ASSURED SUCCESS
Subjective data
Information gathered from patient statements; the patient's
feelings and perceptions. This includes their chief complaint,
hpi, review of systems, social, family, and medical history.
Objective data
Observable and measurable data that can be seen, heard, or
felt by someone other than the person experiencing them.
Found through physical examination, diagnostic tests, and
clinical observations
Review of systems
Physical examination of all body systems in a systematic
manner as part of the nursing assessment.
Document relevant positive and negative findings in each body
system.
It helps screen for any potential health problems beyond the
patients primary complaint.
Speciality populations: pediatric exams
Communication should be age appropriate, trust-building, and
consider developlment stages.
Speciality populations: pregnancy
Attention to maternal and fetal health, as well as agressing
unique concerns
Speciality populations: geriatric
Consider age related changes, comorbidities, and potential
cognitive impairments.
Purpose of cage questionnaire
,Is a brief screening tool used to assess alcohol disorders and
identify individuals? Who may need further evaluation
scoring: "a yes" to two or more questions may indicate
possible alcohol problem.
Cage questions: c
Cut down: "have you ever felt the need to cut down on your
drinking?
Cage questions: a
Annoyed: "have you ever been annoyed by your critism of your
drinking?"
Cage questions: g
Guilty: "have you ever felt guilty about your drinking?"
Cage questions: e
Eye-opener: have you ever had a drink first thing in the
morning to steady your nerves or get rid of a hangover?"
Hits purpose
A screening tool used to assess domestic violence or intimate
partner violence.
Screening: a "yes" to one or more questions may indicate
potential partner violence.
Hits questions: h
Hurt: "have you ever been physically hurt by someone you are
close to?"
Hits questions: i
Insult: have you ever been insulted or made to feel bad about
yourself by someone you are close to?"
,Hits questions: t
Threaten: have you ever been threatened with physical harm
by someone you are close to?
Hits questions: s
Scream: have you ever been screamed or curses at by
someone you are close to?"
Pvs (partner violence screening ) tool purpose:
3 questions used to detect partner violence
1 positive response = positive screen
Pvs questions:
Have you been hit, kicked, punched, or otherwise hurt in the
last year?
Do you feel safe in your current relationship?
Is there a partner from a past relationship that is making you
feel unsafe now?
Fica tool purpose
Used to assess a patient's spiritual, religious beleif and their
impact on healthcare descisions.
Fica components: f
Faith or beleif: do you have spiritual beliefs to help cope with
stress
Fica components: i
Importance: is religion or spirituality important to you
Fica components: c
Community: are you apart of a religious community
Fica components: a
, Adress in care: how would you like your healthcare provider to
adress these spiritual concerns.
What are the sexual history 5 p's
Partners: ask about number and gender of partners.
Practices: sexual practice and behaviors
protection from stis: condom use and safe sex.
Past sti: have they had any?
Prevention of pregnancy: explore methods used for pregnancy
prevention.
Therapeutic communication
A type of communication that health care providers
consciously use when talking with residents in order to
influence residents or help residents to a better
understanding.
When dealing with an angry client use active listening,
acknowledge their feelings, maintain a calm demeanor, and
adress their concerns empathetically.
Cultural considerations things to do
Ask open ended questions about cultural beliefs, practices,
and preferences.
Don't make assumptions based on physical characteristics, as
cultural diversity can exist within any group.
Respect model
Rapport
empathy
support
partnership
explanations