Interventions- Exam 1: Modules 1-5 Answering nursing exam questions….
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● Consider Maslow’s Hierarchy of Needs ● Assessment vs Intervention Assessment-data that you re collection from the patient-vital signs, how much they ate today Interventions- Nursing interv... entions are informed by the results of nursing assessments. While the ultimate goal of an assessment is to decide on a course of treatment, an intervention in many cases is the treatment. Nursing interventions also go beyond simply “fixing” a patient medically Module 1- General Survey ● First impressions of patient ● Includes vital signs, weight, height What are you looking for? ● Hygiene ● Posture ● Who is with the patient? ● Speech problems (education level, ethnicity) ● Posture, gait, coordination ● Signs of distress ● Non-verbal cues Module 1- Physical Exam Inspection, palpation, percussion, auscultation○ Note: for abdominal exams, auscultation and palpation switch places Know what each of these entails ○ Inspection ● Systematic ● using eyes, ears, smell ● focuses the rest of the nursing process o Palpation ● light → deep ● touch painful area LAST Rash-focus interventions on the rash Palpations- touch most painful area last ○ Percussion ■ determines density ■ Tympany (gastric bubble), Hyper-resonance (emphysema), resonance (normal lungs), dullness (organ, “short”), flat (muscle, “dead”) ○ Auscultation ■ Need your stethoscope: diaphragm (high pitched) vs bell (low pitched) ■ Listening for quality (intensity, pitch, duration, “quiet”) Percussion- tap Flat sound-where would you hear… or Auscultation- stethascope-diaogram high pitches sound-bell- low pitch sound – listen to quality of sound, pitch, is it loud or soft. Module 1- Pain ● SUBJECTIVE!!! ● Goals ● reduce and managing pain ● creating a plan with your patient ● Assess for congruency ● Does pain rating match their expression? ● Especially important in older adults [Show More]
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