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Validates the importance of using the assessment techniques.
Evidence
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What the person says about himself during hisory taking
Subjective Data
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What you as the health professional observe by inspecting, percussing, palpating, and ausculating during the pxy examination
Objective Data
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Subjective data, objective data, the patient's record, and laboratory studies form this
Database
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Process of analyzing health data and drawing conclusions to identify diagnoses
Diagnostic Reasoning
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The standards of practice in nursing that include assessment, diagnosis, outcome identification, planning, implementation, and evaluatoin
Nursing Process
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Clincial judgements about a person's response to an actual or potential health state
Nursing Diagnoses
-
Emergent, life threatening, and immediate issues
First-level Priotity Problems
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Issues next in urgency- those requiring your prompt intervention to forestall further deterioration
Second-level Priority Problems
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Issues that are important to the patient's health but can be addressed after the more urgent health problems are addressed
Third-level priority problems
-
Issues in which the approach to treatment involves multiple disciplines
Collaboritive problems
-
Consideration of the whole person. Views that mind, body, and spirit
Holistic health
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Consists of spoken or unspoken rules for behavior. Concerns what the person needs and expects from health care and what you, the health professional, have to offer
Contract
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Both you and the patient should be seated comfortably at eye level
Equal status seating
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Ask for specific information. Limits the pt's answer.
Closed or Direct Questions
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The conventional code of good manners that governs behavior and varies cross-culturally
Etiquette
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The most culturally variable nonverbal behavior
Eye contact
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A subjective sensation that the person feels from the disorder
Symptom
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An objective abnormality that you as the examiner could detect on pxy examination
Sign
-
The HEEADSSS method
home environment, education & employment, eating, peer-related activities, drugs, sexuality, suicide/depression, and safety
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a significant behavioral or psychological pattern that is associated with distress or disability and has a signifant risk of pain, disability, or death or a loss of freedom
mental disorder
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mental disorders due to brain disease of known specific organic cause
organic disorders
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an organic etiology has not yet been established for a mental disorder
psychiatric mental illness
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ABCT
appearance, behavior, cognition, and thought processes
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Concentrated watching. Close, careful scrutiny, first of the individual and then the body system as a whole. Always comes first.
Inspection
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Follows and confirms points you noted during inspection. Applies your sense of touch to assess texture, temp, moisture, organ location and size, swelling, vibration, etc.
Palpation
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Tapping the person's skin with short, sharp strokes to assess underlying structures.
Percussion
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Intensity of a loud or soft sound
Amplitude
-
Frequency. The number of vibrations per second
Pitch
-
Timbre. A sunjective difference due to a sound's distinctive overtones
Quality
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the length of time the note lingers
Duration
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listening to sounds produced by the body
Ausculation
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Illuminates the internal eye structures
Ophthalmoscope
-
Aquired during hospital stay
Nosocomial infection
-
Examining the body areas appropriate to the problem only
Mini database
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The maximum pressure that is felt on the artery during left ventricular contraction
Systolic
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The elastic recoil, or resting, pressure that the blod exerts constantly between each contraction
Diastolic
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The difference between the systolic and diastolic pressures and reflects stroke volume
Pulse pressure
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The pressure forcing blood into the tissues, averaged over the cardiac cycle
Mean arterial pressure (MAP)
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The opposition to the blood flow through the arteries
Peripheral vascular resistance
-
Refers to how tightly the blood is packed into the arteries
Volume of circulating blood
-
The "thickness" of blood
Viscosity
-
A period when Korotkoff sounds disappear during ausculation
Ausculatory gap
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Components of a BP reading first described by a Russian surgeon in 1905
Korotkoff sounds
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A congenital form of narrowing of the aorta
Coarctation
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A noninvasive method to assess arterial oxygen saturation (Spo2)
Pulse oximeter
-
Foundation of hypertension control
Lifestyle modifications
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Thin but tough. Cells bound tightly together into sheets that form a rugged protective barrier. Stratified.
Epidermis
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Forms new skin cells. Major ingredient is keratin.
Basal cell layer
-
Consists of dead keratinized cells that are interwoven and closely packed. Cells are constantly being shed and being replaced with new cells from below
Horny cell layer
-
The inner supportive layer consisting of mostly connective tissues, or collagen.
Dermis
-
-
-
Macular only and occures in children and adolescents. Progresses into the ______ in young adults
- Junctional nevus
- Compound nevi
-
When red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white.
Pallor
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An intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries
Erythema
-
Fine, faint hair that covers most of the body
Vellus hair
-
the darker, thicker hair that grows on the scalp and eyebrows and axillae, the pubic area, and the face and chest in the male
Terminal hair
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Coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Widely distributed throughout the body
Eccrine glands
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Produce a thick, milky secretion and open into the hair follicles. Located mainly in the axillae, anogenital area, nipples, and navel
Apocrine glands
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The vascularity of the skin diminishes while the vascuar fragility increases; a minor trauma may produce dark red discolored areas.
Senile purpura
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Bluish mottled color that signifies decreased perfusion; the tissues do not have enough oxygenated blood.
Cyanosis
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A yellowish skin color indicated rising amnts of bilirubin in the blood
Juandice
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Profuse perspiration
Diaphoresis
-
Small, smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 yrs.
Cherry (senile) angiomas
-
Commonly called liver spots. Small, flat, brown macules
Senile lentigines
-
Lesions that are raised, thickened, areas of pigmentation that look crusted, scaly, and warty
Keratoses
-
Looks dark, greasy, "stuck on." Develop mostly on the trunk but als on the face and hands and on unexposed as well as on sun exposed areas. Not cancerous.
Seborrheic keratosis
-
Red-tan lesions that are scaly plaques that increase over the years to become raised and roughened. Less common
Actinic (senile or solar) keratosis
-
Skin tags. Overgrowth of normal skin that form a stalk and are polyp-like
Acrochordons
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Raised yellow papules with a central depression. More common in men. Forehead, nose, or cheeks. Pebbly look.
Sebaceous hyperplasia
-
A graphic family tree
Pedigree or Genogram
-
A questionaire to identify excessive or uncontroled drinking
CAGE
-
CAGE
- Cut down
- Annoyed
- Guilty
- Eye-opening
-
Being aware of one's own existence, feelings, and thoughts and aware of the environment. Most elementary of mental health status
Conciousness
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Using the voice to communicate one's thoughts and feelings
Language
-
A prolonged display of feelings that color the whole emotional life
Mood
-
A temporary expression of feelings or state of mind
Affect
-
The awareness of the objective world in relation to the self
Orientation
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The power of concentration, the abilty to focus on one specific thing w/o being distracted by many environmental stimuli
Attention
-
The ability to law down and store experiences and perceptions for later recall
Memory
-
Pondering a deeper meaning beyond the concrete and literal
Abstract reasoning
-
The way a person thinks, the logical train of thought
Thought process
-
What the person thinks
Thought content
-
An awareness of objects through the 5 senses
Perceptions
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