NURS3320 Assessment Final Review Save
Terms in this set (255)
Ulcers associated with arterial disease are usually painful and
Arterial ulcers
are often located on the toes, foot, or lateral ankle.
, The nursing assessment varies somewhat depending on the
client's general health status and whether the problem is an
acute or chronic one.
In general, however, a comprehensive nursing assessment can
be described as a five-step process that includes screening for
an infection with urinalysis, obtaining a voiding diary, evaluating
functional status, compiling a health history, and performing a
physical examination. Key features within the five steps follow:
-Record all incontinent and continent episodes for 3 days in a
voiding diary.
-Review medication for any newly prescribed drugs that may be
triggering incontinence. Follow up with physician regarding
need to discontinue therapy or change medication.
-Rule out constipation or fecal impaction as a source of urinary
incontinence. If client has had no bowel movement within last 3
Assessing urinary incontinence. days or is oozing stool continuously, check for impaction by
digital examination or abdominal palpation. Problem should be
treated if identified.
-Assess functional status along with signs and symptoms as they
relate to incontinence. Contributors to incontinence may
include immobility, insufficient fluid intake, and confusion.
Accompanying signs and symptoms include polyuria, nocturia,
dysuria, hesitancy, poor or interrupted urine stream, straining,
suprapubic or perineal pain, urgency and characteristics of
incontinent episodes (precipitated by walking, coughing,
getting in and out of bed, and so forth).
, -Consult physician regarding physical examination and need to
measure postvoid residual volume by straight catheterization
(particularly if client dribbles, reports urgency, has difficulty
starting stream). Components of the physical examination
include direct observation of urine loss using a cough stress
test; abdominal, rectal, genital, and pelvic examination; and
identification of neurolo
Breath odor associated with Fruity or acetone breath
diabetic ketoacidosis.
Breath odor associated with Ammonia breath
kidney disease
Suffering is a part of human existence
Prayer and meditation are used for cleansing and healing.
Terminal illness may be seen as a unique opportunity to reflect
on life's ultimate meaning and the meaning of one's relation with
the world.
Buddhism
Death is associated with rebirth. Serene surroundings are
important to the dignity of dying.
Many are strict vegetarians. Some holy days include fasting
from dawn to dusk.
, Beliefs focus around the Old and New Testaments of the Bible
and view Jesus Christ as the Savior. Prayers may be directed to
one or all of the Holy Trinity (God, Holy Spirit, and Jesus Christ).
Most view illness as a natural process for the body and even as
a testing of faith.
There is belief in miracles, especially through prayer.
Christianity
Western medicine is usually held in high regard.
Memorial services rather than funerals and cremation rather
than burial are more common in Christian religions than in other
sects.
No special or universal food beliefs are common to Christian
religions.
Olfactory; Sensory
-Ask the client to clear the nose to remove any mucus, then to
CN I
close eyes, occlude one nostril, and identify a scented object
that you are holding such as soap, coffee, or vanilla. Repeat
procedure for the other nostril.
Terms in this set (255)
Ulcers associated with arterial disease are usually painful and
Arterial ulcers
are often located on the toes, foot, or lateral ankle.
, The nursing assessment varies somewhat depending on the
client's general health status and whether the problem is an
acute or chronic one.
In general, however, a comprehensive nursing assessment can
be described as a five-step process that includes screening for
an infection with urinalysis, obtaining a voiding diary, evaluating
functional status, compiling a health history, and performing a
physical examination. Key features within the five steps follow:
-Record all incontinent and continent episodes for 3 days in a
voiding diary.
-Review medication for any newly prescribed drugs that may be
triggering incontinence. Follow up with physician regarding
need to discontinue therapy or change medication.
-Rule out constipation or fecal impaction as a source of urinary
incontinence. If client has had no bowel movement within last 3
Assessing urinary incontinence. days or is oozing stool continuously, check for impaction by
digital examination or abdominal palpation. Problem should be
treated if identified.
-Assess functional status along with signs and symptoms as they
relate to incontinence. Contributors to incontinence may
include immobility, insufficient fluid intake, and confusion.
Accompanying signs and symptoms include polyuria, nocturia,
dysuria, hesitancy, poor or interrupted urine stream, straining,
suprapubic or perineal pain, urgency and characteristics of
incontinent episodes (precipitated by walking, coughing,
getting in and out of bed, and so forth).
, -Consult physician regarding physical examination and need to
measure postvoid residual volume by straight catheterization
(particularly if client dribbles, reports urgency, has difficulty
starting stream). Components of the physical examination
include direct observation of urine loss using a cough stress
test; abdominal, rectal, genital, and pelvic examination; and
identification of neurolo
Breath odor associated with Fruity or acetone breath
diabetic ketoacidosis.
Breath odor associated with Ammonia breath
kidney disease
Suffering is a part of human existence
Prayer and meditation are used for cleansing and healing.
Terminal illness may be seen as a unique opportunity to reflect
on life's ultimate meaning and the meaning of one's relation with
the world.
Buddhism
Death is associated with rebirth. Serene surroundings are
important to the dignity of dying.
Many are strict vegetarians. Some holy days include fasting
from dawn to dusk.
, Beliefs focus around the Old and New Testaments of the Bible
and view Jesus Christ as the Savior. Prayers may be directed to
one or all of the Holy Trinity (God, Holy Spirit, and Jesus Christ).
Most view illness as a natural process for the body and even as
a testing of faith.
There is belief in miracles, especially through prayer.
Christianity
Western medicine is usually held in high regard.
Memorial services rather than funerals and cremation rather
than burial are more common in Christian religions than in other
sects.
No special or universal food beliefs are common to Christian
religions.
Olfactory; Sensory
-Ask the client to clear the nose to remove any mucus, then to
CN I
close eyes, occlude one nostril, and identify a scented object
that you are holding such as soap, coffee, or vanilla. Repeat
procedure for the other nostril.
