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How does the nursing process assist the nurse in performing a healthassessment? Helps systematically collect, ordering and analyzing data
What is a focused assessment and how is it used? can occur in any setting and typically involves one or two body systems; more in depth to the health system or areas of concern
What is a comprehensive assessment and what does it entail? Full body assessment; entails head to toe and history
What is a primary health prevention\/example Preventing Problems, Vaccines, Immunization, Health Teaching, Safety Precautions, Annual physicals
Secondary prevention Screening to Promote the early diagnosis of health problems, Mammogram, eye exams, smoking cessation, Vision Screenings, Paps smears, getting tests done
Tertiary prevention involves providing information for a client who already has an illness or disease. The information should focus on preventing complications.
Tertiary prevention example educating patient with broken leg how to walk with a crutch or educating a stroke patient with left sided weakness how to walk with a walker to help prevent fall\/injury
Describe the body system assessment model Looks at issues and reorganize and clusters them to organize and document findings. Example a client with abdominal pain and found that the client has high blood pressure, headache, and nausea.
What are two things that need to happen to have effective communication? Send a message and receive a message
When communicating with a patient what is the best indicator to know thecommunication was effective? Saying it back to the person, body language (nodding)
What role does perception play with a hospitalized patient? It plays a role in how the patient will heal. If they’ve had a bad past experience etc. – Sender, receiver, culture and perception are all components of the process that can influence communication, but this client’s perception is important.
Psychosocial and lifestyle factors family history can be a sensitive subject and the nurse should wait and ask questions about these subjects closer to the end of the interview
Psychosocial and lifestyle factors example Asking about mental health, anyone hurt you, marks or bruises body parts, human violence or sexual history are sensitive subject
Psychosocial Factors Involves asking personal questions. Ask at the end interview since a relationship has been established
Psychosocial Factors examples social, cultural, and spiritual assessment, mental health assessment, human violence assessment (abuse, bruise on body parts, and sexual history and orientation ( i.e. kinds of people to whom you are mainly attracted gender identity lesbian, gay, bisexual, transgender, intersex)
Assessment for Violence & Abuse “\u00b7 Put patient’s safety first\u00b7 Do not question in front of friends and family (abuser could be there)\u00b7 Establish rapport and ask questions simply and directly\u00b7 “”Do you feel safe at home?””\u00b7 Do not assume who abuser is\u00b7 Do not ask about police or pressing charges. This decision is up to the prosecutor”
How do you approach the health interview differently if you suspectabuse? Ask any family\/friends to step out of the room and ask those questions at the endof the interview to avoid any discomfort; make sure questioning is direct (get tothe point – no vague questions)
. Tell me how you perform assessment Non-Abdomen? – Inspect- Palpate- Percuss- Auscultate
Tell me how you assess the abdomen? – Inspect- Auscultate- Percuss- Palpate
If you hear a tympany sound where might you be? Over air pockets (stomach, lungs) high pitched\/drum-like
DAR documentation organizes information by, Data, Action, and Response
SOAP(IE) documentation organizes information by, subject, objective, analysis, planning, intervention\/implementation
SBAR documentation organizes information by, situation, background, assessment, recommendation
What does SOAP stand for in charting? Subject, objective, analysis, planning, intervention\/implementation
Accuracy & Completeness \u00b7 Descriptions should be as clear and precise as possible
Conciseness \u00b7 Be complete with documentation, but avoid unnecessary words
Purpose of documentation in the medical record? Communication with other health care workers.- Assisting health care students in their education to provide care.- Financial reimbursement by insurance companies.- The patient record serves as legal document.
What interacts w\/ grapefruit juice? Statins can cause greater side effects if mixed with grapefruit
Anthropometry (measurement) height & weight
Infants\/young toddlers Fat intake is crucial for brain development
Children and adolescents Extra protein during growth spurts. Protein plays an essential role in many bodily functions, including recovery and repair of tissues in the muscles, skin, organs, blood, hair and nails.
Older adults Older adults do often have a reduce sense of thirst and taste of sweet and salty foods causing them to add sugar and salt to their meals.
What is included in nutritional assessment. 1. Past medical history – Medical conditions, food allergy or intolerance2. Lifestyle and personal habits – Eating patterns, fluid intake, cooking ability3. Medications and supplements – Medication schedule, alcohol and drug use4. Family history – GI or other diseases that influence nutrition
What is subjective\/objective\/comprehensive data in nutritional assessment? like asking about lifestyle and personal habits associated to food
Comprehensive data in nutritional assessment? Asking the client to recall a three-day food diary would be part of a comprehensive nutritional history and would not be necessary unless the client was at risk for malnutrition.
Objective data in nutritional screening Measuring the client’s height and weight and obtaining labs.
Using a balance beam scale to weigh a client. When obtaining a client’s weight using a balance beam scale you would first balance the scale by sliding both bars to zero and ensuring the balancing arm is in the center of the gauge.
Using the ABCT method to organize the data collection.? Appearance, behavior, cognitive function, thought (able to logically follow you,coherent)
What is Lateral violence? Referred to as horizontal violence or bullying, lateral violence is defined as non-physical, aggressive, hostile, and\/or harmful behavior between coworkers.
What is the first step of the comprehensive physical exam and what doesthe first step entail? A general survey may be described as an overall review or first impression that the health care provider has of a person’s wellbeing. This could be as simple as a visual observation and encompasses the following examples and components dependent to some extent on age.
Bradykinin Release at site of injury
Pain Blocking Substances Opioids
Visceral pain originates over organs such as liver.
Somatic described as sharp and occurs in muscles, bones and joints
How to obtain most reliable sources of pain? the patient
How to assess patient of pain numeric scale\/nonverbal- faces scale
What elements are included in pain assessment? PQRST \u00b7 P (Provocation\/Palliation)- What were you doing when the pain started? What caused it?\u00b7 Q (Quality)-what does the pain feel like? Is it sharp, dull, tingling?\u00b7 S (Severe)- on a pain scale from 0-10 with 0 being no pain, where would you rate the pain? How long does the pain last?\u00b7 T (Timing)- How often does it occur? .
Factors that can affect pain response Culture, gender
What is Core Body Temperature The normal core temperature ranges from 96-100.5 degrees Fahrenheit (35.5-38.1 degrees Celsius) and Rectal temp is best to measure core body temp
What is elaboration? is demonstrated by the nurse using a response that encourages the client to keep talking
What is the significance of nonverbal and verbal communication Nurse\/patient relationships develops
What is the first phase of the interview process? Pre-interaction phase
Following an injury like bumping the great toe, pain signals are transmitted to the spinal cord, then up to the brain
If the gate is open, pain signals can pass through and will be sent to the brain to perceive the pain
If the gate is closed, pain signals will be restricted from travelling up to the brain, and the sensation of pain won’t be perceived<\/p>\n","protected":false},"excerpt":{"rendered":"Exam 1: NSG121\/ NSG 121 (Latest 2024\/ 2025 Update) Health Assessment | Review with Questions and Verified Answers| 100% Correct| Grade A- Herzing Exam 1: NSG121\/ NSG 121 (Latest 2024\/2025 Update) Health Assessment | Reviewwith Questions and Verified Answers| 100%Correct| Grade A- HerzingQ: What are two things that need to happen to have effective communication […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-131679","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/131679","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=131679"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/131679\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=131679"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=131679"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=131679"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}