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20 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Subjective Data |
What the patient tells you |
"Pain is 7/10" |
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Objective Data |
What we can see |
Vital Signs |
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Types of assessments: Comprehensive |
Health History &a complete physical exam. Usually on admit. Baseline for later assessments. |
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Types of assessments: ongoing partial assessment |
Conducted at regular intervals, beginning of each shift |
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Types of assessments: focused |
Conducted to assess a specific problem; if the patient complains of pain |
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Types of assessments: emergency |
Rapid focused assessment; determine potentially fatal situations; patient c/o difficulty breathing |
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Techniques of Physical Assessment |
Inspection, Palpation, Percussion, Auscultation |
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Physical assessment |
Systemic collection of objective information |
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Inspection |
Visual, hearing, smell Adequate lighting Quiet environment Noté normal findings and deviation from normal (May be combined with palpation) |
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Palpation |
Uses the sense of touch Assessing temperature, turgor, texture, moisture, vibrations, shape |
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Percussion |
Used to assess location, shape, size, density of tissue Flat-Thigh Dull-Liver Resonance- Lung Hyperresonance- emphysematous lung Tympani- gastric air bubble |
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Auscultation |
Listen with a stethoscope Pitch- high to low Loudness- soft to loud Quality- gurgling or swishing Duration- short to long ❤️ tones- low pitch (Bell) Belly tones- high pitch (diaphragm) |
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Relevant data |
What is applicable to my patient right now |
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Clustering data |
Cluster common problems and develops a prioritized list of patient problems |
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How to write a nursing diagnosis |
Nursing diagnosis related to medical diagnosis as manifested by actual sign and symptoms |
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Planning |
Making a goal= outcome that is individualized per patient and for each nursing diagnosis. These can be long term and short term goals. Develop interventions that will help the patient meet those goals/outcomes. Take into account the variable that might influence a patient to not meet certain goals (developmental/ psychosocial). Communicate the plan of car to the patient (they must buy into the plan) and all of the staff caring for the patient. PATIENT DRIVEN |
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How to write a goal |
Measurable, realistic, specific |
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Initial planning |
Begins with the first patient contact. It refers to the development of the initial comprehensive car plan, which should be written as soon as possible after the initial assessment. |
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Ongoing planning |
Refers to changes made in the plan 1) as you evaluate the patients responses to care or 2) as you obtain new data and make new nursing diagnosis |
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Discharge planning |
Is the process of planning for self-care continuity of care after the patient leaves a healthcare setting |
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