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?

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

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

Vital signs, symptoms, medical history, and current medication. Signup and view all the answers

What is the distinction between primary and secondary illness prevention?

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

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

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

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

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

Identify two modifiable risk factors for disease.

Diet and physical activity. Signup and view all the answers

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

Airway, Breathing, Circulation, Disability, Exposure. Signup and view all the answers

Define acute illness and its typical duration.

Acute illness develops suddenly and lasts a short time. Signup and view all the answers

What is the purpose of the Healthy People Initiative?

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

List one unmodifiable risk factor for disease.

Family history. Signup and view all the answers

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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Description

This quiz covers key concepts related to Maslow's Hierarchy of Needs, the ABCDE approach to patient assessment, and the Survival Potential Triage System used in nursing. It also differentiates between acute and chronic conditions, and discusses modifiable and unmodifiable risk factors in health. Gain insights into primary and secondary illness prevention strategies.