Chapter 13
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| What is the key element of nursing care? | Assessment |
| Objective data | Nurse sees, hears, measures, and feels; more than one person can verify with observation and measurements |
| Signs | Rashes, altered vital signs, abnormal lung or heart sounds, and visible drainage or exudate |
| Drainage | Refers to the passive or active removal of fluids from a body cavity, wound, or other source of discharge by one or more methods |
| Exudate | Refers to fluid, cells, or other substances the are slowly exuded, or discharged from cells or blood vessels through small pores or breaks in the cell membrane, usually as a result of inflammation or injury |
| Perspiration, pus & serum | Identified as exudates |
| Symptoms | Subjective indications of illness that the patient perceives |
| Examples of symptoms | Pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety |
| Subjective data | The interviewer encourages a full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it |
| Pruritus | The symptoms of itching |
| Disease | A pathologic condition of the body, is any disturbance of a structure or function of the body |
| What characterizes a given disease? | Recognized set of signs and symptoms |
| What allows the health care provider to make a medical diagnosis? | The sign & symptoms that are clustered or grouped |
| Disease conditions | Hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental |
| Etiology | Study of all factors that may be involved in the development of a disease; the cause of disease |
| Hereditary diseases | Transmitted genetically from parents to children; examples are cystic fibrosis, sickle cell anemia, color blindness, & hemophilia |
| Congenital diseases | Appear at birth or shortly thereafter but are not caused by genetic abnormalities |
| Inflammatory diseases | Those in which the body reacts with an inflammatory response to some causative agent |
| Degenerative disease | Implies degeneration, often progressive, of some part of the body; osteoarthritis |
| Infectious diseases | Result from the invasion of microorganisms into the body; AIDS, tuberculosis, pneumonia |
| Deficiency diseases | Result from the lack of a specific nutrient; iron deficiency anemia |
| Metabolic disease | Caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body; diabetes mellitus, hypothyroidism |
| Neoplastic disease | Disease is described as an abnormal growth of new tissues; sometimes benign & malignant (cancerous) |
| Malignant neoplasms | A serious threat to health because of the rapid growth of the cells and their ability to invade and metastasize |
| Traumatic conditions | Result from physical and emotional trauma |
| Environmental diseases | Are a group of conditions that develop from exposure to a harmful substance in the environment; carbon monoxide, asbestos |
| Asbestos | Another substance in the environment that potentially leads to lung problems and various cancers |
| Autoimmune responses | The body develops immunoglobulins (antibodies) against its own tissues or body substances; rheumatoid arthritis, ulcerative colitis |
| Risk factor | Any situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the vulnerability of an individual or group to illness or accident |
| What are the 4 major category risk factors for diseases | Genetic and physiologic, age, environment & lifestyle |
| How are diseases described? | In terms of duration |
| Chronic disease | Develops slowly and persists over a long period, often for a person's lifetime; diabetes mellitus |
| Diabetes mellitus | Inability of the body to use glucose |
| What is chronic disease frequently described as? | Early, late, or terminal; another possibility that it is in remission |
| Remission | Means a partial or complete disappearance of clinical and subjective characteristics of the disease has occurred |
| Acute disease | Begins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment; appendicitis |
| Organic disease | Results in a structural change in an organ that interferes with its functioning; stroke |
| Functional disease | Often appear to be those of organic disease, but careful examination fails to evidence of structural or physiologic abnormalities; nervous and mental diseases |
| Infection | Is caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites, that produce tissue damage |
| Inflammation | A protective response of body tissues to irritation, injury, or invasion by disease-producing organisms |
| Cardinal signs of inflammation | Erythema (redness), edema (swelling), heat, pain, purulent drainage (pus), and loss of function |
| Inflammatory response | The body's defense against some causative agent |
| Increased blood flow to the area | Erythema and heat |
| Purulent exudate | The accumulation of neutrophils, dead cells, bacteria, and other debris from the infectious process |
| Assessment | Is an evaluation or appraisal of the patient's condition |
| What does assessment involve? | The orderly collection of information concerning the patient's health status |
| Data collected establishes what? | A baseline |
| What does baseline allow? | Health care providers or the nurse to identify problems and plan care |
| Asthenia | Condition of debility, loss of strength and energy, and depleted vitality |
| Diaphoresis | Secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress |
| Ecchymosis | Discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise) |
| Fetid | Pertaining to something that has a foul, putrid, or offensive odor. Also called malodorous |
| Jaundice | Yellow tinge to the skin; often indicates obstruction in the flow of bile from the liver |
| Orthopnea | An abnormal condition in which a person has to sit or stand to breathe deeply or comfortably. Occurs in many disorders of the respiratory and cardiac systems |
| Sallow | Pertaining to an unhealthy, yellow color; usually said of a complexion or skin |
| Scleral icterus | The color of the sclera is yellow; this jaundice is the result of coloring of thsclera with bilirubin that infiltrates all tissues of the body |
| Frequently noted signs & symptoms of disease conditions | Anorexia, asthenia, bradycardia, constipation, coughing, cyanosis, diaphoresis, diarrhea, dyspnea, ecchymosis, edema, erythema, fetid, fever, inflammation, jaundice, lethargy, nausea, orthopnea, pain, pallor, pruritus, purulent drainage, sallow, sclera icertus, tachypnea, & vomit |
| Nursing assessment | Comprises the gathering, verifying, & communicating data about the patient |
| Purpose of the assessment | Is to establish a baseline database about the patient's level of wellness, health practices, past illnesses, related experiences, & health care goals |
| Data collected during nursing assessment | Health history, physical examination findings, results of laboratory & diagnostic tests, & information from health care team members & the patient's family or significant others |
| Physical assessment techniques | Use inspection, palpation, auscultation, & percussion |
| Postions for examination | Sitting, supine, dorsal recumbent, lithely, sims, prone, lateral recumbent, knee-chest |
| Sitting position | To assess vital signs head & neck lungs breasts etc; provides full expansion of lungs and provides better visualization of symmetry of upper body parts |
| Supine | To assess head, neck, lungs, heart, abdomen, extremities, & pulses; most normally relaxed position & provides easy access to pulse sites |
| Dorsal recumbent | To assess head/neck, lungs, breast, heart, abdomen; positioned for abdominal assessment because it promotes relaxation of abdominal muscles |
| Lithotomy | To assess female genitalia and genital tract; position provides maximal exposure of genitalia & facilitates insertion of vaginal speculum |
| Sims | To assess rectum & vagina; flexion of the hip and knee improves exposure of rectal area |
| Prone position | To assess musculoskeletal system; this position is used only to assess extension of hip joint |
| Lateral recumbent | To assess heart; this position aids in detecting murmurs |
| Knee-chest position | To assess rectum; this position provides maximum exposure of rectal area |
| What is the nurse first task before proceeding to the nurse health history? | To establish an effective nurse-patient relationship |
| First step in initiating the nurse-patient relationship | To introduce oneself, including name, position, & the purpose of the interview |
| Why is it important to state the estimate length of time for an assessment? | It helps ensure cooperation |
| Next step in initiating nurse-patient relationship | To communicate the nurse's trustworthiness & discretion to patients |
| How is the nurse-patient relationship enhanced? | By the professionalism & competence conveyed |
| Nursing health history | The initial step in the assessment process |
| Data collected provide the nurse with what information? | Patient's level of wellness, changes in life patterns, sociocultural role & mental and emotional reactions to illness |
| Inspection | The technique the nurse uses most frequently; begins with the nurse's first contact with the patient & continues throughout the gathering of the nursing history |
| Palpation | The nurse uses the hands and sense of touch to gather data |
| What are the 3 palpation techniques? | Light, moderate, & deep |
| Auscultation | The process of listening to sounds produced by the body |
| 3 systems where you auscultate | Cardiovascular, respiratory, & gastrointestinal systems |
| Percussion | Use of the fingertips to tap the body's surface to produce vibration & sound; technique the nurse uses least frequently |
| Tympany | High-pitched drumlike sound that a hollow organ such as the stomach produces while using percussion |
| Dullness | A low-pitched thud like sound percussion over a dense organ such as the liver produces |
| Flatness | A soft high-pitched flat sound percussion over a muscle produces |
| Common laboratory & diagnosis tests | Blood analysis, urine analysis, diagnostic imaging examinations, stool analysis, & sputum analysis |
| Chief complaint | Patient's subjective reason for seeking healthcare |
| OPQRSTUV method | Questions asked when getting the history of present illness; onset-timing, precipitating-palliative, quality-quanity, region-radiation, severity scale, treatments, understanding, & values |
| Health history | Essential in planning nursing interventions & to identify habits & lifestyle patterns |
| Family history | To determine whether the patient is at risk for illnesses of a genetic or familial nature and to identify areas of health promotion and illness prevention; provides information about family structure, interaction & function that are often useful in planning care |
| Environmental history | Provides data about the patient's home & work environments; identifies areas of concern such as exposure to pollutants that can affect health |
| Psychosocial & cultural history | Includes data about the patient's primary language, cultural group, educational background, attention span, & developmental stage; provides information about the patient's coping skills & support systems |
| If nursing's goal is to promote health while respecting individual value system & lifestyles | Culture-based behavior must be understood |
| Review of systems (ROS) | A systematic method for collecting data on all body systems; the nurse asks the patient about normal functioning of each system & any changes the patient has noted, usually subjective data |
| The correct way to record such information | A clear, concise record |
| ROS guide | Can be used to guaranteed a complete interview |
| Level of consciousness (LOC) | Level of orientation; patient oriented to person, place, time, & purpose |
| Nursing physical assessment | Physical examination performed |