Summary NR+302+Exam+1+-+CAS+SESSION+with+Diane+9.6.

NR+302+Exam+1+-+CAS+SESSION+with+Diane+9.6.HIPAA: When could the information about the patient be given out?  Patient consent  Health care proxy – if it is documented If a patient says they want to kill another patient or you or “I want to kill nurse Devin”  Can you relay that information? YES YOU DO! SUBJECTIVE DATA– what the patient tells you OBJECTIVE DATA – what you observe or lab results NURSING PROCESS: ASSESSMENT   Collect data  General assessment/exam  Physical exam  Neurological Exam  Musculoskeletal Exam  Very important to document what on this FIRST ASSESSMENT? 1. Allergies  Most important; can be life or death 2. Medications 3. History of diseases ** REMEMBER  You’re doing the nursing care plan on what they are admitted for – not what they had in the past unless it correlates Patient comes in and you’re doing an assessment patient says to you:  Patient: “I can’t remember at times where I put my keys, wallet, or can’t remember how to get home sometimes”  Nurse: “Did you have any recent injuries? Did you fall or hit your head?”  Patient: “No it just came on. It’s gradually getting worse”  WHAT KIND OF ASSESSMENT WOULD YOU DO OR TESTING? o MENTAL STATUS EXAM BECAUSE HIS FORGETFULLNESS AND MEMORY IS NOT DUE TO AN INJURY – ITS DUE TO A GRADUAL DETERORIATION o This focuses on cognitive disorders Patient States “Oh you know what, 2 days ago I fell off a ladder and got a headache, now I can’t remember where I put my things”  WHAT KIND OF ASSESSMENT WOULD YOU DO?