NUR2092 Health Assessment Exam 1

NUR2092 Health Assessment Exam 1 What are the 6 steps of the nursing process?

• Assessment
• Diagnosis
• Outcome
• Planning
• Implementation
• Evaluation

Assessment Definition (nursing process)

• Collect data
• Use evidence-based assessment techniques
• Document relevant data

Diagnosis Definition (nursing process)

• Compare clinical findings with normal and abnormal variation and

developmental events

• Interpret data-- make & test hypotheses
• Validate diagnoses
• document diagnoses

Outcome Identification Definition (nursing process)

• Identify expected outcomes
• Individualize to the person
• Culturally appropriate
• realistic and measurable
• include a timeline

Planning Definition (nursing process)

1. ESTABLISH PRIORITIES

• Develop Outcomes
• Set timelines for outcomes
• IDENTIFY interventions

• Integrate evidence-based trends and research
• Document plan of care

Implementation Definition (nursing process)

• Implement in a safe and timely manner
• Use evidence-based interventions
• Collaborate with colleagues
• use community resources
• coordinate care delivery
• provide health teaching and health promotion
• document implementation and any modifications.

Evaluation Definition (nursing process)

• Progress toward outcomes
• conduct systematic, ongoing, criterion-based evaluation.
• Include patient and significant others
• use ongoing assessment to revise diagnoses, outcomes, plan
• distribute results to patient and family

Acute pain

• Is short term and self-limiting, often follows a predictable trajectory, and

dissipates after an injury heals.

• Self-protective purpose; it warns the individual of actual or threatened tissue

damage.

Chronic Pain

• Over 6 months in duration

• Adaptive responses

Phantom pain

• Pain where limb used to exist

Malignant pain Vs nonmalignant pain

• Malignant pain is cancer-related and is caused by tumor cells that cause necrosis

or stretching.

• Nonmalignant pain is often associated with musculoskeletal conditions.

Visceral pain

Originates from internal organs.

Somatic pain and deep somatic pain

• Somatic pain originates from musculoskeletal tissues or the body surface.
• Deep somatic pain comes from sources such as blood vessels, joints, tendons,

muscles, and bone.

Referred pain

Pain that is felt at a particular site but originates from another location.

Nociceptive pain

• Develops when functioning and intact nerve fibers in CNS are stimulated.
• They are triggered by events outside nervous system from actual or potential

tissue damage. 3.Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation

Neuropathic pain

• Pain caused by a lesion or disease of the somatosensory nervous system.
• This implies an abnormal processing of pain message from an INJURY to the

NERVE FIBERS.

• This pain is very difficult to treat and assess.

Subjective Data

Pain is always subjective. What the patient is complaining of; SYMPTOM

Objective data

What the nurse observes ; SIGN

Nutritional Status

• This balance is affected by many factors, including physiologic,

psychosocial, developmental, cultural, and economic factors

Nutritional Assessment  Food intake

• 24 hour recall
• Food diary
• Food frequency
• Direct observation

 Anthropometric measurements  Swallowing assessment prn  Lab tests

Pain assessment tools

• Brief pain inventory
• McGill Pain Questionnaire
• Initial Pain assessment
• Pain rating scales
• Wong-Baker Faces pain rating scale

Pain Assessment

• Posture/behavior

• Facial expression

• Sounds