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Chapter 13


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[Front]


What is the key element of nursing care?
[Back]


assessment

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Chapter 13 - Marcador

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Chapter 13 - Detalles

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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
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
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
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
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
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
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