
3. History of present health concern (use COLDSPA)
4. Personal health history (illnesses, immunizations, allergies, etc)
5. Family health history,
6. Review of body systems (ROS) for current health problems (skin, hair
nails, head, neck, etc)
7. Lifestyle and health practices (social history: Description of Typical Day,
Nutrition and Weight Management, Activity Level and Exercise, Sleep and
Rest, Substance Use)
8. Developmental level.
Auscultation ca be used to detect:
Give this one a try later!
normal heart sounds, breath sounds, and bowel sounds
Process of data analysis
Give this one a try later!
, 1. Identify abnormal data and strengths.
2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those diagnoses. 6. Confirm or rule
out nursing diagnoses.
7. Document conclusions.
7 Steps for Diagnostic Reasoning/Critical Thinking for Diagnosis
Give this one a try later!
1. Identify abnormal data and strengths.
2. Cluster data.
3. Draw inferences.
4. Propose possible nursing diagnoses
5. Check for presence of defining characteristics.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions.
Early signs of sepsis include:
Give this one a try later!
changes in vital signs such as an
elevated temperature (fever)
increased heart rate (tachycardia)
HYPOtension
Hypertension and bradycardia are not associated with sepsis.
