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Exam 1
- to promote health
- to prevent illness
- to treat human responses to health or illness
4. to advcate for individuals, families, communities, and populations
- direct and indirect care
- advocacy
- scholarship and research-provide care on current evidence
health assessment is
gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluation patient care outcomes.
*includes both health history and physical assessment
a national model for health promotion and risk reduction developed by USDHHS
*goals: to increase the length and quality of life for Americans and to eliminate health disparities among different segments of the population
preventing problems
ex. immunizations, health teaching, safety precautions
early diagnosis of health problems and prompt treatment to prevent complications
ex. pap smears, vision and hearing testing, TB testing
tertiary prevention
focuses on preventing complications of an existing disease and promoting health to the highest level
ex. diet teaching for patients with diabetes, inhaler teaching for patients with lung disease
- result oriented
- driven by patient, family, and community needs
- based on the nursing process, evidence-based thinking and scientific method
- requires specific knowledge
- is constantly reevaluating
- gather assessmnt data- abnormal findings
- draw inferences about what the issue is
- active listening
- restatement
- reflection-summary
- encouraging elaboration-assists the patients to more completely describe problems
- silence
- focusing
- clarification
- summarizing
- false reassurance
- sympathy
- unwanted advice
- biased questions
- change of subject
- distractions
- technical language
emergency-nurses collect the most important info and defer obtaining details until patients are stable.
focused-question that relate to the current situation
comprehensive-takes place during an annual physical examination, for sports participation screening, and during a hospital admission
ADLs
activities of daily living
ex. eating, dressing, and grooming
- nursing admission assessment
- history and physical examination by primary provider
- primary provider's orders
- POC (plan of care)
- flow sheets document vital signs, intake and output and routine assessments
- focused assessment sheets
- MAR (medical administration record)
- lab results
- progress results
- consultations
- discharge or transfer summary
Health Insurance Portability and Accountability Act
*gives patients greater control over their medical records became effective in 2003.
SOAP(IE)nursing progress notes format
*format focuses on a single problem:
Subjective-data
Objective-data
Analysis-of data to identify a problem
Plan- for treating or improving the problem
Interventions
Evaluation
Problem, Intervention, Evaluation
*incorporates the POC into the progress note
Data
Action
Response
*focus system of documentation organization
Outcome and Assessment Information Set
*accurately measures the patient's status at various specified points during an episode of care
*a shared mental model for improving communication between and among clinicians
Situation: state concisely why you are communicating
Background: describe the circumstances leading up to the current situation
Assessment: give objective and subjective data pertinent to the situation
Recommendation: make suggestions for what needs to be done to manage the problem
pre- 120-139/ 80-90
stage 1- 140-159/ 90-99
stage 2- >160/ >100
- transduction-stimuli cause impulse
- transmission-periphery to spinal cord
- perception-impulses transmitted to higher areas of the brain are identified as pain
- modulation-inhibitory and facilitating input from the brain modulates or influences the sensory transmission at the level of the spinal cord
from dermis, epidermis, subcut; burning or sharp
subjective
*self-report, grimacing, rocking, guarding
objective data collection
stress,
BP, pulse, and respiration increase
muscle tension
one-dimensional: measures intensity
*Visual analog scale
*verbal descriptor scale
*numeric pain intensity scale
*combined thermometer scale
multidimensional pain scale-chronic pain, malignant pain or complex medical-surgical pain
*McGill pain questionnaire-experimentally induced circumstances
*brief pain inventory-cancer
*FACES
*FLACC
face
legs
activity
cry
consolability
*measure acute postoperative pain in children 2 months to 7yrs old
uses six faces ranging from happy to sad with tears
children 2 yrs and older can identify pain and point to its location
*between 7-10 yrs. children can begin using numeric rating scale
extreme anxiety
acute distress,
pallor
cyanosis
change in mental status
*interventions while continuing assessment
*obtain vitals: pulse, BP, oxygen sat.
stridor
respirations < 10 or >32
oxygen sat. < 92%
pulse < 55 or > 120
systolic BP <100 or > 170
new chest pain
temperature, pulse, respirations, and BP
*pain
**assess medications before vitals
35.9C-38C
96.7-100.5F
*most common and comfortable
.4-.5C
0.7-1F higher than oral
r-most accurate
t-quick, safe
carbohydrates
proteins
fats
vitamins
minerals
warer
major electrolytes
main source of energy
found in starch, fiber, grains, fruits, and vegetables
functions in cell structure and tissue maintenence
metabolism of most nutrients
D-needed for bone strength, and synthesis
B folate-metabolism and cell synthesis; leafy greens, seeks, OJ
B12-only water-soluble vitamin not found in plants; myelination, DNA synthesis
iron
zinc
calcium
potassium and sodium
Na+ regulates fluid balance, acid-base balance, muscular irritability
K+ " and skeletal muscle contractility
catholics: avoid meat on Fridays
Hinduism: avoid beef, pork, and alcohol
mormon: avoid coffee, tea, alcohol, tobacco
seventh day adventist: lacto-ovo-vegetarians
Judaism: eat on Kosher meat no crustaceans; avoid consuming meat and milk together
Islam: avoid pork and birds of prey; fast during Ramadan
Buddhism: lacto-ovo-vegetarian
18.5-24.9
BMI= weight/height2 x 703
suicide risk assessment
sex
age
depression
previous attempt
ethanol abuse
rational thought loss
social supports lacking
organize plan
no spouse
access to lethal means
sickness
objective assessment for mental health
Appearance
Behavior
Cognitive function
Thought process
MMSE-minimental status
biomedical
complementary and alternative medicine CAM
Roy's adaptation
Gordon's functional health
eudaimonistic model of health
individual
community
societal
violent crime committed by an offender who is related to the victim
ex. intimate partner violence (IPV), child maltreatment, sibling violence, elder abuse
- epidermis-first line of defense; does not thin
- dermis-supports epidermis, contains blood vessels, nerves, sebaceous glands which support nutritional needs of the epidermis
- subcutaneous-provides insulation, storage of caloric reserves, and cushioning against external forces
1. eccrine-covers most of the body, open directly onto skin surface, and sweat in response to environmental or psychological stimuli
2. apocrine- in the axillae and genital areas; open into hair follicles and become active during puberty, functioning decreases with age
**UVB-skin cancers
excess growth of scar tissue at the site of a healed skin injury
occur from acne, burns, chicken pox
- inflammatory phase-begins within 30min of injury (2-3days)
- proliferative phase-may last up to 4weeks
- rmodeling phase-may last as long as 2 years
Right upper lung RUL
right lower lung RLL
Right middle lung RML
*right bronchii is more angled than the curved left bronchii
Left lower lung LLL
Left upper lung LUL
midsternal line
midclavicular line
ant., mid., post. axillary lines
vertebral line
scapular line
oblique fissure- between RLL and RML; b/t LUL and LLL (T3 spinous process)
horizontal fissure-b/t RUL and RML; not in the left lobes
base-bottom of lung fields; 6th rib MCL(midclavicular line)
apex-top of lungs; 2-4cm from the inner third of the clavicle
visceral pleura-lines the lungs
parietal pleura-lines the thoracic wall
pleural space- lubricates the two surfaces to reduce friction
declines
lungs lose elasticity, flexibility, and bone density
mucoid-bronchitis; clear, white or gray
purulent-bacterial infection; yellow or green
tenacious-dehydration; thick; heart failure; thin and frothy
hemoptysis-bloody sputum
inspection of patient-chest
palpation of chest
chest expansion
tactile fremitus-99
percussion of chest
diaphragmatic excursion
auscultation
auscultation of voice sounds
soft, low-pitched, and found over fine airways near the site of exchange;
whispering undertones
*inspiration > expiration
found over major bronchi that have fewer alveoli
*inspiration= expiration
loud, high-pitched, and found over the trachea and larynx
*inspiration < expiration
fine-high-pitched, soft crackling sounds (strand of hair)
coarse-low-pitched, moist, longer sounds (velcro)
low pitched snoring or gurgling sound that may clear with coughing
common with pneumonia
loud, coarse, and low-pitchedgrating or creaking sound (squeaky door)
pain that lasts beyond the normal healing period of 3-6 months; may be no cause
lower back pain or sickle cell pain
pain that results from damage to nerves in the peripheral or central nervous system
ex. diabetic peripheral neuropathy, postherapeutic neuralgia
lesions that have not been previously present
ex. macule, pustule, nodule, wheal, vesicle
lesion that has changed over time
ex keloid, lichen..., scars, fissure,
Asymmetry
Border irregularity
Color
Diameter larger than 6mm
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