*NURSING > STUDY GUIDE > NURS 261_Health Assessment for Nursing Practice Midterm Study Guide Spring 2019/2020 – Virginia Co (All)

NURS 261_Health Assessment for Nursing Practice Midterm Study Guide Spring 2019/2020 – Virginia Commonwealth University | NURS261_Health Assessment for Nursing Practice Midterm Study Guide Spring 2019/2020

Document Content and Description Below

NURS 261_Health Assessment for Nursing Practice Midterm Study Guide Spring 2019/2020 – Virginia Commonwealth University NURS261_Health Assessment for Nursing Practice Midterm Study Guide Spring 201... 9/2020 • What are the different types of health assessments, and when would each be performed? P. 3 Box 1-3 • Comprehensive onset in primary care, admission to hospital, long term care (detailed hx and physical examination) • Problem-Based/Focus walk-in clinic, ER (assessment limited to a specific problem) e.g. sprained ankle • Episodic/Follow-up when a pt is following up with a healthcare provider about a previously identified problem or an individual being treated for an ongoing illness (e.g. diabetes; follow up after taking antibiotics) • Shift changes of each shift for hospitalized patients • Screening/Examination health care provider office- preventative care or health fair • What are the purposes of a nursing health assessment? P1 • Systematic model of collecting and analyzing data for the purpose of planning patient centered care. Develop a plan of care that will help maximize patient’s potential. • Objective and Subjective information • What the patient feels/communicates (subjective)
• Clinical findings (objective) collected during physical examination • What are the steps in clinical judgement process? P. 5 (thinking like a nurse) • What are the factors in symptom analysis? P. 15 • Systematic method of collecting data about the history and status of symptoms • Onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, treatment, severity of symptoms • How does the nurse assess pain? • Collect subjective data, interviews patients about present health status, how they manage their pain. Use OLD CARTS • Rely on self-report of patient • Pain Scales • Numeric (NRS) 0-10 , 0 no pain 5 moderate 10 worst pain possible • Wong-Baker FACES, No Hurt-Hurts to Hurts Worst Alternative coding 0-10 (2) • Compare health promotion and health protection. P. 5 Table 1-1 • Health Promotion- desire to increase well-being (individual) • Primary- prevent a disease from developing (immunizations) • Secondary-screening effort (BP screening) • Tertiary-acute or chronic disease minimize, max health benefits (diabetes mgt) • Health Protection- desire to actively avoid illness (guidelines prevent spread of communicable diseases) • Detect illness early • Maintaining functioning within its constraints • Describe the differences between a screening assessment and a follow up assessment. P. 3 • Screening assessment- short exam focused on disease detection/prevention • Blood pressure, glucose, cholesterol, colorectal • Follow-up assessment- previously identified problem • Pneumonia after antibiotics • Diabetes follow ups • Identify infection control procedures to be used when conducting a health assessment. (i.e. when do you wear gloves, and when don’t you) Box 3-1 P. 22 • Gloves • To protect from bloodborne pathogens carried by patient • To protect patient from microorganism on the hands of the nurse • To reduce the potential of infection transmission from patient to patient via the nurse • giving an injection • emptying a urinary catheter drainage bag • giving a bed bath • inserting a peripheral IV (an IV in a smaller vein) • removing a peripheral IV • removing a urinary catheter • Mask, Eye/Face shield • During procedures that may result in splashes or sprays of blood, fluids, secretions • Not usually done during health assessment. • Gowns • To protect arms-exposed skin and prevent contamination of clothing with patients’ blood or fluids • What are the differences between subjective and objective data? See above • Symptoms are considered subjective data • data that is perceived and reported by the patient (e.g. pain, itching, nausea) • Signs are considered objective data • data that can observed, felt, heard, or measured (e.g. rash, swelling) • What assessment techniques are used to evaluate vital signs? P. 23 • BP • Pulse • RR • Pulse O2 • Temperature • Techniques of Physical Assessment: • Inspection- Pain, Respiration, Visual exam of body, movement and posture. • Palpation- HR hands to feel texture, size, shape, consistency, pulsation • Percussion-evaluate size, boarders, consistency of internal organs (fluid) • Auscultation- BP listening to sounds heat blood vessels, lungs, intestine. • Define orthostatic hypotension and describe how to assess for it. P. 42 • Series of BP measurements Lying, sitting and standing position • It is a 20 to 30 mm drop when patient goes from lying to sitting position to standing • State the rationale and technique for the two step blood pressure measurement. • requires that you take the blood pressure by feeling the brachial artery and then using a stethoscope. So, in a sense you will be taking the blood pressure twice using the same arm but with two methods. • Give an example of how each physical assessment technique is used: inspection, palpation, percussion, and auscultation. See Q19 • Inspection: e.g. using a penlight to inspect jugular vein pulsation • Palpation: e.g involves hands to feel • Percussion: • Auscultation: the use of the stethoscope • Identify the use of the bell and diaphragm of a stethoscope. 28 • Bell Low(soft) pitch sounds- extra heart sounds, vascular (bruit-whooshing) • Diaphragm high pitch sounds breath, bowel, normal heart • What is meant by “general survey”, and what are the elements included? P 483 • Collected during the history, Physical Exam LOC/ Mental Status Personal Hygiene Skin Color Posture/position Breathing effort Mobility Ability to hear and speak Example: Cooperative, oriented, alert women; sitting with erect position; maintains eye contact; appropriately groomed and dressed; Vital signs BP 110/7; P7; R14; T 98: Wt 137; Ht 5’3; BMI 24.3 - - - - - - - - - - - - - - - - - - - - - - • Describe the routine exam of the peripheral vascular system, including pulses that should be palpated. Palpate: femoral, popliteal, anterior tibial and dorsalis pedis pulses Temporal: lateral to each eyebrow- amplitude Carotid: lower 3rd of neck, one at a time-amplitude Inspect: Jugular- pulsations Measure Blood pressure Inspect and Palpate upper extremities, pulses Inspect and Palpate lower extremities, pulses Brachial- antecubital fossa Radial- on thumb side of forearm, same time both Ulnar- medial side of forearm For amplitude: Femoral Popliteal Tibial Dorsalis Pedis • Define the scale used to describe amplitude of peripheral pulses. 0+ absent 1+ diminished barely palpable 2+ normal 3+ Full Volume 4+ Full Volume bounding hyperkinetic • Differentiate between arterial and venous insufficiency. Arterial insufficiency: • Usually calf • Pain worse with activity – prolonged walking • If pain is relieved by rest it is called “intermittent claudication” (artery 50% occlusion), if not relieved by rest it is called “rest pain” • Worse with legs elevated, better when dependent • Venous insufficiency: • Intensifies with prolonged standing or sitting • Pain worse in dependent position • Pain is better when legs are elevated and worse at end of the day • Define the scale used to describe the level of pitting edema. P222 • 1+ barely perceptible pit • 2+ deeper pit in a few seconds • 3+ deep pit, rebounds in 10-20 seconds • 4+ deep pit, rebounds > 30 seconds [Show More]

Last updated: 1 year ago

Preview 1 out of 24 pages

Add to cart

Instant download

We Accept:

We Accept
document-preview

Buy this document to get the full access instantly

Instant Download Access after purchase

Add to cart

Instant download

We Accept:

We Accept

Reviews( 0 )

$15.00

Add to cart

We Accept:

We Accept

Instant download

Can't find what you want? Try our AI powered Search

OR

REQUEST DOCUMENT
40
0

Document information


Connected school, study & course


About the document


Uploaded On

Jul 14, 2020

Number of pages

24

Written in

Seller


seller-icon
Martin Freeman

Member since 4 years

485 Documents Sold


Additional information

This document has been written for:

Uploaded

Jul 14, 2020

Downloads

 0

Views

 40

Document Keyword Tags

More From Martin Freeman

View all Martin Freeman's documents »

Recommended For You

Get more on STUDY GUIDE »

$15.00
What is Browsegrades

In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.

We are here to help

We're available through e-mail, Twitter, Facebook, and live chat.
 FAQ
 Questions? Leave a message!

Follow us on
 Twitter

Copyright © Browsegrades · High quality services·