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NURS 1019 Week 1

Stack #67391

QuestionAnswer
What is assessment? Collection of data aout an individual's health state
What is the purpose of assessment? collect relevant info; make judgements; plan activities to address health concerns; evaluate actions taken;
Types of assessment * complete - complete health history and physical exam * episodic - for limited short term prob * follow-up - Ex: gave a tylenol. Did it work? * emergency - rapid data collection, interpretation, and intervention
The steps of the nursing process ADPIE * assessing * diagnosing * planning * implementing * evaluating
Assessing * collect data - objective and subjective assessment * validate data * document/communicate data
Diagnosing * Analyze data - cluster, hypothesize, identify gaps * Identify health problems/risks (pot. probs) * Formulate nursing dx (problem statement)
Planning * prioritize pt probs * formulate goals/desired outcomes * select nursing interventions * consult w/other healthcare professionals * write nursing care plan inc nursing interventions * communicate care plan
Implementing * Reassess client * Determine need for assistance * Implement interventions * Delegate/supervise * Document nsg actions, give verbal reports as necessary
Evaluating Did what we do work? * Reassess pt * Relate nrsg actions to client goals/outcomes * Draw conclusions abt prob status * Continue, modify, or terminate pt's care plan
Assessment Ex - COLD * gather data (subjective & objective) * Formulate hypotheses, gather supporting info & pt data, organize/cluster data * Make a nursing diagnosis * Formulate nrsg care plan * Carry out care accordingly * Evaluate and reassess
What is partnership? Complex interpersonal relationship btwn people who work together to achieve a mutually defined goal
ABC's Airway; Breathing; Circulation; Consciousness; Safety; always do ABC's first! esp for Initial and Emerg Assessments
Medical Dx finding the etiology of disease Ex: Cold
Nursing Dx evaluate the response of the whole person to actual or potential health probs
Pain Assessment LOTARP
LOTARP -- L Location Where does it hurt?
LOTARP -- O Onset How long have you had this problem?
LOTARP -- T Timing; Is the pain/problem constant? Rate the pain on a scale between 1 and 10. Type; What does the pain feel like?
LOTARP -- A Associated symptoms like nausea, vomiting, fever, dizziness, etc Aggravating/Alleviating Factors What makes it better or worse?
LOTARP -- R Radiation Does the pain move anywhere else?
LOTARP -- P Precipitating Event What was happening when the pain started?
Symptom subjective sensation
Sign objective abnormality
Mental Status Exam ABCT
ABCT -- A Appearance
ABCT -- B Behavior
ABCT -- C Cognition
ABCT -- T Thought process
Aphasia Language comprehension and production secondary to brain damage
Dysarthia Distorted speech sounds; basic language (word choice, grammar, comprehension) intact
Global aphasia No language comprehension or language production
Expressive aphasia No language production but language comprehension present
Receptive aphasia No language comprehension but language expression present.
Diaphoresis profuse sweating
Skin Color Changes pallor (white); erythema (red); cyanosis (blue); jaundice (yellow)
Function of the skin protection; perception; first line of immune defense; temperature regulation
Components of Skin epidermis; dermis; subcutaneous layer; hair; sebaceous glands; sweat glands
Skin Assessment CWMS; edema; integrity; lesions; turgor; nails; hair
Communication techniques FUSE CIRL; Facilitation, Use of Silence, Summarizing, Empathy, Clarification/Confrontation, Interpretation, Reflecting, Leading
Nonverbal Communication PPG FEET V; Physical appearance; posture; gestures; facial expressions; eye contact; touch; voice
Communication traps providing false reassurance; giving unwanted advice; using authority; using avoidance language; distancing; professional jargon; leading or biased questions; interrupting; "why" questions
Created by: clarashin
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