Assessment Exam 1 Study Giude.

1. Be able to identify normal and abnormal values for vital signs. ● Normal BP: 120/80 ● Normal Pulse: 60-100 Beats/Min ● Normal Temp: 96.4 F - 99.1 F ● Normal Resp: 10-20 Breaths/Min ● Normal O2: 97-100 % ● Abnorm ...

1. Be able to identify normal and abnormal values for vital signs. ● Normal BP: 120/80 ● Normal Pulse: 60-100 Beats/Min ● Normal Temp: 96.4 F - 99.1 F ● Normal Resp: 10-20 Breaths/Min ● Normal O2: 97-100 % ● Abnormal BP: Lower than 90/60 or Higher than 140/90 ● Abnormal Pulse: Lower than 60 or higher than 100 Beats/Min ● Abnormal Temp: Lower than 95 F or higher than 100 F ● Abnormal Resp: Lower than 10 or higher than 20 Breaths/Min ● Abnormal O2: 96% and below 2. Be able to compare temperature values obtained by different routes. ● Oral Temp: Place the thermometer in the mouth under the tongue and advise patient to keep mouth closed. (98.6 F) ● Axillary Temp: Place the thermometer in the armpit and leave it in place. (Usually 1 C lower than oral temp) ● Tympanic Membrane (Ear) Temp: Place thermometer in the ear but do not force it in or occlude the ear canal. (Usually 0.3 C - 0.6 C higher than oral temp) ● Rectal Temp: Use only when other routes are not available (Usually 1 C higher than oral temp) 3. Be able to compare Centigrade and Fahrenheit temperatures. ● C to F Formula: (C*9/5) +32 ● F to C Formula: (F-32) *5/9 4. What is an appropriate reason for doing a health history? ● The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. 5. Why would a nurse do a focused assessment? ● Focused assessments are done in response to a specific problem recognized by the assessor as needing further assessment of a body system. Chapter 1 1. What is the basic purpose for doing assessment? ● Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process. ● Assessment is analyzing and synthesizing data, making judgments about the effectiveness of nursing interventions, and evaluating client care outcomes. ● Although the assessment phase of the nursing process precedes the other phases (diagnosis, planning, implementation, and evaluation), it is ongoing and continuous throughout all phases of the nursing process. ● The end result of a nursing assessment is the formulation of nursing diagnoses that require nursing care, the identification of collaborative problems that require interdisciplinary care, the identification of medical problems that require immediate referral, or client teaching for health promotion. 2. Review the ANA definition of nursing. ● Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. 3. Extra Chapter Notes: ● Assessment is collecting objective and subjective data. This includes physiologic, psychological, sociocultural, developmental, and spiritual data. The nurse also assesses how the client interacts within their family and community. ● A comprehensive health assessment consists of a health history and physical examination. ● The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. ● Preparing for the assessment: review the client’s medical record, avoid premature judgments that may alter your ability to collect accurate data, validate information from the chart with the client and be prepared to collect additional data, educate yourself about the client’s diagnoses and lab test performed, take a minute to reflect on your own feelings about the client to avoid biases and judgment, and obtain and organize materials that you will need for the assessment. ● Steps of health assessment: Collection of subjective data, collection of objective data, validation of data, and documentation of data. ● Collecting subjective data: Subjective data are sensorimotor symptoms (pain and hunger), feelings (happiness and sadness), perceptions, desires, beliefs, preferences, ideas, values, and personal information that can be elicited and verified only by the client. This is the interviewing/ health history process. The major areas of subjective data include, biographical info, history of present health concern, personal health history, family history, and health and lifestyle practices. ● Collecting objective data: This type of data is directly observed by the examiner and is obtained by using the 4 physical examination techniques (inspection, palpation, percussion, and auscultation) These data include: physical characteristics, body functions, appearance, behavior, measurements, and results of lab testing. ● Validating assessment data: Serves to ensure that the assessment process is not ended before all relevant data have been collected. It helps to prevent documentation of inaccurate data. ● Documenting data: This forms the database for the entire nursing process and provides data for all other members of the healthcare team. ● Step 2 of the nursing process: analysis of of assessment data to come up with a nursing diagnosis. A nursing diagnosis is a clinical judgment about individuals, family or community responses to actual and potential health problems and life processes. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable. ● Process of data analysis: identify abnormal data and strengths, cluster the data, dram inferences and identify problems, propose possible nursing diagnoses, check for defining characteristics of those diagnoses, confirm or rule out nursing diagnoses, and document conclusions. ● Factors affecting health assessment: the client’s culture, spirituality, family and community.