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17 Cards in this Set
- Front
- Back
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These are notes on how to assess the patient. Assessment is done by ...
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gathering data
verifying data communicating data |
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what is the purpose of the assessment?
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to establish a database
includes: level of wellness health practices past illness |
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the information you document should be...
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descriptive
concise NO INTERPRETATIONS |
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Nurse will record...
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observations and
statements made by others |
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why do we need data?
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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 |
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what are the 3 methods of assessment?
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observation
interviews physical assessment |
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so, there are 3 methods of assessment, and the observation method is done by ...
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looking
being observant what can one learn |
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so, the assessment by observation by looking, looking at what?
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skin
grooming nourishment body language LOC level of consciencous O2 status emotional status |
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there is the assessment by interview. what kind of questions would we ask?
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what is your name
do you know where you are do you know who I am can you tell me what day it is? |
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then the method of assessment that concerns physical assessment, what about that?
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done many times per shift
become automatic do it systematic fashion do it in same order each time |
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so we have discussed the observation, the interview, and the physical assessments. what is the challange to all this?
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to recognize changes and then address them
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so, the physical assessment has 4 techniques you can do or use to get this job done. name them
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inspection looking
palpation use of hands/touch percussion tapping auscultation listening sounds |
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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?
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good light so see skin, eyes
to expose body parts, observe looking for symmetry |
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how do you start the P A ?
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enter the room
wash your hands introduce yourself identify the patient provide for privacy explain in lay term |
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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?
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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 |
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our professional approach to the P A should convey ....
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be open to the patient
be receptive to the patient be professional to the patient |
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this might be out of order but this question has to do with being observant. Observe the enviroment. what do we look for?
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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 motion...is 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. |
