NUR 109: Physical Assessment, General Survey, Pain Assessment (Exam 1) Questions And Answers Solved Graded A+.

What are the primary goals of nursing? - correct answers 1. Determine client/family responses to human problems, level of wellness, and need for assistance 2. Provide physical care, emotional care, teaching, guidance, and counseling 3. Implement interventions aimed at prevention and assisting the client to meet his or her own needs and health-related goals. What mnemonic do we use for the nursing process? - correct answers ADPIE What does ADPIE stand for in the nursing process? - correct answers Assessment Disgnosis Planning outcomes and interventions Implementation Evaluation Can ADPIE be delegated to a LPN or CNA? - correct answers Absolutely NOT Why is it important to have a care plan for a patient? - correct answers 1. Ensures care is complete 2. Provides continuity of care and efficient use of nursing efforts 3. Provides a guide for assessments and charting 4. Meets requirements of accrediting agencies What is done in the assessment phase? - correct answers the nurse will collect validate organize record data What are the two ways we as nurses are able to collect data? - correct answers Objective data Subjective data What do we do in the diagnosis phase? - correct answers Cluster and analyze data What do we do in the planning of outcomes phase? - correct answers Set goals for the patient predict outcomes Plan interventions What do we do in the implementation phase? - correct answers perform interventions What do we do in the evaluation phase? - correct answers we see if the goals were met and if the plan worked. if it didnt work then we start over again What are the 4 different things we need to do with the data? - correct answers Collect validate organize record What kind of data is a LPN aloud to collect? - correct answers VS pain FBG (fasting blood sugar test) What does the joint commission require of nurses regarding assessments? - correct answers 1. RN must assess client's need for nursing care within 24 hours of inpatient admission 2. Agency policy dictates time frames for reassessment; which disciplines can do reassessment; 3. All client's must be assessed for pain; nutritional status; and risk for falls in the beginning of the assessment what are some things that are covered? - correct answers -physical, mental, spiritual, cultural, socioeconomic status of client -getting the person into the patient/client database -setting goals for the patient What are the four substeps in the assessment phase? - correct answers 1. Collect data 2. Validate data 3. Organize data 4. Document During the assessment phase how do we collect data? - correct answers 1. Observation -are they dressed appropriately for the weather, eye contact, is the IV pump okay, is there anything on the floor that the patient could trip on, there is wound care stuff on the counter so I should be looking for a wound and are there enough supplies, etc 2. Interview: health & medical history Open-ended questions elicit more information 3. Physical assessment (head-to-toe) 4. Documentation (Chart) 5. Collaboration -talk to others that are also treating the patient or family members What are the different assessments? - correct answers 1. Initial and ongoing 2. Comprehensive 3. Focused 4. Special Needs -nutrition, family, community, etc 5. Functional Ability Assessment -what kind of ADLs can they do on their own when do we want to validate data? - correct answers -when something doesn't match -when subjective and objective data do not make sense together -when clients statements differ at different times during interview -data is far outside the normal range ex: no signs or symptoms of infection but has a super high temp -factors are present that interfere with accurate measurement -did anything make you go hmmm? ex: when a patient says he doesn't have high BP but it reads 190/95 and he is on BP meds what are the different frameworks for organizing data? - correct answers 1. heat to toe 2. body systems 3. gordons functional health 4. maslows hierarchy What is white coat syndrome? - correct answers A fear of going to the doctor and then vital signs might be off due to this prior to choosing a ___________ __________ , meaning must be made of the ___________ ___________. - correct answers nursing diagnosis assessment data Describe Maslow's Hierarchy of Needs - correct answers Emphasizes an individual's motivation in the continuous quest for self-actualization. The lower needs requiring fulfillment before those at higher levels can be achieved, with self-actualization being fulfillment of one's highest potential. What are the physiological needs in maslows model? - correct answers food, air, water, temp regulation, elimination, rest, sex, physical activity what are the safety and security needs in maslows model? - correct answers protection, emotional and physical safety/security, order, law, stability, shelter What are the love and belonging needs in maslows model? - correct answers giving and receiving affection, meaningful relationships, belonging to groups What are the self-esteem needs in maslow model? - correct answers pride, accomplishment, recognition by others what are the cognitive needs in maslows model? - correct answers knowledge, understanding, exploration what are the levels of maslows hierarchy of needs starting from the bottom - correct answers 1. physological 2. safety and security 3. love and belonging 4. self-esteem 5. cognitive 6. aesthetic 7. self-actualization 8. transcendence When your assessment is complete what questions should you ask yourself? - correct answers 1. Is the data complete? 2. How do I know the data is accurate? 3. Have I recorded data rather than conclusions (cues, not inferences)? 4. Did I validate any data that didn't make sense? Does any piece of data conflict with other data? 5. Did I record the data appropriately? 6. Have I followed up with in-depth assessments when appropriate? 7. Have I included only relevant data and protected client privacy? Define: assessment - correct answers •Gathering data •Nursing Assessment: - correct answers •Focuses on functional abilities and physical responses to illness or other stressors •Includes physical assessment and nursing history •Medical Assessment: - correct answers •Focus on disease and pathology Who cares/regulates the nursing assessment? - correct answers The Joint Commission •RN must assess client in timely fashion upon client arrival on unit; at start of shift; and prn throughout shift ANA Standard •The RN collects comprehensive data pertinent to the healthcare consumers health and/or situation Purposes of physical nursing assessment - correct answers Obtain-•Obtain baseline data of physical/functional status Identify-•Identify nursing diagnoses; plan nursing care Monitor-•Monitor status of previously identified problem(s) Screen-•Screen for health problems Types of Assessment - correct answers Comprehensive Focused Ongoing Shift assessment comprehensive assessment - correct answers An assessment that includes a complete health history and physical assessment; it is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or every 8 hours for patients in intensive care. focused assessment - correct answers assessment conducted to assess a specific problem; focuses on pertinent history and body regions ongoing assessment - correct answers continuing assessment activities that proceed from the initial nursing assessment Shift Assessment - correct answers RNs conduct assessments each shift. Purpose is to identify changes in a PT's condition from baseline. General Survey - correct answers A written summary of the impression of the client's overall health. The nurse gathers this information from the first encounter with the client and continues to make observations throughout the assessment process. a) Physical appearance b) Body structure c) Mobility d) Behavior e) Vital signs 60 second situational assessment Consider cultural background Gives nurse general idea of where to focus the assessment assessment techniques - correct answers Inspection Palpation Percussion Auscultation objective data (signs) - correct answers information that is seen, heard, felt, or smelled by an observer data can be measured subjective data (symptoms) - correct answers things a person tells you about that you cannot observe through your senses; symptoms nociceptive pain - correct answers -pain from a normal process that results in noxious stimuli being perceived as painful - occurs when nociceptors respond to stimuli that are potentially damaging examples: Ex: touch a burning stove, extreme cold, irritants, pinching. A lot of times due to trauma, surgery, inflammation etc neuropathic pain - correct answers -pain from damage to neurons of either the peripheral or central nervous system -occurs when injury to one or more nerves results in repeated transmission of pain signals even in absence of painful stimuli examples: feeling of foot being asleep. Can result from injury to spine, uncontrolled diabetes, stroke. NERVE Damage Pain Origins of pain - correct answers cutaneous, deep somatic, visceral cutaneous pain - correct answers skin, subcutaneous tissue, bruises deep somatic pain - correct answers Originates in ligaments, tendons, nerves, tissues, bones. More diffuse than cutaneous and will last longer visceral pain - correct answers pain originating in the internal organs in the thorax, cranium, or abdomen example: menstrual cramps, GI infection, labor pains radiating pain - correct answers starts at an origin but stems to other locations. referred pain - correct answers Referred Pain: Pain that occurs in an area that is distant from original site. (ex: heart attack...pain radiating to left arm). phantom pain - correct answers Phantom Pain: perceived to be radiating from area that has been removed. Ex: amputees psychologic pain - correct answers pain that is believed to have arrived from the mind. Duration of pain - correct answers acute and chronic acute pain - correct answers •Short duration •Rapid onset usually r/t injury or surgery chronic pain - correct answers •Persistent pain, lasts 3-6 months or longer •Often interferes with ADLs •Remission & exacerbation •r/t neuropathic pain; progressive disorder Factors affecting pain - correct answers •Emotions •Developmental Age •Previous Experience •Sociocultural •Communication & Cognitive Impairment Examples: Previous experience: I have had 10 surgeries vs 1st surgery Developmental Age: five year thinks everything is the worst pain ever Sociocultural: not supposed to express pain physiological pain response - correct answers Sympathetic Parasympathetic While the sympathetic nervous system is designed to send out pain signals at appropriate times to get the body ready for action, the parasympathetic nervous system is designed to calm these pain signals, to relax the body when pain doesn't need to be felt, so that the body is experiencing pain in an effective and normal way. sympathetic pain response - correct answers increased BP, pulse, respiration, pupil dialation, muscle tension, pallor, increased glucose parasympathetic pain response - correct answers nausea, decreased BP pulse and breathing, faint behavioral pain response - correct answers changing the action that causes the pain Ex: toothache . Pain hurts when eating hard things so patient stops eating hard things. psychologic pain - correct answers Fear of pain, acceptance of pain (Jan with her sciatica), Depression as a result of pain PQRSTU - correct answers *PQRSTU* stands for *Point or palliative, *Q*uality or quantity, *R*egion or radiation, *S*everity scale, *T*iming, and *U*nderstanding the patient's perception of the problem. PQRSTU - correct answers P: Point: Palliates (what causes to get worse) Provokes Q: Quality: what does the pain feel like R: Radiation: Is the pain radiating S: Severity: Scale of 1-10 or faces T: Timing: How long/when do you have the pain? U: You (patient) how does it affect you?