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NUR 216 Exam 1;COMPREHENSIVE GUIDE 2024 EDITION
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NUR 216 Exam 1;COMPREHENSIVE GUIDE 2024 EDITION
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NUR 216 Exam 1;COMPREHENSIVEGUIDE 2024 EDITION
comprehensive assessment - //An assessment that includes a
complete health history and physical assessment; Usually brand
new patients
focused assessment - //assessment conducted to assess a specific
problem; focuses on pertinent history and body regions
HIPAA - //Health Insurance Portability and Accountability Act
The nursing process - //Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment (ADPIE) - //Data collection (objective/subjective)
Prioritize Data: Primary (life threatening), Secondary (requires
prompt attention), Tertiary (not urgent)
Planning (ADPIE) - //Develop SMART goals, plan nursing
interventions
,Implementation (ADPIE) - //Perform planned nursing interventions
Evaluation (ADPIE) - //Were the goals met? If not, re-assess
assessment skills - //Inspection
Palpation
Percussion
Auscultation
(Bowels: Inspection, Auscultation, Percussion. Auscultation) Do
not want to alter the bowel sounds
Inspection - //Observe for Symmetry, size, color, shape
Direct: Visualize with our eyes
Indirect: Use and instrument
Fingertips/pads: Palpation - //Fine sensation (texture, swelling,
pulsation. lumps)
Dorsa of hands: Palpation - //Best for determining temperature
Base of fingers or ulnar surface: - //vibrations
Palpation - //Light: surface characteristics
, Deep: Organs, masses, tenderness (use intermittent pressure)
Ballpottement: Size/Shape of free floating objects
- Always palpate tender areas last
Percussion - //tapping on a surface to determine the difference in
the density of the underlying structure
Ausculation - //listening to sounds within the body
Bell - //low pitched sounds
(mummers)
Diaphragm - //high pitched sounds
(bowel and lung sounds)
What should we do before leaving the patients room? - //Patients
safety
Bed to lowest position
Side Rails
Call button and personal belongings in reach
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