Assessment
Collection of subjective and objective data
Diagnoses
Analysis of subjective and objective data to make a professional nursing judgement
Planning
Developing a plan of nursing care and outcome criteria
Implementation
Carrying out the plan of care
Evaluation
Assessing whether outcome criteria have been met and revising the plan of care if necessary
Nursing Diagnosis
Clinical judgement about individual, family or community responses to actual or potential health problems and life processes
Subjective Data
Sensations or symptoms that can be verified only by the client (ex. pain)
Objective Data
Findings directly observed or indirectly observed through measurements (ex. body temperature)
Collaborative Problem
Physiologic complications that nurses monitor to detect their onset or changes in status
Referral Problem
Problem that requires the attention or assistance of other health care professionals
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
Physiologic status
The result of a nursing assessment is the
Formulation of nursing diagnoses
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
Continuous
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
Comprehensive
An ongoing or partial assessment of a client
Includes a brief reassessment of the client's normal body system
The purpose of the comprehensive health assessment is to
Arrive at conclusions about the client's health
The use of this type of question can keep a client interview from going off track
Closed-ended
A nurse can clarify a client's statements by
Rephrasing the client's statements
During what phase of the interview between a nurse and client do you collaborate to identify problems and goals
Working phase
When dealing with a manipulative client it is important for the nurse to
Provide structure and set limits
The primary purpose of the health history is to
Identify risk factors to the client and his or her significant others
Define the "COLDSPAA" accronym
Character, Onset, Location, Duration, Severity, Pattern, Associated factors, how it Affects the client
Sim's position
Side-lying position used during the rectal examination
Sitting Position
Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities
Supine Position
Back-lying position used for examination of the abdomen (with one small pillow under the head and another under the knees); this position also allows easy access for palpation of peripheral pulses
Standing Position
Position used to examine male genitalia and to assess gait, posture, and balance
Prone Position
Client lies on abdomen with head turned to the side; may be used to assess back and mobility of hip joint
Lithotomy Position
Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
What part of the examiner's hand is used to feel for fine discriminations: pulses, texture, size, consistency, shape, and crepitus
Fingerpads
Part of the examiner's hand used to feel for vibration, thrills, or fremitus
Ulnar surface or palm of hand
Part of the examiner's hand used to feel for temperature
Dorsal surface of hand
Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)
Bell of stethoscope
Larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds
Diaphragm of stethoscope
Name the four basic techniques used for physical assessment
Inspection, palpation, percussion, auscultation
Name the five steps of the nursing process
Assessment, diagnosis, planning, implementation and evaluation
What are the four sections of the nursing assessment framework?
History of present health concern, past health history, family history and lifestyle and health practices
What are the four basic types of assessments?
Initial comprehensive assessment, ongoing or partial assessment, focused or problem oriented assessment and emergency assessment
Name the four major steps of the assessment phase
Collection of subjective data, collection of objective data, validation of data and documentation data
Explain the importance of a contextual approach to nursing health assessment
The client's culture, family, community and spirituality all affect their overall health
What is the purpose of conducting a health history interview?
Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information and to gather information on the client's developmental, psychological, physiologic, sociocultural and spiritual statuses
What are the steps or phases of the health history interview?
Introductory phase, working phase, summary and closing phase
What are the three variations in communication that must be considered as you interview clients?
Gerontologic, cultural and emotional
What are the components of a complete health history?
Biographic data, reasons for seeking health care, history of present health concern, past health history, family health history, review of body systems (ROS) for current health problems, lifestyle and health practices profile, developmental level
What is the purpose of the physical assessment?
To obtain objective data
What preparation is required for conducting a physical assessment?
Necessary equipment and how to use it, preparing the setting, onself and the client for examination and how to perform the four basic assessment techniques
Why must subjective and objective data be verified?
Failure to validate data may result in premature closure of the assessment or collection of inaccurate data
What methods are used to verify data?
Recheck objective data through reassessment, clarify with client by asking additional questions and compare your objective findings with subjective findings for discrepencies
What is the purpose of the general survey assessment?
To provide the nurse with an overall impression of the client's whole being.
What does the general survey assessment include?
Physical development and body build, gender and sexual development, apparent age vs reported age, skin condition and color, dress and hygiene, posture and gait, LOC, behavior, body movements and affect, facial expression, speech and vital signs
What is included in the vital signs assessment?
Temperature, pulse, respiration, blood pressure and pain
What is the normal temperature range of an adult?
96-99.9 F orally 36.5-37C
What is the normal pulse rate for an adult?
60-100 beats per minute
Define tachycardia
Pulse rate of greater than 100 beats per minute
Define bradycardia
Pulse rate of less than 60 beats per minute
When assessing the pulse what should the nurse note?
Rate, rhythm, amplituded and contour
What is the normal respiratory rate for an adult?
12-20 per minute
What should the nurse be assessing when observing respiration?
Rate, rhythm and depth
What is the normal blood pressure of an adult?
120/80
Older adults may experience this variation in blood pressure
Isolated systolic hypertension 140/90
Describe the subjective components of the pain assessment
Pain is whatever the client says it is, directly quote description of pain use COLDSPA mneumonic
Describe the objective components of pain assessment
Use of pain assessment tools
What are three types of pain assessment tools?
Visual analog scale (VAS), numeric pain intensity scale (NRS) and simple descriptive pain intensity scale (VDS)
What are the three classifications of pain?
Acute pain, chronic nonmalignant pain and cancer pain
This type of pain is usually associated with a recent injury
Acute pain
This type of pain is usually associated with a specific cause or injury and described as a constant pain that persists for more than six months
Chronic nonmalignant pain
This type of pain is usually due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemo, radiation or tumor growth and infiltration
Cancer pain
When converting inches to centimeters what is the conversion factor?
Multiply by 2.54
When converting pounds to kilograms what is the conversion factor?
Divide by 2.2
Define mental status
Client's level of cognitive and emotional functioning and stability reflected in their speech, appearance and thought patterns
Normal findings for level of consciousness
Client is alert, awake and orientated to time, place, date and purpose. Responds to questions and answers appropriately
Define lethargy
Client opens eyes, answers questions and falls back asleep
Define obtunded
Client opens eyes to loud voice, responds slowly with confusion and seems unaware of environment
Define stupor
Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
Define coma
Client remains unresponsive to all stimuli, eyes stay closed
Define decorticate posture
aka Abnormal flexor posture, client with lesions of the corticospinal tract draws hands up to chest when stimulated
Define decerebrate posture
aka Abnormal extensor posture, client with lesions of the diencephalon, midbrain or pons extends arms and legs arches neck and rotates hands and arms internally when stimulated
What is the subjective component of a nutritional assessment?
Client interview which may include a 24 hour dietary recall
What is the objective component of a nutritional assessment?
Anthropometric measurements are used to evaluate the client's physical growth, development and nutritional status as well as physical examination and hydration assessment
What are the three anthropometric measurements?
Triceps skinfold (TSF), Mid upper arm circumference (MUAC), Arm muscle circumference (AMC)
What are some indicators of good nutritional status?
Alert, energetic, good endurance, good posture, good attention span, psychological stability, weight within range for height, age and body type, no skeletal changes, eyes bright and clear, shiny hair, skin glowing, elastic, good turgor, smooth, healthy re
What are some indicators of poor nutritional status?
Withdrawn, apathetic, easily fatigued, stooped posture, inattentive, irritable, overweight or underweight, flaccid muscles, wasted appearance, diminished reflexes, skin dull, pasty, scaly, dry, bruised, eyes dull, hair brittle, skeletal malformations
What factors influence dietary habits?
Lower socioeconomic status, long working hours and fast food consumption, poor food choices, chronic dieting, chronic diseases, dental issues, limited access to sufficient food, eating disorders, illness or trauma
What BMI is considered obese?
30-34.9
What waist circumference measurement is considered to put the client at risk for disease?
35 inches or greater for women and 40 inches or greater for men
How is BMI calculated?
Weight in kg/height in meters squared
What is spirituality?
One's search for life's meaning and purpose
What is religion?
Shared practices and rituals used to express one's faith
What is a spiritual assessment?
An assessment used to determine a client's spiritual needs
What is spiritual care?
Actions used to assist the client in meeting spiritual needs
What are the three types of normal breath sounds?
Bronchial, bronchovesicular and vesicular
Where are bronchial sounds heard?
In the trachea and thorax
Where are bronchovesicular sounds heard?
Over the major bronchi: between the scapulae, around the upper sternum in the first and second ICS
Where are vesicular sounds heard?
In the peripheral lung fields
What pitch do bronchial sounds have?
High pitched
What pitch do bronchovesicular sounds have?
Moderate pitch
What pitch do vesicular sounds have?
Low pitched
When assessing breath sounds what do you need to note?
Pitch, quality and amplitude
What amplitude do each of the 3 breath sounds have?
B-loud, BV-moderate, V-soft
What breath sound is short during inspiration and long during expiration?
Bronchial
What breath sound is the same during inspiration and expiration?
Bronchovesicular
What breath sound is long during inspiration and short during expiration?
Vesicular
Which lung lobe is located from 3cm above the medial 1/3 of the clavicle to the 4th rib at the right sternal border to the 5th rib at the midaxillary line to T3-T1
Right upper lobe
This fissure seperates the RUL from the RML
Horizontal fissure
Where is the right middle lobe located?
From the 4th rib at the right sternal border to the 5th rib at the midaxillary line to the 6th rib at the midclavicular line
This fissure seperates the RML from the RLL as well as the LUL from the LLL
Oblique fissure
This lung lobe is located from the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL
Right lower lobe
Where is the left upper lobe located?
From 3cm above the medial 1/3 of the clavicle to the 6th rib at the MCL to the 5th rib at the MAL to T3-T1
Where is the left lower lobe located?
From the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL
Where is S1 best heard?
At the apex of the heart
Where is S2 best heard?
At the base of the heart
What are the 5 sites of auscultation for normal heart sounds?
Aortic area, pulmonic area, erb's point, tricuspid area and mitral (apical) area
Why is it important to only palpate one carotid artery at a time?
Bilateral palpation of the carotid arteries can result in reduced cerebral blood flow
How long should you palpate/auscultate the apical pulse for?
60 seconds
Where is the aortic area of the heart?
2nd ICS right
Where is the pulmonic area of the heart?
2nd ICS left
Where is erb's point of the heart?
3rd ICS left
Where is the tricuspid area of the heart?
4th ICS left
Where is the mitral (apical) area of the heart?
5th-6th ICS midclavicular
S1 can be described as this sound
LUB
S2 can be described as this sound
DUB
S1 represents
Systole
S2 represents
Diastole
A swishing sound caused by turbulent blood flow throught the heart valves or great vessels
Murmur
A difference between radial and apical pulses
Pulse deficit
Define adventitious sounds
Abnormal breath sounds heard during auscultation of the lung fields which may include crackles, wheezes or pleural friction rubs
Define kyphosis
Abnormally increased forward curvature of the upper spine
Identify 3 age related changes that occur within the lungs
Loss of elasticity, fewer functional capillaries and loss of lung resiliency
The vertebra prominens is also called
C7
Define fremitus
Vibrations of air in the bronchial tubes transmitted to the chest wall
Define crepitus
Crackling sensation like bones or hairs rubbing against eachother
Define edema
The abnormal accumulation of fluid in interstitial spaces of tissues
What is a wheal?
Elevated mass with transient borders size and color may vary. ex hives or insect bites
What is a nevus?
aka a mole, is a flat or raised tan/brownish marking up to 6mm wide
What is a pustule?
A pus-filled vesicle or bulla ex. acne or impetigo
What is a cyst?
An encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis
What is an ulcer?
Skin-loss extending past epidermis, necrotic tissue ex. pressure ulcer
Cicatrix is another name for?
A scar, a skin mark left after healing wound or lesion
What is a fissure?
A linear crack in the skin ex. chapped lips and athlete's foot
What color fluorescence indicates the presence of fungus?
A blue-green color
What is the Romberg test?
Tests the client's equilibrium, client stands with feet together and arms at sides eyes open and then closed. Client should be able to maintain the position for 20 secs with minimal or no swaying
What is used to test distant visual acuity?
The Snellen chart or E chart results are expressed as 20/20 representing the distance from the chart and the last line the client was able to read
What test is used to test near visual acuity?
The Jaeger reading card results are expressed as 14/14 representing the distance in inches from the chart and the last line the client was able to read
What test is used to test peripheral vision?
The confrontation test
What are normal findings of a corneal light reflex test?
The reflection of light on the corneas should be in the exact same spot on each eye which indicates parallel alignment
What does the cover test detect?
Deviation in alignment or strength and slight deviations in eye movement
What are normal results of the cover test?
The uncovered eye should remain fixed straight ahead, the covered eye should remain fixed and straight ahead after being uncovered
Define estropia
An inward turn of the eye
Define exotropia
An outward turn of the eye
What does the positions test consist of?
Testing the six cardinal positions of gaze to assess for extraocular muscle weakness or dysfunction of the cranial nerve
When testing pupillary reaction to light what is the normal result?
Pupils should constrict in both eyes
When testing accomodation of pupils what is the normal result?
Pupils constrict and eyes converge
When palpating lymph nodes what should the nurse be assessing?
Tenderness, mobility, size and shape
Are the lymph nodes normally palpable?
No