Expert Verifed Ace the Test
medical dx - ANSWER ✔✔only made by doctors
nursing dx - ANSWER ✔✔used to evaluate the response of the whole
person to actual or potential health problems
nursing process - ANSWER ✔✔- iterative process allowing
practitioners to move back and forth while caring for the needs of
complex pts.
- Includes six phases: assessment, diagnosis, outcome identification,
planning, implementation, evaluation
"A Delicious Orange PIE" - ANSWER ✔✔Assessment- collect data
,Diagnosis- interpret data
Outcome identification- identify the expected outcomes
Planning
Implementation- doing what you planned
Evaluation- was the outcome we wanted achieved?
inspection phase - ANSWER ✔✔concentrated watching. Checking for
abnormalities before continuing. Inspection begins the moment you first
meet a person and develop a "general survey"
purpose of percussion - ANSWER ✔✔- mapping out the location and
size of an organ by exploring where the percussion note changes b/n the
borders of an organ and its neighbors
- signaling the density (air, fluid, or solid) of a structure by a
characteristic note
- detecting an abnormal mass if its fairly superficial; the percussion
vibrations penetrate a/b 5 cm deep---a deeper mass would give no
change in percussion
- eliciting a deep tendon reflex using the percussion hammer
, diaphragm - ANSWER ✔✔used for high-pitched sounds → breath,
bowel, and normal heart sounds. Hold the diaphragm firmly a/g the
person's skin, firm enough to leave a slight ring afterwards
bell - ANSWER ✔✔used for soft,low-pitched sounds such as extra
heart sounds or murmurs. Hold it lightly a/g the person's skin, just
enough that it forms a perfect seal
1st level priorities - ANSWER ✔✔emergent, life threatening
airway, breathing, circulation, vital signs
2nd level priorities - ANSWER ✔✔requires prompt intervention to
forestall further deterioration
acute pain, mental status change, abnormal labs, risk of infection
3rd level priorities - ANSWER ✔✔those that are important to the pt's
health but can be addressed after more urgent problems. Interventions
to treat these problems are more long term, and the response to
treatment is expected to take more time
subjective data - ANSWER ✔✔what the pt says, biased
objective data - ANSWER ✔✔unbiased, what the pt cannot see, labs
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