Inpatient Assessment

Flashcards covering key concepts from the Inpatient Assessment lecture notes.

Inpatient Assessment Importance

Treatment provided during a patient's visit, ensuring continuity of care and follow-on care with the best knowledge available.

Nursing Process

An approach to identify, diagnose, and treat human responses to health and illness, focusing on the patient's nursing needs.

Five Steps of the Nursing Process

Assessment, Nursing Diagnosis, Planning, Implementation, and Evaluation.

Nursing Assessment - Step 1: Data Collection

Collection and verification of data from primary and secondary sources using subjective and objective data.

Nursing Assessment - Step 2: Data Analysis

Analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care.

Nursing Diagnosis

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that can be treated by nursing measures.

Considerations when Developing a Nursing Diagnosis

Physical, Emotional, Social, and Spiritual needs.

Planning (Nursing Process)

Setting patient-centered goals and expected outcomes, and planning nursing interventions.

Characteristics of Well-Set Goals

Patient-centered, singular, observable, measureable, time-limited, mutual, and realistic.

Implementation (Nursing Process)

Performing or carrying out the nursing measures using interventions developed during planning.

Evaluation (Nursing Process)

Determine whether the patient's condition or well-being has improved after the application of the nursing process.

General Appearance (Inpatient Assessment)

Demeanor, facial expression, and gait.

Mental Status Assessment

A&O x3 [time, person, and place]/responsiveness/ level of consciousness.

Pain Assessment

Collect AND/OR verify the history of present illness (OPQRS)-[worse or better since admission].

Gastrointestinal Assessment

Inspect, auscultate, and palpate all four quadrants of the abdomen- check for excretion [last bowel movement] Record and/or verify last oral intake.

Integumentary Assessment

Inspect and palpate skin anterior and posterior, note any edema, dry or oily skin, lesions, contusion, and/or abrasions.

Forms to Document Physical Assessment Findings

SF 510 and DD Form 792.