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NSG 121 exam 1
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Exam of 14 pages for the course NSG 121 exam 1 at NSG 121 exam 1 (NSG 121 exam 1)
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NSG 121 exam 1/148 Q’s and A’snurse's role in health assessment: 4 goals - -promote health
prevent illness
treat human responses to health or illness
advocate for individuals, families, communities, and populations
- types of assessment - -Emergency (center on immediate and highest
priority problem)
Comprehensive
General Survey
Focused
- emergency assessment - -involves a life-threatening or unstable situation
A—Airway (with cervical spine protection if an injury is suspected)
B—Breathing—rate and depth, use of accessory muscles
C—Circulation—pulse rate and rhythm, skin color
D—Disability—level of consciousness, pupils, movement
E—Exposure
- comprehensive assessment - -broad and complete; includes a complete
health history and physical assessment and all body systems and areas; a
patient's perception of health, strengths to build upon, risk factors for illness,
functional abilities, methods of coping, and support systems
- general survey assessment - -begins immediately upon meeting client and
continues throughout assessment; no measurements are done
-overall appearance, hygiene and dress, skin color, body structure and
development, behavior, facial expressions, posture, ROM, gait, speech, LOC
- focused assesssment - -based on the patient's health issues; usually
involves one or two body systems and is smaller in scope than the
comprehensive assessment, but more in-depth on the specific issue or issues
example is a patient who presents to the clinic with a cough.
- levels of intervention to promote healthy change - -Primary prevention
Secondary prevention
Tertiary prevention
- primary prevention - -involves strategies aimed at preventing problems
and focuses on people and groups. Examples: Immunizations, health
teaching, safety precautions, and nutrition counseling, family planning
services, providing poison-control information, and accident-prevention
education
, - secondary prevention - -focus on screening for early detection of disease
with prompt diagnosis and treatment
examples: Vision screening, Pap smears, BP screening, hearing testing,
scoliosis screening, and tuberculin skin testing
- tertiary prevention - -focuses on preventing complications of an existing
disease and promoting health to the highest level
examples: Diet teaching, exercise programs, physical therapy, medication,
surgical treatment
- what is health assessment? - -gathering information about the health
status of the patient, analyzing and synthesizing those data, making
judgments about nursing interventions based on the findings, and evaluating
patient care outcomes
- health assessment includes - -healthy history and physical assessment
- critical thinking in nursing - --Purposeful, outcome-directed (result-
oriented) thinking
-Is driven by patient, family, and community needs
-Is based on the nursing process, evidence-based thinking, and the scientific
method
-Requires specific knowledge, skills, and experience
-New nurses must question
-Guided by professional standards and ethic codes
-Is constantly reevaluating, self-correcting, and striving to improve
- health promotion - -the behavior of a person who is motivated by a
personal desire to increase well-being and health potential
- All life-threatening problems identified during the initial assessment
require the initiation of critical interventions: - -Provide assistance with
circulation (cardiopulmonary resuscitation if needed).
Open the patient's airway.
Assist the patient's breathing.
Protect the cervical spine if the patient is injured.
Ensure that the disoriented or suicidal patient is safe.
Provide pain management and sedation.
- functional assessment - -focuses on the functional patterns that all
humans share: health perception and health management, activity and
exercise, nutrition and metabolism, elimination, sleep and rest, cognition and
perception, self-perception and self-concept, roles and relationships, coping
and stress tolerance, sexuality and reproduction, and values and beliefs;
used to collect subjective data and a head-to-toe approach for the physical
assessment
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