Nurse Assessment Overview

Study Notes

Nurse Assessment

Recognizing Cues: Nurses assess subjective (symptoms) and objective (signs) data for changes in patient condition. Identifying warning signs is essential.
Subjective Data (Symptoms): Patient reports feelings, experiences, and concerns (e.g., pain, dizziness, fatigue).
Objective Data (Signs): Measurable or observable information (e.g., vital signs, physical examination, lab results).
Health History: Comprehensive information about the patient's health.
- Components:
  - Chief complaint: Main concern.
  - History of present illness (HPI): Detailed description of current problem.
  - Past medical history: Previous surgeries, chronic illnesses.
  - Family history: Medical conditions within the family.
  - Social history: Lifestyle, tobacco/alcohol use, sexual health, employment.
  - Review of systems (ROS): Evaluation of all body systems for symptoms.
- Purpose: Guide diagnosis and treatment.
Functional Assessment: Assessing a patient's self-care abilities.
- Components: Daily living activities (ADLs), mobility, self-care, social interactions.
- Purpose: Assess independent functioning and identify potential quality of life issues.
Cultural Assessment: Recognizing cultural beliefs affecting healthcare.
- Purpose: Identify cultural practices impacting patient decisions and compliance.
- Social Determinants of Health (SDOH): Barriers related to socioeconomic factors (e.g., income, education, healthcare access).
- Important Practices: Understanding cultural practices influencing health (e.g., diet restrictions, treatment preferences, religious beliefs).
Therapeutic Communication: Building trust and promoting safety for the patient during information gathering.
- Purpose: Establish trust, gain information, and address patient safety and comfort during history-taking.

Vital Signs

Temperature:
- Normal Ranges: 36-37°C (96.8-98.6°F) orally, different ranges for axillary, temporal, tympanic, and rectal (for core temperature).
- Fever Causes: Infection, inflammation, trauma.
Pulse:
- Newborn Normal: 110-160 bpm.
- Adult Normal: 60-100 bpm.
- Factors Affecting Pulse: Fever, pain, anxiety, activity, stimulants.
Respiration:
- Procedure: Count for one full minute (rate, depth, pattern, effort).
- Adult Normal: 12-20 breaths per minute.

Description

This quiz focuses on the critical aspects of nurse assessment, including recognizing cues from both subjective and objective data. Participants will examine elements such as patient history, symptoms, and vital signs that inform diagnosis and treatment decisions. Understanding these components is essential for effective patient care.