1811 Quiz 2 Part B

What is a focus assessment

"A focused assessment is used to gather information about a specific health problem. ... A focused assessment is advisable when the patient is critically ill, disoriented, or unable to respond."

What is subjective data?

Subjective data are information that is provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data

What is objective data?

Objective data are observable and measurable signs. For example, the LPN/LVN is able to observe capillary refill, measure a patient’s blood pressure, and observe and measure edema."

Understand what secondary sources of information is

"Family members, significant others, medical records, diagnostic procedures, and previous nursing progress notes."

Know the 2 primary methods used to collect data from pt

The nurse conducts an interview… and the physical examination."

Major differences between current diagnosis & likely future problem

"An actual patient problem statement identifies health-related problems that exist and are discovered during the nursing assessment. Potential patient problems are health-related problems that the nurse deems as having a strong possibility of occurring."

Primary purpose of nursing interventions

"Activities that promote the achievement of the desired patient goal."

Understand what implementation charting example looks like

"Implementation includes actions such as patient teaching, medication administration, monitoring the patient’s condition through assessment, delegating care to appropriate personnel, and providing ordered treatments."

Understand which assessment is performed continuously throughout a nurse patient contact

"Focused assessments also are performed continuously throughout nurse–patient contact."

Understand the purpose of data clustering of related signs and symptoms

"Helps to identify patterns that assist with the identification of patient’s health problems."

Know organized approach nurse would use when performing a physical examination

"Once the interview is complete, proceed to the physical assessment. Use inspection, palpation, auscultation, and percussion to collect physical examination data."

Understand difference between RN and LVN when it comes to analyzing data

"The RN is responsible for identifying the appropriate nursing diagnosis (patient problem) for the patient with the assistance of the LPN/LVN."

Know what the basis is for developing nursing interventions

"Treatments based on clinical judgment and knowledge, supported by evidence, that a nurse performs to enhance client outcomes."

Understand what happens in the planning phase of the nursing process

" priorities of care are established and nursing interventions are chosen to best address the patient problem statement."

Understand the rational for involving the patient in the development of the care plan

"It is very important for the nurse to involve the client and/or family in determining appropriate outcomes. Can help increase client motivation to progress toward outcomes."

Understand the components of an outcome statement

"Uses the word patient... • Uses a measurable verb • Is specific... • Does not interfere with the medical plan... • Is realistic... • Includes a time frame"

Getting admitted with abdominal pain, dyspnea (shortness of breath), what type of assessment changes this?

Focus assessment

Which is appropriately written to show a pt problem

the risk to skin impairment, physical immobilization

What are the components to a medical diagnosis

3-part Actual Patient Problem (Problem, Etiology/Contributing Factors, Symptoms), 2-partPotential Patient Problem (Potential, Risk Factors)

What are sources of secondary information?

Everything OTHER than the patient is secondary

Phase 1 of the nursing process

assessment

Phase 2 of the nursing process

diagnosis

Phase 3 of the nursing process

outcomes identification

Phase 4 of the nursing process

planning

Phase 5 of the nursing process

implementation

Phase 6 of the nursing process

evaluation

Understand nurses initial bx when entering a nurse pt relationship

"The first step in initiating the nurse–patient relationship is to introduce oneself, including name, position, and the purposes of the interview."

Know initial step of conducting a complete pt assessment

"Assessment is the first step in delivering nursing care."

Understand what type of history would produce data that would reveal the pts lifestyle patterns & habits

"Use the health history to identify habits and lifestyle patterns."

Know the term that relates to collecting data on all body systems

"The review of systems (ROS) is a systematic method for collecting data on all body systems."

Understand the critical step in forming the nursing care plan

"Assessment... It is the initial step used to form the nursing care plan."

When doing head to toe approach, where do you begin?

Begin with a neurologic assessment, followed by an assessment of the skin, the hair, the head, and the neck."

When would you most often auscultate crackles

"During inspiration."

Understand what makes the lub sound in the lub dub heartbeat

"Caused by the closure of the AV [atrioventricular] valves..."

Understand expected refill time for the capillary bed

"In a person with good cardiac function and distal perfusion, capillary refill usually takes less than 3 seconds."

Understand the normal rate for bowel sounds per minute

"The normal rate of bowel sounds is 4 to 32 per minute."