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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
What is Objective vs Subjective data?
-"My leg hurts"
-Febrile, P=72, RR-22
-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.
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.
Define nursing health assessment.
"..a hollistic collection of info. about factors that affect one's health"
"..to plan, implement, and evaluate (PIE) teaching of care to prevent illness, restore health, & cope w/ disabilities or death."
Define physical assessment.
"..a SYSTEMATIC collection of OBJECTIVE info."
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.
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?
- -crackles caused by FLUID.
IN&EX: Wheezing & friction rub.
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
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.
Differentiate how assessment of children varies form assessment of adults.
Refer to notes: 9/3, LO #4.
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)
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.
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).