phy assesment 1

Every _ hours (eg: every 3 hours)

Q_H; Q3H

Twice a day

BID

Three times a day

TID

Four times a day

QID

As needed

PRN

Immediately

Stat

As desired

Ad lib

Do not resucitate

DNR

Level of consciousness

LOC

Glasgow Coma Scale

GCS

sequential compression device

SCD

Out of bed

OOB

Head of bed

HOB

Heart rate

HR

Respiratory rate

RR

Blood pressure

BP

Oxygen saturation

SpO2

No known drug allergies

NKDA

No known allergies

NKA

Range of motion

ROM

Passive range of motion

PROM

Active range of motion

AROM

Bathroom previleges

BRP

Activities of daily living

ADL

Complete blood count

CBC

Basic metabolic panel

BMP

do not abbreviate

Orange juice

do not abbreviate

Daily

do not abbreviate

Every other day

do not abbreviate

Left year, right ear, both ears

do not abbreviate

Three times a week

Why do nurses assess?

- To gather comprehensive information about the client's health status to help the nurse make judgments and informed decisions

- To prioritize patient centered care while enhancing patient outcomes

What are the components of a physical/health assessment?

- Obtaining subjective & objective data

- Reviews the clients medical record & diagnostic test results

- Nurse uses critical thinking to assess (identify important data, obtain additional data according to the identified problems, organize data accordingly)

What is a focused assessment?

assessment of a body system or body part that is guided by the clients presenting concern

What is a comprehensive assessment?

- head to toe

- full examination of all body systems conducted from head to toe

Define the nursing process. What is it? Why do we use it?

Is a systematic problem-solving approach to the care of each client, used by the nurse to ensure quality care

What are the registered nurses responsibilities in regard to the nursing process?

RN is to validate & analyze the information collected by the PN then plan and initiate the interventions to address the clients health care needs

What are the steps of the nursing process?

AAPIE = Assessment, Analysis, Planning, Implementation, Evaluation

What happens in the Assessment step of AAPIE?

information gathered through interview, physical exam, and observation

What happens in the Analysis step of AAPIE?

using clinical judgement to develop a plan of care and find potential problems

What happens in the Planning step of AAPIE?

using evidence-based practices (EBP) to plan the provision of care supported by research using problempsoliving and decision-making skills

What happens in the Implementation step of AAPIE?

carrying out interventions using clinical judgement and monitor client progress

What happens in the Evaluation step of AAPIE?

- evaluate the effectiveness and achievability of the goals

- finding the needs for change and help in adjusting & keeping goals attainable

What are the components of critical thinking?

- contextual awareness

- analyzing assumptions

- exploring alternatives

- using credible sources

- reflecting & deciding

What are the basic skills of a health assessment?

- inspection, palpation, auscultation, critical thinking, & therapeutic communication

- documentation of findings, collaboration with all the members of the health care team & collaborate with the client

Within the ethical principles of health assessment _________ is defined as doing no harm, first and foremost in health.

nonmaleficence

Within the ethical principles of health assessment _________ is defined as acting to promote the good of the client.

beneficence

Within the ethical principles of health assessment _________ is defined as the clients right to make decisions and refuse treatment.

autonomy

Within the ethical principles of health assessment _________ is defined as treating everyone regardless of the ability to pay, social status, gender identity, or cultural and religious background.

justice

Within the ethical principles of health assessment _________ is defined as respecting the rights of the client to maintain privacy. (HIPAA)

confidentiality

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

What are the safety principles of health assessment?

- Infection control

- Hand hygiene

- PPE

What are the privacy principles of health assessment?

- Physical: making clients feel secure

- Personal: maintaining confidentiality & identifying the patient properly

- Mandated reporting: occurs when nurse observes suspected abuse

What communication skills are important for the nurse?

- Demonstrates holistic care, compassion, inclusivity, and professionalism

- Identifies opportunities for health promotion throughout the assessment and collaborates with clients.

What personal factors are important for the nurse?

- Evaluate own thoughts and feelings regarding the client, health care issues or other aspects and maintain a neutral attitude.

- Reflection of personal biases will allow for easier interactions.

What expected variations are important for the nurse?

Determine whether alternate or additional communication methods are needed by reading communication cues from clients

How does the nurse assess a non-English-speaking client?

Assistance from a warranted interpreter is needed (The facility should have a professional interpreter)

What is therapeutic communication?

an approach to communication that is both verbal and nonverbal, allowing you to focus on the person

What is verbal communication?

- preferred name & pronouns

- questioning techniques (open ended)

- client engagement

- language use (avoid medical jargon)

- managing conversation

- positive reinforcement

What is non-verbal communication?

maintaining an awareness of personal space and body language

What questions should the nurse avoid?

asking personal questions that are not relevant to the situation

What are things the nurse should avoid when communicating therapeutically?

- using inappropriate plural pronouns (we)

- assuming client knows about a health interview/physical

- giving personal opinion

- using automatic responses & false reassurances

- relaying disapproval of client statements or health practices

What are the components of documentation for a health assessment.

Health history (subjective data)

Physical exam (objective data)

Documentation findings

How does the nurse utilize ISBARR as a tool for clear communication with other members of the healthcare team to ensure effective client care?

To provide clear and concise communication to reduce the risk of errors or misunderstandings in healthcare

What are the components of ISBARR?

Identify

Situation

Background

Assessment

Recommendations

What is subjective data? What is an example?

- clients reason

- ex. physical symptoms "i've had a dry cough"

What is objective data? What is an example?

- observations or measurements of ones condition

- ex. nurse reviews medical records & diagnostic test results

What are sources of data?

client, family, and team members (healthcare professionals)

The nurse collects _______ data in the interview process.

subjective

The nurse collects _______ data in the inspection, palpation, and auscultation process.

objective

Know, the order of head-to-toe, proximal to distal, front to back while avoiding unnecessary position changes, compare both sides for symmetry.

Name three of the four assessment techniques.

inspection, palpation, & auscultation

What is the proper assessment technique for all systems EXCEPT abdomen?

inspection, palpation, & auscultation

What is the proper assessment technique for the abdomen?

inspection, auscultation, & palpation

How does the nurse inspect?

- Look and observe before touching

- Note the following characteristics while inspecting color, patterns, size, location, symmetry, consistency, movement, behavior, odors, or sounds

- Compare the appearance of symmetric body parts (e.g., eyes, ears, hands, arms) or both sides of any individual body part

- Exposed body parts being observed while keeping the rest of the client properly draped

- Use good lighting as abnormalities can be overlooked in dim

Lighting

- Be aware of the temperature in the room.

- Be aware of temperature, warm room or use warm blankets as needed

How does the nurse palpate?

Using the palmar surfaces of the fingers and finger pads, not the fingertips, when palpating for fluid, crepitus, size, and consistency of masses and pulses because these areas of your finger are more sensitive

What parts of the hands are used to palpate fine discrimination & pulses?

finger pads

What parts of the hands are used to palpate vibrations & thrills?

palmar/ulnar

What parts of the hands are used to palpate temperature?

dorsal surface

How do you auscultate in order to determine pulse, texture, temp, moisture?

light palpation

How does the nurse auscultate?

Place the stethoscope against the client's skin, use gentle pressure, just enough to form a seal. If the pressure is too hard, the sounds will be diminished and ineffective for assessment.

The diaphragm is to listen to _______ pitched sounds.

high

Examples of high pitched sounds are...

breath sounds, bowel sounds, & expected heart sounds

Bell is used to listen to ______ (______) pitched sounds.

low, (soft)

Examples of low (soft) pitched sounds...

extra heart sounds or murmurs

What are health records?

- An individualized collection of health information & data about a client's health

- Identifies procedures & hospitalization

What is the nurse's scope in documentation?

Nurses are legally allowed to record in a patient's medical record, including assessments, interventions, patient responses, and any changes in condition s all while staying within hospital policies

What is the nurse's role in documentation?

Providing accurate reflection of assessments, changes in clinical state, or care provided

What is the importance of documentation?

Legal proof of what was done in case something comes up in court

What if the nurse does not document?

It didn't happen, can late chart, can be a legal risk

What are the elements of documentation?

- Factual: Objective data

- Accurate & concise:

Avoid unnecessary words/details, only used approved abbreviations

- Complete & current: Do and document timely

- Organized

What are the legal implications of documentation?

Falsifications of Health Records:

1. Doesn't document a client assessment

2. Doesn't document communication with members of the interprofessional team

3. Documents inaccurate assessment data

4. Documents care, events, assessments, or activities that did not actually occur

Know how to decide whether data needs to be validated (verified).

Know how to validate data.

Confirm clients information

Ensure all prescriptions are complete

Record the prescription on the designated area of the clients chart

Read the prescription on the designated area of the clients chart

Read the prescription back to the provider

Use clarifying techniques

Ask additional questions as needed to ensure completeness and accuracy of the prescription

What are the different forms of documentation?

flow charts, narrative documentation, charting by exception, problem oriented medical records, electronic health records

What is a flow chart?

shows trends and vital signs, blood, glucose levels, pain level, and other frequent assessments

What is a narrative documentation?

records information as a sequence of events in a story like matter

What is charting by exception?

documenting only unexpected or unusual findings - shorthand method of documenting routine & normal findings

What are problem oriented medical records?

SOAP, PIE, FACT

What is the most common type of documentation used in the hospital setting?

Electronic health records

What are the EHR documentation security guidelines/protocols?

Never use anyone else's login information

Passwords must be strong, unique, & should be changed frequently

Log off when documentation is complete

Never leave a computer station without logging off first

Computer monitor/screen should be protected to avoid information being seen by others

If an electronic signature is used, ensure your name is correct & professional credentials are noted