Assessment Concept PPT¬es

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Assessment Concept PPT¬es
2014-09-17 21:08:14

week 1-3 for Exam 1
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  1. What does the nurse consider when preparing for DATA COLLECTION? (6)
    • Health Practice
    • Health beliefs & values
    • Dev. stage of PT
    • Need for nursing
    • Avoiding repetitive ?s
    • Validation
  2. What is Objective vs Subjective data? 

    -"My leg hurts"
    -Febrile, P=72, RR-22
    -Abdomen soft
    -Pt's ability to cope with illness
    Ob: observable & measurable data; seen, heard, or felt.

    Sub: perceived only by the affected person.

    • -CBC: Ob.
    • -"leg": S.
    • -Feb, P-72, RR-22: Ob.
    • -Abdomen soft: Ob.
    • -Pt's ability: S.
  3. Identify 5 sources of Pt data useful to the nurse.
    • 1) Pt: primary & BEST source of info.
    • 2) Fam & sig. othersN
    • 3) Pt record
    • 4) Other HC pros.
    • 5) Nursing & other lit.
  4. Define nursing health assessment.
    "..a hollistic collection of info. about factors that affect one's health"

    " plan, implement, and evaluate (PIE) teaching of care to prevent illness, restore health, & cope w/ disabilities or death."
  5. Define physical assessment.
    "..a SYSTEMATIC collection of OBJECTIVE info."
  6. Why can't the apical pulse validate the radial pulse?
    If there is a "pulse deficit" in which the pulse is different than the HR, blood is not circulating as it should to that arterial point.
  7. What causes the wheezing of the lungs?

    --> Which is only heard during IN?

    Which is only heard during EX?

    Which is heard during IN & EX?
    Narrow airways.

    • -crackles caused by FLUID.
    • -->crackles

    EX: ronchi

    IN&EX: Wheezing & friction rub.
  8. What is expected RR of adults?

    Name two abnormal findings of breathing.
    RR adults: 12-20.

    • 1) Use of accessory muscles
    • 2) nasal flaring, pursed lips
  9. What are the 4 types of assessments and there purposes?
    • 1) Initial assessment (comprehensive)
    • -establish a complete database for problem identification & care planning.
    • 2) Focused A.
    • -collects info. about a specific problem.
    • 3) Emergency A.
    • -identify life-threatening problems
    • (e.g., choking, bleeding, stab wound, etc.)
    • 4) Time-elapsed A.
    • -Compares current status to baseline data.
  10. Differentiate how assessment of children varies form assessment of adults.
    Refer to notes: 9/3, LO #4.
  11. What are expected & abnormal findings for the abdominal assessment?
    Expected: evenly rounded, symmetric w/o visible peristalsis.

    • Abnormal: swelling (indicates ascites, fluid retention), tenderness, masses.
    • -hyperactive: increased BS (diarrhea)
    • -hypoactive: decreased BS (bowel obstruction)
  12. What are expected & abnormal findings for the respiratory assessment?

    Abnormal: wheezing, crackles, ronchi, friction rub.

    • -Wheezing due to narrowed airways.
    • -Crackles due to fluid retention.
  13. What are expected & abnormal findings for the cardiac assessment?
    Expected: "lub dub" S1&S2 (aortic&mitral)

    • Abnormal: irregular rate or rhythm.
    • -Extra heart sounds, murmurs, bruits (abnormal sounds).