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Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
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Practice questions for this set
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The initial survey and assessment will help determine a client's health status. The
observation begins right when you step into the room. While performing the initial
survey be sure to establish trust and build a rapport with the client through therapeutic
communication.
Choose an answer
1 comprehensive assessment 2 Base of fingers or ulnar surface:
approach of the initial survey and
3 4 Assessment (ADPIE)
assessment
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Terms in this set (84)
comprehensive assessment An assessment that includes a complete health history and
physical assessment; Usually brand new patients
focused assessment assessment conducted to assess a specific problem; focuses
on pertinent history and body regions
HIPAA Health Insurance Portability and Accountability Act
The nursing process Assessment
Diagnosis
Planning
Implementation
Evaluation
, Assessment (ADPIE) Data collection (objective/subjective)
Prioritize Data: Primary (life threatening), Secondary (requires
prompt attention), Tertiary (not urgent)
Planning (ADPIE) Develop SMART goals, plan nursing interventions
Implementation (ADPIE) Perform planned nursing interventions
Evaluation (ADPIE) Were the goals met? If not, re-assess
assessment skills Inspection
Palpation
Percussion
Auscultation
(Bowels: Inspection, Auscultation, Percussion. Auscultation) Do
not want to alter the bowel sounds
Inspection Observe for Symmetry, size, color, shape
Direct: Visualize with our eyes
Indirect: Use and instrument
Fingertips/pads: Palpation Fine sensation (texture, swelling, pulsation. lumps)
Dorsa of hands: Palpation Best for determining temperature
Base of fingers or ulnar surface: vibrations
Palpation Light: surface characteristics
Deep: Organs, masses, tenderness (use intermittent pressure)
Ballpottement: Size/Shape of free floating objects
- Always palpate tender areas last
Percussion tapping on a surface to determine the difference in the
density of the underlying structure
Ausculation listening to sounds within the body
Bell low pitched sounds
(mummers)
Diaphragm high pitched sounds
(bowel and lung sounds)
What should we do before leaving the Patients safety
patients room? Bed to lowest position
Side Rails
Call button and personal belongings in reach
Contextual awareness Understanding the status of the client and the events that led
to their interaction