NUR 242 Module 1: Introduction to Health Assessment

Comprehensive vs. focused assessment

Comprehensive = all systems, head to toe; Focused = one system/area, guided by the presenting concern

Subjective vs. objective data

Subjective = what the client says; Objective = what the nurse observes or measures

5 steps of the nursing process

Assessment, Analysis, Planning, Implementation, Evaluation (AAPIE)

Nursing process step outside PN scope

Analysis

Nonmaleficence

Do no harm (comes first)

Beneficence

Act to promote the client's good

Autonomy

Client's right to decide, including refusing treatment; requires mental capacity

Justice

Fair, impartial care for everyone

Law protecting confidentiality

HIPAA (1996)

Alcohol hand rub is NOT OK when…

Hands are visibly soiled (use soap and water 15–30 sec)

PPE for airborne precautions

N95 mask

Suspected abuse: required action

Report to the provider (mandated reporter); document verbatim

Interpreter for a client who speaks another language

Professional interpreter or language line, not family

How to first address a client

By surname, then ask preferred name and pronouns

Nontherapeutic responses to avoid

False reassurance, personal opinions, "we," disapproval

When to raise emotionally charged topics

Last

ISBARR: where the latest vital signs go

Assessment

Stethoscope diaphragm vs. bell

Diaphragm = high-pitched (breath, bowel, normal heart); Bell = low-pitched (murmurs, extra heart sounds)

Palpation: hand part for each purpose

Dorsal = temperature; Finger pads = pulses/masses/fluid; Ulnar = vibration

Who performs percussion

Advanced providers, not entry-level nurses

Correcting a paper chart error

Single line through it, then initial

Words to avoid in documentation

"Appears," "seems," "apparently"

Barriers vs. facilitators of learning

Barriers: pain, disinterest, disabilities; Facilitators: interest, quiet environment, comfort

Sweet, fruity breath suggests…

Diabetes mellitus