Jarvis Physical Assessment Chapters 1-5, 8-10 (Exam 1) Already Passed

Jarvis Physical Assessment Chapters 1-5, 8-10 (Exam 1) Already Passed Nursing Process 1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation Diagnostic Reasoning The process of analyzing data and drawing conclusions to identify diagnoses Clinical Reasoning Models 1. Diagnostic Reasoning 2. Nursing Process 3. Critical Thinking Order of assessment 1. Inspection 2. Palpation 3. Percussion 4. Auscultation Assessment of Pain PQRSTU P- provocative or palliative Q- quality or quantity R- region or radiation S- severity scale 1-10 T- timing or onset U- understanding patients perception of problem Main Components of Mental Evaluation ABCT A- Appearance B- Behavior C- Cognition T- Thought Process Cultural Competence - Understand heritage-based values, beliefs, attitudes, and practices -Identify meaning of "Health" to patient - Acquire knowledge of social backgrounds -examine patient in cultural context Categories of Interest - Legal permanent residents -Naturalized citizens -undocumented alien -Refuges, asylees, and parolees -legal non-immigrant residents 3rd Level Priority Problems with lack of knowledge, activity, rest, family coping 2nd Level Priority -mental status change -untreated medical problems -acute pain -abnormal lab values -risks of infection, safety, or security 1st Level Priority emergent, life threatening, and immediate ABC plus V A- Airway Problems B- Breathing problems C- cardiac/ circulation problems V- vital sign concerns Critical Thinking 1. Identify Patterns 2. Find missing info 3. Health promotion -Avoid making assumptions - Identify risks Evaluation -evaluate conditions and compare actual outcomes with expected outcomes -identify reasons for failure to achieve expected outcomes -Take corrective action to modify plan or care Implementation -review planned interventions -delegate appropriate responsibilities -counsel patient and significant others (health promotion) - document implementation Planning - establish priorities -develop outcomes (set time frames) -document plan of care Outcome Identification Identifying expected outcomes that are realistic and measurable (time frame included) Diagnosis -interpret data -identify cluster cues -document data Types of Databases 1. Complete Total Health 2. Focused or Problem- centered Health 3. Follow- up 4. Emergency Assessment Frequency interval of assessment varies with illness and wellness needs Effective Care positive outcomes and satisfaction for patient Respectful care values, preferences, and expressed needs of patient Acculturation The process of adapting to and acquiring another culture Assimilation The process of developing a new cultural identity and becoming like members of the dominant culture Bilculturalism Dual pattern of identification and often of divided loyality WIPE W- Wash Hands I- Introduce self P- Provide privacy E- Explain procedure Reflection Echoing patients words, repeating what person has just said Interpretation If your inference is incorrect, the patient may correct it, and thus prompt further discussion of the topic Palpatation -Applies sense of touch to assess - Start light and perform deeper if needed *Fingertips best used for tactile discrimination (texture, swelling, lumps) *Dorsa of hands best used for determining temperture Percussion -Tapping of skin with short, sharp, strokes to assess underlying structures - Direct and Indirect methods *Helps map location and size of organs *Elicit deep tendon reflex Auscultation -listening to sounds produced by the body Height Conversion 2.54 cm/ 1 inch Weight Conversion 2.2 kg/ 1 lb Temperture -"normal" is 98.6 F Temperture Varies with patient circumstances: -Age - Dinural Cycle (circadian rhythm) - Menstruation cycle -Excerise Pulse Force - 3+ = full, bounding - 2+ = normal -1 + = weak, thready (barely felt/ weak) - 0 = absent Pulse - normal resting rate for adults = 60-100 bpm Respiration -Normal rate= 12-20 breaths per min -4 heartbeat= 1 Blood Pressure The force of blood pushing against the side of its container (vessel walls) -average BP in young adult = 120/80 mm Hg Systolic First sound/ number Diastolic Second sound/ number Pulse Pressure difference between systolic and diastolic numbers Unmodifiable BP factors -Age -Gender -Race Modifiable BP Factors -Cardiac output -Peripheral vascular resistance - Volume of blood circulating - Viscosity - Elasticity of vessel walls Oxygen saturation 90-100% perfusion rate of oxygen gas Pulse Oximeter Used to calculate oxygen saturation Aphasia the loss of ability to speak or write coherently or to understand speech or writing due to brain damage Orientation Patient ability to comprehend time, place, and person -"What brought you here?" - " What season is it?" - "Where do you live?" Visceral Pain malfunctioning organ Cutaneous Pain Superficial pain Psychogenic Pain Head pain Acute Pain - 6 months or less - is short term and self-limiting - example include: surgery, trauma, kidney stones Chronic Pain -lasting longer than 6 months - does not stop when injury heals -outlasts its protective purpose, and the level of pain intensity does not correspond with physical findings