N109: Foundations in Nursing Practice

N109: Foundations in Nursing Practice Study Guide

Nutritional data: o

Weight, height, and body mass index o History of recent weight gain or loss o Food allergies and preferences o Daily fluid intake o Toileting pattern o Skin turgor and condition of hair o Daily diet: Which foods are commonly eaten o Chewing or swallowing problems o Dental problems or disease

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• A sexual assessment should include the extent of sexual characteristics, development, and the level of knowledge the individual has about reproduction and reproductive cycles. This assessment should also include an assessment of sexual practices and the individual’s knowledge of safe sex. • Vital signs and physical assessment • Tools for assessment: o Apgar score: This score is measured one minute and five minutes after an infant’s birth to assess the child’s general condition. Heart rate, respiratory function, muscle tone, color, and irritability are each given a score of 0, 1, or 2 for a maximum total score of 10 for a “perfect” infant. A score less than seven might indicate the child is having some difficulty in acclimating; a score of four or less is an indication that resuscitation efforts should be initiated. o Denver Developmental Screening Test (DDST): This test is used to assess children from birth to six years in the social, gross motor, fine motor, and language domains. The DDST is the most widely used test for screening developmental problems in children. o Functional Independence Measure (FIM): The FIM is the most widely accepted functional assessment measure in use in the rehabilitation community. o Barthel index score: The Barthel ADL index is a scale used to measure performance in basic activities of daily living. The components assessed on this tool include:  Fecal continence  Urinary continence  Grooming  Toilet use  Feeding  Transfers  Walking  Dressing  Climbing stairs  Bathing o CAGE assessment: This is a widely used tool of screening for alcoholism. The CAGE questionnaire should prompt a nurse to suggest further intervention if the patient answers “yes” to two or more of the questions:  Have you ever felt you should C ut down on your drinking?  Do you get A nnoyed by people criticizing your drinking?  Have you ever felt G uilty about drinking?  Have you ever felt the need for an E ye opener in the morning to get rid of a

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