| What is the key element of nursing care? | assessment |
| objective data | nurse sees, hears, measures, and feels; more than one person can verify with observation and measurements |
| signs | rashes, altered vital signs, abnormal lung or heart sounds, and visible drainage or exudate |
| drainage | refers to the passive or active removal of fluids from a body cavity, wound, or other source of discharge by one or more methods |
| exudate | refers to fluid, cells, or other substances the are slowly exuded, or discharged from cells or blood vessels through small pores or breaks in the cell membrane, usually as a result of inflammation or injury |
| perspiration, pus & serum | identified as exudates |
| symptoms | subjective indications of illness that the patient perceives |
| Examples of symptoms | pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety |
| subjective data | the interviewer encourages a full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it |
| pruritus | the symptoms of itching |
| disease | a pathologic condition of the body, is any disturbance of a structure or function of the body |
| What characterizes a given disease? | recognized set of signs and symptoms |
| What allows the health care provider to make a medical diagnosis? | the sign & symptoms that are clustered or grouped |
| Disease conditions | hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental |
| etiology | study of all factors that may be involved in the development of a disease; the cause of disease |
| hereditary diseases | transmitted genetically from parents to children; examples are cystic fibrosis, sickle cell anemia, color blindness, & hemophilia |
| congenital diseases | appear at birth or shortly thereafter but are not caused by genetic abnormalities |
| inflammatory diseases | those in which the body reacts with an inflammatory response to some causative agent |
| degenerative disease | implies degeneration, often progressive, of some part of the body; osteoarthritis |
| infectious diseases | result from the invasion of microorganisms into the body; AIDS, tuberculosis, pneumonia |
| deficiency diseases | result from the lack of a specific nutrient; iron deficiency anemia |
| metabolic disease | caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body; diabetes mellitus, hypothyroidism |
| neoplastic disease | disease is described as an abnormal growth of new tissues; sometimes benign & malignant (cancerous) |
| malignant neoplasms | a serious threat to health because of the rapid growth of the cells and their ability to invade and metastasize |
| traumatic conditions | result from physical and emotional trauma |
| environmental diseases | are a group of conditions that develop from exposure to a harmful substance in the environment; carbon monoxide, asbestos |
| asbestos | another substance in the environment that potentially leads to lung problems and various cancers |
| autoimmune responses | the body develops immunoglobulins (antibodies) against its own tissues or body substances; rheumatoid arthritis, ulcerative colitis |
| risk factor | any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the vulnerability of an individual or group to illness or accident |
| What are the 4 major category risk factors for diseases | genetic and physiologic, age, environment & lifestyle |
| How are diseases described? | in terms of duration |
| chronic disease | develops slowly and persists over a long period, often for a person's lifetime; diabetes mellitus |
| diabetes mellitus | inability of the body to use glucose |
| What is chronic disease frequently described as? | early, late, or terminal; another possibility that it is in remission |
| remission | means a partial or complete disappearance of clinical and subjective characteristics of the disease has occurred |
| acute disease | begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment; appendicitis |
| organic disease | results in a structural change in an organ that interferes with its functioning; stroke |
| functional disease | often appear to be those of organic disease, but careful examination fails to evidence of structural or physiologic abnormalities; nervous and mental diseases |
| infection | is caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites, that produce tissue damage |
| inflammation | a protective response of body tissues to irritation, injury, or invasion by disease-producing organisms |
| Cardinal signs of inflammation | erythema (redness), edema (swelling), heat, pain, purulent drainage (pus), and loss of function |
| inflammatory response | the body's defense against some causative agent |
| increased blood flow to the area | erythema and heat |
| purulent exudate | the accumulation of neutrophils, dead cells, bacteria, and other debris from the infectious process |
| assessment | is an evaluation or appraisal of the patient's condition |
| What does assessment involve? | the orderly collection of information concerning the patient's health status |
| Data collected establishes what? | a baseline |
| What does baseline allow? | health care providers or the nurse to identify problems and plan care |
| asthenia | condition of debility, loss of strength and energy, and depleted vitality |
| diaphoresis | secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress |
| ecchymosis | discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise) |
| fetid | pertaining to something that has a foul, putrid, or offensive odor. Also called malodorous |
| jaundice | yellow tinge to the skin; often indicates obstruction in the flow of bile from the liver |
| orthopnea | an abnormal condition in which a person has to sit or stand to breathe deeply or comfortably. Occurs in many disorders of the respiratory and cardiac systems |
| sallow | pertaining to an unhealthy, yellow color; usually said of a complexion or skin |
| scleral icterus | the color of the sclera is yellow; this jaundice is the result of coloring of thsclera with bilirubin that infiltrates all tissues of the body |
| Frequently noted signs & symptoms of disease conditions | anorexia, asthenia, bradycardia, constipation, coughing, cyanosis, diaphoresis, diarrhea, dyspnea, ecchymosis, edema, erythema, fetid, fever, inflammation, jaundice, lethargy, nausea, orthopnea, pain, pallor, pruritus, purulent drainage, sallow, sclera icertus, tachypnea, & vomit |
| nursing assessment | comprises the gathering, verifying, & communicating data about the patient |
| purpose of the assessment | is to establish a baseline database about the patient's level of wellness, health practices, past illnesses, related experiences, & health care goals |
| data collected during nursing assessment | health history, physical examination findings, results of laboratory & diagnostic tests, & information from health care team members & the patient's family or significant others |
| physical assessment techniques | use inspection, palpation, auscultation, & percussion |
| postions for examination | sitting, supine, dorsal recumbent, lithely, sims, prone, lateral recumbent, knee-chest |
| sitting position | to assess vital signs head & neck lungs breasts etc; provides full expansion of lungs and provides better visualization of symmetry of upper body parts |
| supine | to assess head, neck, lungs, heart, abdomen, extremities, & pulses; most normally relaxed position & provides easy access to pulse sites |
| dorsal recumbent | to assess head/neck, lungs, breast, heart, abdomen; positioned for abdominal assessment because it promotes relaxation of abdominal muscles |
| lithotomy | to assess female genitalia and genital tract; position provides maximal exposure of genitalia & facilitates insertion of vaginal speculum |
| sims | to assess rectum & vagina; flexion of the hip and knee improves exposure of rectal area |
| prone position | to assess musculoskeletal system; this position is used only to assess extension of hip joint |
| lateral recumbent | to assess heart; this position aids in detecting murmurs |
| knee-chest position | to assess rectum; this position provides maximum exposure of rectal area |
| What is the nurse first task before proceeding to the nurse health history? | to establish an effective nurse-patient relationship |
| First step in initiating the nurse-patient relationship | to introduce oneself, including name, position, & the purpose of the interview |
| why is it important to state the estimate length of time for an assessment? | it helps ensure cooperation |
| next step in initiating nurse-patient relationship | to communicate the nurse's trustworthiness & discretion to patients |
| How is the nurse-patient relationship enhanced? | by the professionalism & competence conveyed |
| nursing health history | the initial step in the assessment process |
| Data collected provide the nurse with what information? | patient's level of wellness, changes in life patterns, sociocultural role & mental and emotional reactions to illness |
| inspection | the technique the nurse uses most frequently; begins with the nurse's first contact with the patient & continues throughout the gathering of the nursing history |
| palpation | the nurse uses the hands and sense of touch to gather data |
| what are the 3 palpation techniques? | light, moderate, & deep |
| auscultation | the process of listening to sounds produced by the body |
| 3 systems where you auscultate | cardiovascular, respiratory, & gastrointestinal systems |
| percussion | use of the fingertips to tap the body's surface to produce vibration & sound; technique the nurse uses least frequently |
| tympany | high-pitched drumlike sound that a hollow organ such as the stomach produces while using percussion |
| dullness | a low-pitched thud like sound percussion over a dense organ such as the liver produces |
| flatness | a soft high-pitched flat sound percussion over a muscle produces |
| common laboratory & diagnosis tests | blood analysis, urine analysis, diagnostic imaging examinations, stool analysis, & sputum analysis |
| chief complaint | patient's subjective reason for seeking healthcare |
| OPQRSTUV method | questions asked when getting the history of present illness; onset-timing, precipitating-palliative, quality-quanity, region-radiation, severity scale, treatments, understanding, & values |
| health history | essential in planning nursing interventions & to identify habits & lifestyle patterns |
| family history | to determine whether the patient is at risk for illnesses of a genetic or familial nature and to identify areas of health promotion and illness prevention; provides information about family structure, interaction & function that are often useful in planning care |
| environmental history | provides data about the patient's home & work environments; identifies areas of concern such as exposure to pollutants that can affect health |
| psychosocial & cultural history | includes data about the patient's primary language, cultural group, educational background, attention span, & developmental stage; provides information about the patient's coping skills & support systems |
| if nursing's goal is to promote health while respecting individual value system & lifestyles | culture-based behavior must be understood |
| Review of systems (ROS) | a systematic method for collecting data on all body systems; the nurse asks the patient about normal functioning of each system & any changes the patient has noted, usually subjective data |
| the correct way to record such information | a clear, concise record |
| ROS guide | can be used to guaranteed a complete interview |
| level of consciousness (LOC) | level of orientation; patient oriented to person, place, time, & purpose |
| nursing physical assessment | physical examination performed |
| usually the first to detect changes in the patient's condition | nurses |
| the critical step in forming the nurse care plan | the nursing assessment |
| Best time to assess the patient | as soon after admission as possible |
| who performs the initial baseline assessment? | RN |
| Who's responsibility is it to perform the ongoing assessment? | RN or LVN |
| When can portions of the assessment be performed? | when observation of changes in the patient's condition are noted |
| focused assessment | attention is concentrated or focused on a particular part of the body, where signs and symptoms are localized or most active, to determine their significance |
| if the patient expresses special concerns, or observation of changes in a patient's status is noted | it is necessary to analyze the system presented by performing a focused assessment |
| if a complete physical assessment is necessary | any painful areas are best assessed last; ensures better cooperation from patient |
| For accuracy when should you measure the patient's height & weight? | on admission then compare the results with the patient's staled height & weight |
| Physical assessment guide | neurologic(LOC), integumentary(skin condition), cardiovascular(apical pulse/pitting edema), respiratory(lungs), gastrointestinal(abdomen), urinary(urine), mobility(activity level) |
| pain assessment scale | most commonly used numeric scale 0-10 |
| mild pain | ratings of 3-5 |
| moderate pain | ratings of 5-7 |
| severe pain | ratings greater than 7 |
| turgor | refers to the elasticity of the skin caused by the outward pressure of the cells & interstitial fluid |
| dehydration results in | decreased skin turgor |
| marked edema results in | increased skin turgor |
| normal carotid pulse | regular & palpable without a thrill |
| thrill | a vibrating sensation the nurse perceives during palpation along the artery |
| bruits | abnormal "swishing" sounds heard over organs, glands, & arteries; results from a narrow or partially occluded artery, such as occurs in atherosclerosis |
| crackles | adventitious breath sounds produced by fluid in the bronchioles and the alveoli, are short, discrete, interrupted, crackling, or bubbling sounds; defined as fine, medium, or coarse |
| wheezes | sounds produced by the movement of air through narrowed passages in the tracheobronchial tree; classified as sibilant or sonorous |
| sibilant wheezes | have a high-pitched squeaking and musical quality and are produced by airflow through narrowed airways |
| sonorous wheezes | have a lower-pitched, coarser, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and the large airways; most likely to clear at least somewhat with a cough |
| stridor | a high-pitched, inspiratory, crowing sound, louder in the neck than over the chest wall |
| pleural friction rubs | are produced by inflammation of the pleural sac; the nurse hears a rubbing, grating, or squeaky sound on auscultation |
| "lub-dub" sound of the heart | caused by the closure of the atrioventricular and the semilunar valves |
| first normal heart sound | occurs with closure of the atrioventricular valves; auscultated most clear at the apex |
| second normal heart sound | occurs with closure of the semilunar valves and signals the end of systole; auscultated most clear at the base |
| 3rd & 4th heard sounds | extra heart sounds; auscultated best at the apex |
| third sound of the heart | sometimes normal in children, abnormal in adults; dull soft sound & sometimes a early sign of heart failure |
| fourth sound of the heart | heard immediately before sound 1, soft with a low pitch; sometimes normal & sometimes pathologic, it is heard in patients with coronary artery disease after myocardial infarction or cardiomyopathy |
| peripheral vascular system | arteries provide oxygen & nutrients to the tissues |
| ischemia | results if there is a decreased supply of oxygenated blood to the tissues; often this is caused by a narrowing of an artery |
| fine crackles | high-pitched, discrete; not cleared by a cough |
| medium crackles | lower more moist sound heard during the mid stage of inspiration; not cleared by a cough |
| coarse crackles | loud, bubbly noise; not cleared by a cough |
| rhonchi (sonorous wheeze) | loud, low coarse sounds like a snore; most likely cleared by a cough |
| wheeze(sibilant wheeze) | musical noise sounding like a squeak; usually louder during expiration |
| anorexia | any reports of nausea, vomiting, or altered or deceased appetite |
| peristalsis | wavelike movements of the intestine |
| How often do bowel sounds occur? | 15-60 seconds |
| what are bowel signs classified as? | active, hyperactive, hypoactive, or absent |
| normal rate for bowel sounds | 4 to 32 per minute |
| How long do you listen to bowel sounds for? | 1 minute for all four quadrants |
| 2 significant alterations in bowel sounds | decreased & increased |
| borborygmii | increased sounds with a characteristically high-pitched, loud, rushing sound |
| decreased bowel sounds | diminished or absent bowel sounds accompany inhibition of bowel motility; occurs with inflammation |
| increased bowel sounds | loud,gurgling borborygmi often accompanies increased motility of the bowel, such as diarrhea |
| edema | an excessive accumulation of fluid in the interstitial spaces caused by leakage of fluid from veins and capillary beds |
| pitting edema scale | Trace(1+), Mild(2+), Moderate(3+), severe(4+) |
| trace edema | a barely perceptible pit (2mm) |
| mild edema | a deeper pit (4mm), with fairly normal contours, that rebounds in 10 to 15 seconds |
| severe edema | an even deeper pit(8mm), edema that possibly lasts as long as 2 to 5 minutes before rebounding |
| unilateral edema | likely the result of occlusion of a major vein |
| how does the health care provider perceive signs | by using senses of sight touch smell & hearing |
| universal signs of infection | erythema, edema, pain, heat, loss of function, and purulent, malodorous drainage |
| what does interviewing a patient initially help with? | identify signs, symptoms, and areas of patient concern that examination seeks to clarify |
| what does the nurse's role require? | the nurse to be familiar with normal assessments and thus able to identify abnormalities |
