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Inspection
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involves use of vision, hearing, and smell to scrutinize physical
characteristics of a whole person and individual body systems
Symmetry should be assessed by comparing the right and left sides of the
body
Clinical Pathways
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multidisciplinary resources designed to guide patient care. developed
through EBP research. Impacts interventions.
, independent, dependent, direct, and indirect interventions are included in
this
Informal Counseling
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patients use professional guidance to address and express personal
conflicts or emotional concerns.
Risk nursing diagnostic two segments:
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1. diagnostic label
2. risk factors preceded by the phrase as evidenced by
Orientation (introductory phase)
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, Nurse establishes name patient prefers to be addressed.
ex: Mr. Mrs, Surnames, or firstnames
This phase is essential for establishing trust between nurse and patient.
Demographic data should be collected by asking focused/close-ended
questions. General info gathered with open-ended communication.
Identifying patient needs and determining extent patient wants to be
involved in care planning are important aspects
Outcome
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listing behaviors or observable items that indicate attainment of a goal.
added by the ANA in 1991
Clinical/Focused Assessment
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beginning of each shift or more often, depending on patient's condition
and health care facility's policies/guidelines
establish current patient status, or during ongoing patient encounters in
response to a specific patient concern
conducted when signs indicate a change in a patient's condition or the
development of a new complication
edema, peripheral pulses, capillary refill, skin turgor, and muscle strength
are routinely identified. Wounds, intravenous sites, supplemental oxygen
, levels and delivery systems, nasogastric (NG) tubes, cardiac monitoring,
and urinary catheters are assessed and documented.
Emergency Assessment
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includes triage, conducted in emergent situations to assess extent of
patient injuries and determine care priorities
treatment is based on a quick survey of accident or illness onset, followed
by a narrowly focused physical examination of critical injuries or symptoms
and signs.
nurse may never have time to do a complete assessment and may work to
stabilize one body system at a time
nurse may never have time to do a complete assessment and may work to
stabilize one body system at a time
Referrals
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sending a patient to another member of healthcare team or agency for
consult of other services
Standing Orders
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