Summary
Summary NSG 121 HESI Study Guide
- Course
- NSG 121
- Institution
- Herzing University
This is a comprehensive and detailed HESI study guide for NSG 121. *Essential!!
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Primary Data = the pt.Secondary Data = charts & info. from family members
Type of health history:
Emergency = Get info regarding reason for seeking care, current health problems, meds.,
allergies
History taking- Focused = Questions related to the current situation
document Comprehensive = Full health history, demographic data, individual/family health history,
functional status, physical/psychosocial health, review of systems
History of present Illness:
OLDCARTS (onset, location, duration, character, associated or aggravating
factors, relieving factors, timing, severity)
Falls or sudden jerking of the head/neck (whiplash) can result in dislocation of the cervical
vertebrae (C1-7, landmark is vertebral prominence, locate & palpate C7 for accurate findings)
Fall-assess (Neck muscles = sternocleidomastoid, trapezius)
after Headfirst Falls Fractures may occur
Morse scale used to assess risk for falls
Assisted living- Self-Care Ability = Older adults Functional ability
self ADLs Ability measured with Lawton Instrumental ADLs:
Ability to Telephone
1. Operates telephone on own initiative: looks up and dials number and
so on.
2. Answers telephone and dials a few well-known numbers.
3. Answers telephone but does not dial.
4. Does not use telephone at all.
Shopping
1. Takes care of all shopping needs independently.
2. Shops independently for small purchases.
3. Needs to be accompanied on any shopping trip.
4. Completely unable to shop.
Food Preparation
1. Plans, prepares, and serves adequate meals independently.
2. Prepares adequate meals if supplied with ingredients.
3. Heats and serves prepared meals or prepares meals but does not
maintain adequate diet.
4. Needs to have meals prepared and served.
Housekeeping
1. Maintains house alone or with occasional assistance (e.g., heavy work
done by domestic help).
2. Performs light daily tasks, such as dishwashing and bed making.
3. Performs light daily tasks but cannot maintain acceptable level of
, cleanliness.
4. Needs help with all home maintenance tasks.
5. Does not participate in any housekeeping tasks.
Laundry
1. Does personal laundry completely.
2. Launders small items; rinses socks, stockings, and so on.
3. All laundry must be done by others.
Mode of Transportation
1. Travels independently on public transportation or drives own car.
2. Arranges own travel via taxi, but does not otherwise use public
transportation.
3. Travels on public transportation when assisted or accompanied by
another.
4. Travel limited to taxi, automobile, or ambulette, with assistance.
5. Does not travel at all.
Ability to Handle Finances
1. Manages financial matters independently (budgets, writes checks,
pays rent and bills, goes to bank); collects and keeps track of income.
2. Manages day-to-day purchases but needs help with banking, major
purchases, controlled spending, and so on.
3. Incapable of handling money.
Scoring: Circle one number for each domain. Total the numbers circled.
The lower the score, the more independent the older adult is
Anus-
NSG121.09.03.01
hemorrhoids
Low BMI BMI = Height x weight
Criteria for eating disorder = Adult BMI < 17.5 or Child/adolescent BMI < 5th percentile
Underweight = < 18.5 BMI
Ideal body weight = (Current weight/ideal weight x 100) pt. should be within 10% of ideal body
weight
Residents of nursing home meaning weight loss = Lost 5% of usual body weight in 30 days or
10% in 6 months
Nursing Point of Assessment Nursing Interventions
Diagnosis* Differentiation Characteristics
Imbalanced Nutrient intake Bodyweight 20% or more Weigh the patient daily. Monitor
nutrition: that fails to below ideal, BMI less than the intake.
Less than meet 18.5, lack of interest in
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