Nurs 1094 Laurentian

subjective vs objective data

Subjective data= history, what the person says

Objective data= physical assessment or what the health care provider observes

steps of diagnostic reasoning

-attending to cues

-formulating hypotheses

-gathering data

-evaluating hypotheses + data

levels of clinical judgement

novice, competent, proficient, expert

what are the 4 levels of critical thinking and priority setting

First-level priority problems= Emergent, life-threatening, immediate

Second level = Urgent, necessitating prompt intervention

Third level= Important, addressed after more urgent problems

Collaborative problems = Treatment involves multiple disciplines

name the 4 concepts of health

-biomedical model

-behavioural model

-socioenvironmental model

-social determinants of health

explain the biomedical model

health is absence of disease

explain the behavioural model

treatment of disease+ primary/ secondary interventions

explain the Socioenvironmental model

incorporates sociological and environmental aspects

explain the social determinants of health

the social, economic, and political conditions the shape the health;th of individuals, families, and communities

what are 4 collecting data formats?

-complete (total health) database

-episodic or problem entered database

-follow-up database

-emergency database

explain complete database

a complete health history and results of a full physical examination

explain episodic or problem-centred database

for a limited or short term problem

explain follow up database

motors short term or chronic health problems

explain emergency database

a rapid collection of data, often complied while life- saving measures are occurring

what is a nursing process?

-a special way of thinking that nurses use

-a thinking or doing approach that nurses use their work

Why is the nursing process important? (10)

-promotes collaboration

-is cost-efficient

-helps people understand what nurses do

-is required by professional standards of practice

-increased client participation in care and promotes client autonomy

-promotes individualized care

-promotes efficiency

-helps you develop good thinking habits

-fosters continuity and coordination of care

-increases job satisaction

explain the 6 keys the nursing process

1.Involves creativity & intuition

2.Special way of thinking or acting

3.Systematic problem solving approach

4.Used to identify, prevent & treat health problems

5.Promotes wellness

6.Provides a framework in which nurses use their knowledge & skills to express caring

what is the purpose and characteristics of the nursing process?

-Dynamic and cyclic - phases interrelated, no absolute beginning or end

-Client centered - encouraged to exercise control & make decisions

-Planned & outcome-directed - interventions chosen & based on principles and research

-Universally applicable - individuals, families, groups, & communities

-Patient-status oriented - statements about health status

-Cognitive (thinking) process - critical thinking to apply nursing knowledge systematically & logically to client data

what are the 2 types of data

primary= client

secondary= sources other than the client

what is an initial assessment

-during 1st client nurse encounter

-usually comprehensive

-all subjective & objective data

-admission assessment

what is an ongoing assessment

-data gathered after the database is complete

-every nurse-client interaction

-identify new problems

-evaluate the status of current problems

What is a comprehensive assessment?

-Overall picture of health status

-Obtain data about all body systems & functional abilities

-Without a particular health problem in mind

-Agency form

what is a focused assessment?

-Gathers data about actual, potential, or possible problem

-Focuses on a specific topic or area of body

-Evaluate existing problems or identify new problems

what are different data collection methods?

-observation

-physical examination

-interview

what is observation

-conscious, deliberate use of physical senses to gather data from pt and environment

-occurs when nurse is in contact with client or support persons

-must be systematic so no significant data are missed

what occurs in physical examination

- systematic assessment of all body systems, identifies strengths, deficits, & functional abilities

-provides objective data to validate subjective data

-data from initial PE serves as baseline

-one approach is head to toe

-techniques of inspection, palpation, percussion, and auscultation

what is an interview

-purposeful, structured communication in which nurse questions client to obtain subjective data

-admission interview is formal and planned

-ongoing assessment may be informal, brief, narrowly focused interactions

what are 2 types of interviews?

-Directive- highly structured, nurse controls subject manner, asks questions to obtain specific data

-nondirective- nurse allows pt to control purpose, subject manner, pacing

what are 2 types of interview questions?

-Open-ended - invites pts to discover and explore their feelings and thoughts

-Close-ended - require 'yes' 'no' answers, or short, factual answers, often begin with, when, where, who, what

What is Gordons 3 levels of functions of health patterns?

-Functions: at optimal level of functioning

-Dysfunctional- assessed & found to have deficits

-Potentially dysfunctional: risk for disability & illness

what are the 11 functions of health patterns

-Health Perception-Health Management

-Nutrition-Metabolism

-Elimination ---Activity-Exercise

-Cognition-Perception -Sleep-Rest

-Self-Perception-elf-Concept -Roles-Relationships

-Sexuality-Reproduction -Coping-Stress

-Values-Beliefs

what are major challenges in regards to health assessment and culture?

-overcoming ethnocentrism

-tendency to view your own way of life as the most desirable & to act in a superior manner toward another culture's ways

what is it important to remember about culture?

-no single definition of culture exists

-culture Is a universal phenomenon

what is culturalism?

a process of conceptualizing, in fairly narrow terms, that people act in a particular way because of their culture.

defining culture from what perspective helps counter culturaism?

critical culture perspective

what is ethnicity?

-inferring geographic and national affiliation

what are ethnic groups?

shared heritage, cultural, language

what is race?

a socially constructed category used to classify humans according to common ancestory

What is UNESCO?

dismisses race as a biological category

what does a comprehensive care plan include?

1.Strengths

2.Wellness diagnoses

3.Actual, potential, & possible nursing dx

4.Collaborative problems

5.Medical problems (although nurses do not diagnose, they are expected to recognize & refer situations beyond expertise)

what are ways of avoiding diagnostic errors?

1.Don't jump to conclusions based on just a few facts

2.Build a good knowledge base & acquire clinical experience

3.Examine your beliefs & values

4.Keep your mind open to all possible explanations of the data clusters

5.Validate all diagnoses with data, not intuition

6.Develop cultural sensitivity

7. Incomplete wording of nursing diagnoses

what is diagnostic reasoning?

is a critical thinking process used within the nursing process to identify patterns from the data and to draw conclusions about the health status of a client (individual, family, or community)

what are ways of interpreting and allaying data in diagnostic reasoning?

1.Consider the organized data from the nursing framework and compare data to standards and norms (eg, anatomy, physiology, psychology, nursing knowledge, developmental theory, lab values, nutritional requirements) to find/ identify significant cues

2.Cluster significant cues from other categories and also cluster cues that seem to be related (relationship between facts)

-identify patterns in data

-identify data gaps & inconsistencies

what are 4 types of nursing diagnosis?

-wellness

-actual

-potential

-possible

what is wellness diagnosis?

are statements of health that show client strengths however, interventions can be initiated to promote growth or to maintain the healthy response

what is an actual nursing diagnosis?

health concerns (maladaptive human responses) that are present now based on the presence of symptoms (subjective data from history) and signs (objective data eg, physical examination findings) Nursing care is directed towards dealing with the diagnosis now

what is a potential nursing diagnosis?

health concerns (maladaptive human response) that are likely to develop if interventions are not initiated. Risk factors are present that make a person more likely to develop a health concern. Nursing care is directed towards preventing the development of these diagnoses

what Is a possible nursing diagnosis?

you have a hunch that a health concern might exist because you have some data. You do not have enough data to confirm or to eliminate a nursing diagnosis so you identify a possible diagnosis so that monitoring will occur.

what is a medical diagnosis ?

-is a disease process that is usually identified by a physician and/ or nurse practitioner

-involves medical treatments to manage, and/ or cure the disease

-some examples, migraine headaches, hypertension, diabetes mellitus, urinary tract infection

wha are ways of prioritizing nursing diagnosis?

Decided on the basis of nurse's judgement and client preferences

Prioritize from highest to lowest (Maslow)

Life-threatening diagnoses are highest priority

Medium-priority dx. May produce destructive physical and/or emotional changes

Low-priority dx- minimum nursing interventions are needed

what are the 3 layers of the skin?

epidermis, dermis, hypodermis

what are the 2 parts of the epidermis?

a.Stratum germinativium (basal cell layer)

b.Stratum corneum (horny cell layer)

what are the 2 parts of the dermis?

a. Connective tissue (collagen)

b. Elastic tissue

what is contained in the subcutaneous layers

-adipose tissue

What are the 4 epidermal appendages?

1. Hair

2. Subaceous glands

3. Sweat glands

a. Eccrine glands

b. Apocrine glands

4. Nails

what are the functions of the skin?

Protection

Prevents penetration

Perception

Temperature regulation

Identification

Communication

Wound repair

Absorption and excretion

Production of vitamin D

what are some developmental considerations of the skin in newborns?

lanugo, vernix caseosa; skin thin and more permeable, greater risk for fluid loss, ineffective temperature regulation

what are some developmental considerations of the skin at puberty?

increased sweat gland secretions, more active sebaceous glands, evidence of secondary sex characteristics in skin

what are some developmental skin considerations in pregnant women?

linea nigra, chloasma, straiae gravidaru; increased secretions from sweat and sebaceous glands, fat deposits

what are some developmental skin conditions in older adults?

Slow atrophy of skin structures

Loss of elasticity, collagen, subcutaneous fat

Thinning of stratum corneum and dermis

Decreased sweat and sebaceous glands

Greater risk for heat stroke

Senile purpura

Increased risk for skin disease

Change in hair distribution

Psychological impact of visible aging

what are cultural and social considerations in regards to skin?

-Recognition of unique clinical manifestations of disease

Related to variation in skin pigmentation and hair texture

-genetic advantage of dark pigmentation and lower incidence of skin cancer

what is important in regards to skin cancer?

•Prolonged exposure to ultraviolet (UV) rays

•Individuals most at risk

oHistory of skin cancer

oUnder 18 years of age

oFair skinned

oHave freckles or moles

oHave a family history

oUsing medications that increase sensitivity to UV rays

oTanning beds: Are they safe? What is the issue, or is there one?

what are important additional history questions in regards to infants and children?

oBirthmarks

oSkin colour changes

Jaundice

Cyanosis

oAllergic rash

oDiaper rash

oBurns or bruises

oExposure to contagious skin conditions

oSelf-destructive habits

oSun protection

what are important additional history questions in regards to older adults?

oSkin changes

oDelay in wound healing

oSkin pain

oFoot/nail changes

oFalling

oDiabetes or cardiovascular disease

oSkin care

What is the ABCDE rule in regards to moles?

•A: asymmetry

•B: border irregularity

•C: colour variation

•D: diameter

•E: elevation and enlargement

what are primary and secondary skin lesions?

Primary Skin Lesions:

-Macule, papule, patch, plaque, nodule, wheal, tumour, urticaria (hives), vesicle, cyst, bulla, or pustule

Secondary Skin Lesions:

-Crust, scale, fissure, erosion, ulcer, excoriation, scar, atrophic scar, lichenification, or keloid

explain pressure ulcers

•Appear on the skin over a bony prominence

when circulation is impaired (confined to bed, immobilized)

•Risk factors: impaired mobility, thin fragile skin of aging, decreased sensory perception, impaired level of consciousness, moisture from urine or stool incontinence, excessive perspiration or wound drainage, shearing injury, poor nutrition, and infection

•Assessed by stage (I-IV), depending on depth

what are different types of vascular lesions?

-hemangiomas

-tellangiectases

-purpuric lesions

-lesions caused by trauma or abuse

what type of lesion is associated with AIDS? what are the 3 stages?

Kaposi's sarcoma

-patch stage

-plaque stage

-advanced disease

what are the structures of the head?

-cranial structures

-facial bones

-facial muscles

-salivary glands

what is the structure of the neck?

-neck muscles

-anterior & posterior triangles

-thyroid glands

What are 10 lymph nodes of the head/neck?

-preauricular

-posterior auricular

-occipital

-submental

-submandibular

-jugulogastric

-superficial cervical

-deep cervical chain

-posterior cervical

-supraclavicular

what are developmental considerations with the head in regards to infants & children

-fontanelles

-head growth

oSkull: head circumference, cephalohematoma

oFace: symmetry, appearance, presence of swelling

oNeck: muscle development and head control

what are developmental considerations with the head in regards to pregnant women

-slightly enlarged thyroid gland

what are developmental considerations with the head in regards to older adults

-sagging facial skin

-Presence of senile tremors, concave cervical curve, dizziness on range of motion (ROM)

what is subjective data when talking about the head and neck?

-Headache

-Head injury

-dizziness

-neck pain or limitation of motion

-lumps or swelling

-history of head or neck surgery

what are additional health history questions to ask infants and children in regards to head and neck?

-prenatal drug exposure

-type of delivery

-growth pattern

what are additional health history questions to ask older adults in regards to head and neck

-dizziness

-neck pain

what is objective data while completing a head and neck physical exam?

•Head- Inspect and palpate the skull

•Size and shape (normocephalic)

• Temporal area

o Temporal artery

o Temporomandibular joint

•Head- Inspect the face

•Facial Structures

what objective data is measured when palpating the neck and head?

•Symmetry

•Range of Motion

•Lymph nodes

oIf palpable, note: location, size, shape, delimitation, mobility, consistency, and tenderness

•Trachea

•Thyroid gland

oPosterior approach

oAnterior approach

oAuscultate for presence of bruit

what are 2 common abnormal findings of the head and neck?

-abnormalities in head size and contour

-swelling of the head and neck

what are paediatric facial abnormalities

•Fetal Alcohol syndrome

•Congenital hypothyroidism

•Downs syndrome

•Atopic (allergic) facies

•Allergic salute and crease

what chronic illnesses can cause abnormal facial appearances

•Parkinson's syndrome

•Cushing's syndrome

•Hyperthyroidism

•Myxedema (hypothyroidism)

•Bell's palsy

•Stroke or cerebrovascular accident

•Scleroderma

what is the external anatomy of the eye?

-eyelids

-palpebral fissure

-limbus

-canthus

-caruncle

-tarsal plates

-meibomian glands

-conjunctiva

-lacrimal apparatus

what are the extra ocular muscles of the eye?

•Superior rectus

•Inferior rectus

•Lateral rectus

•Medial rectus

•Superior oblique

•Inferior oblique

what are the 3 divisions of internal anatomy of the eye?

-outer fibrous sclera

-middle vascular choroid

-inner nervous retina

what is included in the outer fibrous sclera

-cornea

what is included in the middle vascular choroid?

-ciliary body and iris

-pupil

-lens

-anterior chamber

-posterior chamber

what is included in the inner nervous retina?

-optic disc

-retinal vessels

-macula

-fovea centralis

what are examples of visual reflexes?

-pupillary light reflexes

-fixation

-accommodation

what are developmental considerations over adults in regards to the eye?

oPresbyopia

oMacular degeneration

oCataracts

oGlaucoma

oDiabetic retinopathy

what is the second leading cause of preventable blindness in Canada

glaucome

what is the #1 leading cause of preventable blindness in Canada?

macular degeneration

what are risk factors for glaucoma?

oAge > 60 years

oAfrican descent

oFemale gender

oIncreased intraocular pressure

oFamily history

oSteroid use

oDecreased central corneal thickness

oHypertension

oEye injury

oSevere myopia

oDiabetes

oUse of certain medications

what is subjective data in regards to the eye?

•Vision difficulty (decreased acuity, blurring, blind spots)

•Pain

•Strabismus (cross eyed) , diplopia (double vision)

•Redness, swelling

•Watering, discharge

•History of ocular problems

•Glaucoma

•Glasses or contact lenses

•Self- care behaviours

•Medications

•Vision loss

what are additional health history questions to ask infants and children in regards to eyes?

oMothers vaginal infection during delivery

oDevelopmental milestones

oRound vision testing

oSafety measures

what are additional health history questions to ask older adults in regards to eyes

oMovement and visual difficulty

oGlaucoma testing

oCataracts

oDryness of eyes

oDecreased activities

what tests are done for central visual acuity?

-snellen eye chart

-pocket vision screener for near vison

what test is performed to test visual fields?

confrontation test

what tests are done to test extra ocular muscle function

-corneal light reflex (Hirschberg test)

-cover- uncover test

-diagnostic positions test