Nursing Triage and Health Needs Overview

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Questions and Answers

What are the first two steps in the clinical decision-making process for patient assessment?

Recognize cues and analyze cues.

How should a nurse prioritize different hypotheses during patient assessment?

By evaluating and ranking the possible explanations for the patient's situation.

What are the key levels of Maslow's Hierarchy of Needs?

The key levels are physiological, safety, love/belonging, esteem, and self-actualization.

What types of tasks can assistive personnel perform to support patient care?

<p>Tasks such as further assessment, assisting with bathing, and taking vital signs.</p> Signup and view all the answers

Which factors are assessed to determine a patient's level of acuity?

<p>Vital signs, symptoms, medical history, and current medication.</p> Signup and view all the answers

What is the distinction between primary and secondary illness prevention?

<p>Primary prevention aims to prevent health problems, while secondary prevention focuses on early detection and treatment.</p> Signup and view all the answers

What is the significance of subjective and objective data in a mobility assessment?

<p>Subjective data provides insights into the patient's movement abilities, while objective data assesses their physical capabilities.</p> Signup and view all the answers

Describe the correct way a nurse should instruct a patient to use a cane during ambulation.

<p>The patient should hold the cane on their stronger side and move it forward with their weaker leg.</p> Signup and view all the answers

Identify two modifiable risk factors for disease.

<p>Diet and physical activity.</p> Signup and view all the answers

What does the ABCDE framework stand for in prioritizing patient care?

<p>Airway, Breathing, Circulation, Disability, Exposure.</p> Signup and view all the answers

Define acute illness and its typical duration.

<p>Acute illness develops suddenly and lasts a short time.</p> Signup and view all the answers

What is the purpose of the Healthy People Initiative?

<p>To improve the health of the United States by setting nationwide health goals.</p> Signup and view all the answers

List one unmodifiable risk factor for disease.

<p>Family history.</p> Signup and view all the answers

Flashcards

Survival Potential Triage System

A system used in nursing to prioritize care during mass casualty events.

Maslow's Hierarchy of Needs

A framework that outlines the needs that motivate human behavior, starting from basic needs and moving towards self-actualization.

ABCDE

A framework used to quickly assess a patient's condition in an emergency, focusing on airway, breathing, circulation, disability, and exposure.

Acute Illnesses

Illnesses that develop suddenly and often last a short time.

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Chronic Conditions

Conditions that develop slowly and may worsen over time.

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Modifiable Risk Factors

Factors that increase the risk of developing a disease and can be changed through lifestyle modifications.

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Unmodifiable Risk Factors

Factors that increase the risk of developing a disease and cannot be changed.

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Primary Prevention

Actions taken to prevent disease before it occurs.

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Clinical Decision Making

The process of identifying relevant information, analyzing its meaning, and prioritizing potential explanations for a patient's condition. This leads to making informed choices about patient care.

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Mobility Assessment

A structured evaluation that helps nurses understand a patient's movement capabilities. It involves gathering information from the patient about their experience and conducting a physical assessment to observe their range of motion, strength, balance, and walking pattern.

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Cane Usage for Ambulation

The ability to walk independently with the aid of a cane. It involves proper positioning of the cane on the stronger side of the body, opposite the affected leg, and using it for balance while moving.

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Ambulation

The ability to walk independently without assistance.

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Objective Mobility Assessment

A physical examination that assesses a patient's range of motion, muscle strength, balance, and gait.

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Study Notes

Maslow's Hierarchy of Needs

  • Maslow's Hierarchy of Needs is a conceptualization of human needs.

ABCDE

  • Airway, Breathing, Circulation, Disability, Exposure

Survival Potential Triage System

  • Used in nursing to determine the priority of care for patients during a mass casualty event.

Acute vs. Chronic Conditions

  • Acute illnesses develop suddenly and last a short time.
  • Chronic conditions develop slowly and may worsen over an extended period of time.

Determining Levels of Acuity

  • Healthcare professionals assess a patient's clinical condition by considering factors like vital signs, symptoms, medical history, and current medications.

Modifiable Risk Factors

  • Diet
  • Tobacco use
  • Physical activity
  • Alcohol use
  • Sleep
  • Blood pressure
  • Obesity

Unmodifiable Risk Factors

  • Age
  • Race
  • Ethnicity
  • Family history
  • Social determinants of health

Primary and Secondary Illness Prevention

  • Primary prevention aims to prevent problems from happening.
  • Secondary prevention aims to detect problems early so they can be treated.

Healthy People Initiative

  • A national program aiming to improve the health of the United States.

Nursing Process Steps

  • Assessment: Collect data to identify health issues and patient condition.
  • Diagnosis: Review data to create a nursing diagnosis.
  • Planning: Develop a treatment plan considering short- and long-term goals.
  • Implementation: Put the treatment plan into action.
  • Evaluation: Review the patient's experience and modify the care plan as needed.

Clinical Judgment Model Steps

  • Recognize cues: Identify relevant pieces of information.
  • Analyze cues: Organize cues and consider how they relate to the patient's situation.
  • Prioritize hypotheses: Evaluate and rank possible explanations.
  • Generate solutions: Use hypotheses to identify likely conditions and outcomes.
  • Take action: Prioritize care for the patient.
  • Evaluate: Assess if the actions were effective.

Clinical Decision Making

  • The process of making decisions about a patient's health based on evidence, experience, and patient needs.

Physical Examination for Mobility Assessment

  • Assess the patient's movement abilities.
  • Conduct a physical examination to objectively assess range of motion, muscle strength, balance, and gait, using standardized tests.
  • Collect data about the patient's movement abilities.

Cane Usage Instruction

  • Instruct the patient to hold the cane on the stronger side.
  • Move the cane forward opposite the affected leg.
  • Use the cane for balance as the patient steps forward with the stronger leg.

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