HA

• The nursing process involves collecting data in a systematic and ongoing process that involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection.
• The nursing process prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation.
• The nursing process uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data.
• Leukoplakia (ventral surface)
• Assessing the tonsils in a client with both tonsils and a sore throat can be done with a grading scale from 1 to 4, where 1+ indicates that the tonsils are visible, 2+ indicates that the tonsils are midway between tonsillar pillars and uvula, 3+ indicates that the tonsils touch the uvula, and 4+ indicates that the tonsils touch each other.
• Abnormalities of the tonsils include acute tonsillitis and pharyngitis.
• The nursing process uses analytical models and problem-solving tools.
• The nursing process synthesizes available data, information and knowledge relevant to the situation to identify patterns and variances.
• The nursing process documents relevant data in a retrievable format.
• The nursing process consists of five phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation.
• Health history consists of subjective data collected during an interview, including information about the patient's current state of health, medications they take, previous illnesses and surgeries, and family history and a review of systems.
• Patients may report feelings or experiences associated with health problems, which are called symptoms and are considered subjective data.
• Subjective data acquired directly from the patient are considered primary source data, while data acquired from another individual are referred to as secondary source data.
• Subjective data can be elicited and verified only by the client and provide clues to possible physiologic, psychological, and sociologic problems.
• Subjective data provides information that may reveal a client’s risk for a problem as well as areas of strengths for the client.
• Subjective data consists of sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information.
• Interviewing patients to obtain health history involves planned communication, conversation with a purpose, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, provide counseling or therapy.
• Abnormalities of the side of the tongue include canker sore, gingivitis, receding gums, Kaposi’s sarcoma lesions, hairy leukoplakia (lateral surface), candida albicans infection (thrush), and smooth, reddish, shiny tongue without papillae due to vitamin B12 deficiency.
• The Rinne’s test compares air and bone conduction sounds.
• Abnormalities of the external ear and ear canal include malignant lesion, otitis externa, buildup of cerumen in ear canal, and more.
• The nose and paranasal sinuses constitute the first part of the respiratory system and are responsible for receiving, filtering, warming, and moistening air to be transported to the lungs.
• The Weber test helps to evaluate the conduction of sound waves through bone to distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear).
• Leukoplakia is a precancerous lesion, and the client should be referred for evaluation.
• The mouth and throat make up the first part of the digestive system and are responsible for receiving food, taste, preparing food for digestion, and aiding in speech.
• Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and XII (hypoglossal) assist with some of these functions.
• Receptors of cranial nerve I (olfactory) are also located in the nose.
• Abnormalities of the tympanic membrane include acute otitis media, blue/dark red tympanic membrane, perforated tympanic membrane, serous otitis media, scarred tympanic membrane, and retracted tympanic membrane.
• Hearing acuity and the conduction of sound waves through the outer, middle, and inner divisions of the ear are tested to assess these parts of the ear.
• Abnormalities of the tongue include tongue-tied, palpating area under the tongue, fissured tongue, varicose veins on ventral surface of the tongue, and more.
• Directive interview is highly structured and elicits specific information, with the nurse establishing the purpose of the interview and controlling the interview, at least at the outset.
• Non-directive interview is a rapport-building interview, with the nurse allowing the client to control the purpose, subject matter, and pacing.
• Hand hygiene involves washing hands with soap and water, using alcohol-based hand sanitizers, and avoiding touching the eyes, nose, and mouth.
• Susceptible hosts include babies, children, the elderly, people with a weakened immune system, unimmunized people, and anyone else.
• Purpose of hand hygiene is to reduce the number of microorganisms on the hands, to reduce the risk of transmission of microorganisms to clients, to reduce the risk of cross-contamination among clients, and to reduce the risk of transmission of infectious organisms to oneself.
• Thermoregulation center is the hypothalamus, a section of the brain that controls thermoregulation.
• Factors that influence body temperature include age, diurnal variations, exercise, hormones, stress, and illness.
• Objective data include information about the client that the nurse directly observes during interaction with the client and information elicited through physical assessment techniques.
• Portal of exit for germs includes the mouth, cuts in the skin, and during diapering and toileting.
• Portals of entry for germs include the mouth, cuts in the skin, eyes, and hands.
• Temperature is the balance between the heat produced by the body and the heat lost from the body.