WIT COMPLETE SOLUTIONS VERIFIED
What is the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
Nursing assessment: collection of data includes
compiling information about the patient
Nursing assessment: validate data by
confirming the accuracy of assessment data collected
Nursing assessment: organize data using
a framework to establish an organization scheme of collected assessment data
what does a Health assessment encompass?
physical, psychological, social, and spiritual dimensions
why do we use the Admission assessment ?
to determine reference baseline
why do we use the Focus assessment?
to determine the status of a specific problem
What is a time-lapsed assessment?
determining the change from previous findings (usually several months)
what is an Emergency assessment?
Determining presence of life-threatening conditions
Subjective findings includes...
,what the patient is feeling (symptoms)
Objective findings includes....
observing signs
interviewing a patient includes
using subjective date for the nursing history, effective communication, broad opening
statements, open ended questions
Physical exam is used for?
observation and measurements, objective
what/who are primary information?
patients themselves
What/who are secondary information?
family members, medical records
what are the Eight Critical Characteristics?
• Location
• Associated Factors
• Character
• Patient's Perception
• Quantity or severity
• Timing
• Setting
• Aggravating or Relieving Factors
what are the 3 types of pain assessment rating scale?
, -numeric
-wong baker
-descriptor
Past Health History includes
1. Medical history (disease processes/conditions, treatment, compliance)
2. Surgical history (any procedures and try to get the year; complications)
3. Meds - prescribed and OTC
4. Any communicable diseases or in the past
5. Allergies (food, drug, environmental, seasonal, etc.)
6. Disabilities/handicaps - diagnosed and temporary
7. Injuries or accidents
8. Hx of blood transfusions and reactions
9. Hx of childhood illness (example: chicken pox)
10. Immunizations (up to date or need any; see CDC)
Family Health History includes
a record of any illnesses or medical conditions that have afflicted members of a person's
family
review of symptoms are described as a ?
description of individual body systems in order to discover any symptoms not directly
related to the main problem
obtaining objective data: what are physical exam techniques ?
-inspection
-palpation