NUR 220 ~ FINAL EXAM Study Guide

I. Evidence-based Health Assessment a. Priority Levels i. First level 1. Life threatening problems – LIFE THREATENING a. AIR WAY PROBLEMS b. BREATHING PROBLEMS i. Rate, depth, pattern and breathing sounds c. CIRCULATION PROBLEMS i. Heart rate, BP, tissue perfusion, beating of the heart (what is their EKG?) ii. Second Level 1. Avoid deterioration 2. Change in mental status 3. Acute pain a. Short term – 3to 6 months b. Soft tissue i.e. sprains, paper cut i. Gradually resolves 4. Acute Urinary elimination problems 5. Abnormal labs – life threatening 6. Risks of infection 7. Safety or security problems 8. DM w/ no insulin iii. Third Level 1. These interventions take more time and are planned out over a long period of time 2. UTI – depending on what other issues are presented… iv. Collaborative Problems 1. Physiological complication that nurses monitor for to detect the onset of changes in a patient’s status. Nurses intervene in collaboration with other personnel from other disciplines a. Physical therapy, surgical wound b. Types of Assessment: i. Complete 1. Full physical – includes current and past health history a. Review systems ii. Focused/problem-centered/episodic 1. Problem-centered/episodic/focused a. Whatever system is affecting them b. Addresses specific problem i. After asthma attack, cough, surgery iii. Follow-up 1. Assessment after treatment 2. Determine status to see if treatment is working 3. Inform of side effects from treatment 4. Relapse iv. Emergency 1. Rapid collection of data a. Happens while life saving measures are being performed II. General Survey a. Components of the General Survey i. First impression of a patient 1. Physical appearance a. LOC: Alert, oriented, verbally responds, Motor response, Age, gender, expression, facial features, signs of stress 2. Body structure: gait, posture, ROM, nutrition status, deformities (Accident or hereditary), assistive devices 3. Behavior: Mood/affect, Eye contact, Speech, Dress, Grooming III. The Interview a. Interview Phases i. Working phase 1. Data gathering phase a. Obtain subjective (what the pt says) & objective data (what you obtain from tests or observations) b. Your verbal skills include ability to form questions appropriately and receive appropriate from patient. ii. Types of Interview Questions 1. Open ended questions a. Why are you here? You said…tell me more? Anything else? b. Responses are in paragraphs 2. Closed/direct questions a. 1- or 2-word responses b. Ask one question at a time b. Communication: Verbal, Non-verbal, Therapeutic i. Verbal: What you say to the patient ii. Non-verbal – patients are more perceptive to this (how you act towards/around the patient): Facial expressions, tone, posture, appearance, movement, eye contact, gestures, iii. Therapeutic 1. What you do f