Review
Nursing Process - ✔✔Systematic method of planning & providing patient care organized
around a series of phrases that integrate evidence-informed practice & critical thinking
ADOPIE
Assessment's goal - ✔✔objective data collection
organize data
validate data
document data
Critical thinking skills during interview - ✔✔use critical thinking
find what is relevant
look for inconsistencies
look for patterns
see if there's any info missing
find opportunities to promote health
is there any potential risk for the patient
Criticial thinking skills with patient - ✔✔setting priorities
identify patient-centered expected outcomes
Evaluate and revise thinking
determine a comprehensive plan
levels of priorities - ✔✔1st level
,ABCs + V
2nd level : urgent but not ABCs + V
change in mental status
patient that need insulin
3rd level: can be done later
4th level: collaborative problem
interprofessional problems
Patient-centered-expected outcomes - ✔✔should include a time frame
what will be done to help
the expected result
the specific interventions
evaluation of the outcome
SBAR to communicate - ✔✔Situation
Background
Assessment
Recommendation
SOAP to communicate - ✔✔Subjective
Objective
Assessment
Plan
4 factors before a decision - ✔✔1- evidence from research
2- evidence from assessment
,3- clinical expertise
4- patient preference & values
purpose of the interview - ✔✔to collect subjective data
id health issues & strengths
perform physical assessment
teaching opportunity
Health history - ✔✔biographical data
reason for seaking care
current health/ history of current health
past health history
review of system
functional assessment
general survey - ✔✔overall impression
- physical
- body structure
- mobility & motor activity
- behavior
general survey - physical - ✔✔appears the right age
sex, appropriate dev. for age
level of consciousness
skin color
facial expression
, signs of distress
general survey - body structure - ✔✔stature - normal range for genetics
nutrition - normal range of height & built
posture/position
symmetry
general survey - mobility & motor activity - ✔✔gait
range of motion
general survey - behavior - ✔✔facial expression
mood & affect
speech
dress
personal hygiene
measurement - ✔✔BMI (Why?)
height
weight
waist
Why do you need to take height & weight? - ✔✔in case you need to administer any
medications
different sites to take temperature - ✔✔oral (official 6+)
rectal (official infants)