last class

difference between privacy and confidentiality

4 types of history- dependent on reason for seeking are and guides assessment

categories of history- bio

  • Biographical History: This includes personal details such as age, gender, and background, which can influence the individual's health and treatment options.

  • current history of illness. current health state. OPQRSTU, OLDCARTS

  • past medical history- allergies to medications food latex, environment. what happens

  • medications- prescribed, otc

  • family history

  • functional history- ADLs, substance use, what do you do in a day, what do you work, where, who do you work with, etc

  • clients understanding of heath

Documentation

what is documentation used for? for heath care team and clients

  • communication- clear and comprehensive pic of the clients needs, nursing interventions and the client outcomes

  • accountability- nurses are accountable foe ensuring their documentation of client care is accurate, timely and complete

  • security- nurses safeguards client health information by maintaining confidentiality, and acting in accordance with information retention and destruction policies and procedures that are consistent with the stanardts.


How do these doucmatnatin standars apply to assessmnet:

  • conduscr assessment then doument in a space that is not visbible to the public

  • if condctin electronic chrting, make sure screen is seen only by tehe nurse

  • when useing an eectronc course for doucmentaion ensure that all assessment information is captures. if there is not a tick box fotr an assessment, DO enure it is written in a text box

  • use assessment tools as expeted, ie braden scale, glasgow scale, gradphic sheet for vital signs

  • follow picniples of the assessment and comment all the findings, if WNL, indicate so, if not ensure that there is enough description so that other professionals understand including measurements or and marks.

Interview:

  • goal of an interview is to build trust and obstain information to support assessment plan and plan of care

  • provide exmaples of strategies that ehance communication- active listening summarzing at the end, verbal affirmation, silence, asking opnened questions, eye contact, being at eye level. hinders communication- closed off body language, taking notes while talking like not looking at them, not giving enough time to answer, getting distracted with own issues, too much medical jargon


general survery:

  • categories- helps to remember

  • when documenting document in order in which assessment was conducted


  • phyiscal appearce (LOC connects to mental statuc sna dmeolpic exaination)

  • body structure

  • mobility (ROm connected to MCK nuro

  • Behavior (mental status)

general survery leds to additonal assisments.


Blood pressure vital signs

  • hypertension

  • hypotecsio

  • ortho hypotension- lying, sitting, standing, also get pulse

  • widence pulse pressure- subtract sys from dias. (contract vs relaxed), tells us heart is not functinoning at opitmum. if the dfference is getting biger that is a danger sign (difference of 42 then 50)

  • right and elft arm diff

  • systolic

  • diatolic

Pulse

  • tachycardia

  • bradycardia

  • range

  • rate

  • rythym

  • force

  • equlaity

  • stroke volume- how much blood is being ejected from the heart- in adult its 70 mls.

  • asuatory gap

  • 2 step methos

  • sinus aymthmia

  • whent o count for 1 min

temp

  • hyper

  • hypo

  • range

  • methods

  • temp measures core temp, cellular metabolsim

Resp

  • tachypnea

  • brady

  • range

  • rate

  • rythm

  • effort

  • ehn to count 1 min

  • telationship of HR and RR 4 beats of heart- to 1 breathe


Ox Sat

  • what does it refelct -amount of ox satruated in blood and attached to hemoglobin , 4 ox to 1 hemo

  • range

Pain

  • O

  • P

  • Q

  • R

  • S

  • T

  • U

  • other pain scales- descriptor (mild, moderate, severe), won baker faces

  • taypes of pain

  • soucres of apin- visceral, somatic, neruopathic, noscioceptive, superficial