Latest NR 302 Final Exam Concepts

Latest NR 302 Final Exam Concepts Chapter 1: Evidence-Based Assessment • Define and recognize examples of Subjective and Objective data • Objective is obtained through observation and is verifiable; information gathered from the patient by the use of observation, palpation, percussion, and auscultation, as well as the use of instruments and techniques that provide specific measurements • Subjective is information that the patient shares about his or her health situation. They are gathered through the patients report and are verifiable only by the patient. • Identify order and tasks of each step of the Nursing Process • ADPIE • Assessment- information collection/ gathering data • Diagnosis- information interpretation, stating problems & strengths • Plan/ Outcome- setting nursing goals desired outcomes and planning interventions • Implementation- performing nursing interventions • Evaluation- patient’s status and effectiveness of nursing interventions • Recognize the difference between different levels of Nursing Experience • Novice: starting out in an area of learning; uses rules to guide performance • Competency: building on 2 to 3 years of clinical experience; see actions in the context of patient goals or plans • Proficient: adding to time and -experience; understands the patient situation as a whole rather than individual parts-apply long term goals • Expert: attained mastery of an area of learning; performs clinical judgement using intuitive analysis Chapter 4: The Complete Health History • Identify guidelines for recommending immunizations • Recommend vaccine and how important it is • Use the current CDC recommendations for adults; but be aware or primary conditions/ precautions, person’s lifestyle, occupation, and travel • Identify examples of what should be documented in the medication reconciliation • Medication reconciliation: comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit • Identify and understand each component of mnemonic PQRSTU and its place within the health history • P= provocative or palliative- What brings it on? What were you doing when you first noticed it? What makes it better/ worse? • Q= quality or quantity- How does it look, feel, sound? How intense/ severe is it? • R= region or radiation – where is it? Does it spready anywhere? • S= severity scale: 1 to 10 • T= timing or onset- exactly when did it first occur? Duration- how long did it last? Frequency- How often does it occur? • U= understand patients’ perception of problem – what do you think it means? • Identify how a review of systems should be recorded • Evaluate past and present state of each body system • Assess that all pertinent data relative to each body system have been noted • Avoid writing in negative for body systems as you want to record either presence of absence of symptoms • Do not include objective data • Limit to patient statements or subjective data • Include all relevant body systems • Approach: • General overall health state • Skin and hair • Head • Eyes and ears • Nose and sinuses • Mouth and throat • Neck • Breast and axilla • Focus on body systems looking at specific indicators and focusing on health promotion • Respiratory • Cardiovascular • Peripheral vascular • Gastrointestinal • Urinary • Musculoskeletal • Neurologic • Hematologic • Endocrine • Focus on systems specific to gender looking at specific indicators an focusing on health promotion • Male genital • Female genital • Sexual health Chapter 5: Mental Status Assessment • Define orientation • The awareness of the objective world in relation to the self, including person, place, and time • Define Alert, Lethargy, Coma, and Delirium • Alert: awake or readily arouse; oriented fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions • Lethargic: not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal choice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased • Coma: completely unconscious no response to pain or any external or internal stimuli; light coma has some reflex activity but no purposeful movement; deep coma has not motor response • Delirium: clouding of consciousness; inattentive; incoherent convo; impaired recent memory and confabulatory for recent events; often agitated and having visual hallucinations; disoriented, with confusions worse at night when environmental stimuli decreased • Define ABCT and differentiate the components involved within each level • Appearance • Posture- erect and position relaxed • Body movements- body movements voluntary, deliberate, coordinated, and smooth and even • Dress- appropriate for setting, season, age, gender, and social group • Grooming and hygiene- congruence between grooming and age • Behavior • Level of consciousness- person is awake, alert, aware of stimuli from environment and within self, and responds appropriately and reasonably soon to stimuli • Facial expression- appropriate to situation changes appropriately with topic; comfortable eye contact unless precluded by cultural norm • Speech- judge the quality of speech, noting that person makes sounds effortlessly and shares conversation appropriately. Pacing, articulation, and word choice • Mood and affect- judge by body language and facial expression and by direct questioning. Mood should be appropriate to persons place and condition and should change appropriately with topics; person is willing to cooperate. • Cognition • Orientation • Person: own name, age, who examiner is, type of worker • Time: day of week, date, year, season