N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide associated with developmental stages • History of the present illness: What symptoms is the patient having? What are the characteristics and location of the symptoms? When did the symptoms start? Also include what makes the symptoms worse or better and any treatments the patient has attempted to alleviate the symptoms. • Past medical history: This will include allergies, medications, past medical history,or surgeries and immunizations for pediatric patients • Family history: This assessment will include the health status of both parents and any acute or chronic diseases (heart disease, lung disease, mental illness, cancer, diabetes, etc.) that have been experienced by the patient’s siblings, parents, or grandparents • Social history: This will include a review of smoking, dietary, drug, alcohol, and sleep habits; might also include education level, since this information will be very helpful when doing education for the patient; documenting data about the patient’s home environment can provide clues as to the home health services that might be needed • Vital signs: Vital signs should be assessed at every assessment contact with the patient • Body system assessment: A head to toe assessment should be conducted • Functional assessment: For health maintenance, the functional assessment will provide information related to how the individual is responding to health issues and behaviors that might be producing unhealthy effects • Diagnostic tests: To provide a high level of health maintenance, the nurse must reviewall diagnostic tests ordered to assess health maintenance. Common tests include: o Complete Blood Count (CBC): The CBC includes:  White blood cell count (WBC) of 4500-11,000/uL, which may be indicative ofinfection.  Differential count, which is helpful in diagnosing disorders that have characteristic patternsof white blood cell distribution.  Hemoglobin level (male: 14-18 g/dl and female: 12-16 g/dl) is the concentration of oxygen carrying hemoglobin in the blood; low counts may be indicative of anemia.  Hematocrit (HCT) in males is 45% and in females is 40%. This measures the proportion of theblood that is made up of red blood cells.  Red blood count (RBC) of 4.5-6.2 m/uL in a male and 4-5.5 m/uL in a female. This is the number of circulating RBCs in the blood. Red cells provide the vehicle for hemoglobin and oxygen transport to the body tissues.  Platelet count (150,000-400,000/uL) refers to the number of platelets in the bloodstream. Platelets are critical in the clotting mechanism. o Urinalysis is a component of a health maintenance plan to check for infection, elevated glucose, and protein. o An electrocardiogram will often be done, particularly as a patient approaches middle age and beyond. o A chest x-ray (CXR) may be done to assess for pneumonia and other lung disorders. o For a female, a mammogram should be done as part of health maintenance. Analysis and Diagnoses

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