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17 Cards in this Set

  • Front
  • Back
These are notes on how to assess the patient. Assessment is done by ...
gathering data
verifying data
communicating data
what is the purpose of the assessment?
to establish a database
level of wellness
health practices
past illness
the information you document should be...
Nurse will record...
observations and
statements made by others
why do we need data?
to identify problems
is the bases for individual care plan
must be accurate so plan is appropiate
ERRORS in data mean ERRORS in care plan
what are the 3 methods of assessment?
physical assessment
so, there are 3 methods of assessment, and the observation method is done by ...
being observant
what can one learn
so, the assessment by observation by looking, looking at what?
body language
LOC level of consciencous
O2 status
emotional status
there is the assessment by interview. what kind of questions would we ask?
what is your name
do you know where you are
do you know who I am
can you tell me what day it is?
then the method of assessment that concerns physical assessment, what about that?
done many times per shift
become automatic
do it systematic fashion
do it in same order each time
so we have discussed the observation, the interview, and the physical assessments. what is the challange to all this?
to recognize changes and then address them
so, the physical assessment has 4 techniques you can do or use to get this job done. name them
inspection looking
palpation use of hands/touch
percussion tapping
auscultation listening sounds
so to get a physical assessment we are trying to use all our own senses to gather data. we need tools and technique. like what?
good light so see skin, eyes
to expose body parts, observe
looking for symmetry
how do you start the P A ?
enter the room
wash your hands
introduce yourself
identify the patient
provide for privacy
explain in lay term
we need to have a nice enviroment to do a P A. how do you provide a nice enviroment? how do we prepare the patient both physically & psycologically?
the patient could be tense, anxious, may not want to cooperate
provide for their comfort by asking them to go to the bathroom first
provide for their modesty
there should be privacy
warm not cold room
proper clothing
adequate lighting
quiet, no tv sounds
no interuptions
our professional approach to the P A should convey ....
be open to the patient
be receptive to the patient
be professional to the patient
this might be out of order but this question has to do with being observant. Observe the enviroment. what do we look for?
IV in the room, is it the right solution? flow rate set right?
O2 ... is the flow rate set right? tubing, prongs, mask, all ok? not obstructed?
feeding tube...pump,rate,
NG tube, suction, drainage apperance
SCDs are they wearing them?
CPM continual path it being used?
foley catheteur,, color of urine, amts.
if there is any equipment in the room, what is it and for what reason? need to know all this to be able to observe.