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NURS 341 - Assessment study guide Holy Family University NURSING Medical-Surgical Nursing I (NURS 341)
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NURS 341 – In the beginning How does a Nurse Help P – pain, physical (plan of care) PSY – psychological S – social, safety, sex SP – speech and swallowing EN – engaged H – health of patient, coworkers, or yourself R - reposition Nursing Process A - Assessment D - Diagnosis P – Planning I – Implementation E - Evaluation Nursing Priority Problems vs. Medical Diagnosis
SBAR – in test S - Situation B - Background A - Assessment R – Recommendation Delegation – in test (5 rights) UAP…Unlicensed Assistant Personnel (CNA. Med Tech) Licensed Practical Nurse (LPN) Only RN Electronic Health Record (EHR)…Where does the information go? EHR – EMR – Downtime – shut down all the systems to reboot and must do manual charting.
Culturally Competent Care Cultural Competence …yes Assessment
- Know cultural norms - Ask about cultural values - Same gender preference No… - Stereotyping -overgeneralized view - Ethnocentrism -one culture is superior - Cultural imposition -impose own culture on others Patient is not English-speaking What does a nurse do? - National Patient Safety Goals Joint Commission – an organization of volunteers that looks at the plan of care looking for harmful events. Identify patients correctly – pictures, and other identifiers in chart. Get important test results to the right staff person on time Use medicines safely Prevent infection with hand washing Prevent mistakes in surgery QSEN – makes the NCLEX, gives ANA -
Assessment Patient’s health history - Physical examination - Identify the patient’s current and past health status Provide a baseline for further evaluation Formulate nursing priority problem Data Collection Nursing focus…support priority problems Types of data
- Ingestion, digestion, absorption, and metabolism are assessed from a 24-hour diet recall to evaluate the quantity and quality of foods and fluids consumed. Assess the impact of psychologic factors and socioeconomic and cultural factors, the patient’s present condition, food allergies, and food intolerances on diet and nutrition Elimination pattern - Bowel, bladder, and skin function Activity–exercise pattern - Pattern of exercise, work activity, leisure, and recreation. Ability to perform activities of daily living Subjective Data…Functional Health Patterns 2 Sleep–rest pattern - Pattern of sleep, rest, and relaxation in a 24-hour period. Cognitive–perceptual pattern - Description of all of the senses and cognitive functions. In addition, pain is assessed as a sensory perception Self-perception–self-concept pattern - Patient’s self-concept, including attitudes about self, perception of personal abilities, body image, and general sense of worth Role–relationship pattern - Roles and relationships of the patient, including major responsibilities Subjective Data…Functional Health Patterns 3 Sexuality–reproductive pattern - Satisfaction or dissatisfaction with personal sexuality and describes reproductive issues Coping–stress tolerance pattern - Specific stressors or problems that confront the patient, the patient’s perception of the stressor, and the patient’s response to the stressor Value–belief pattern - Values, goals, and beliefs (including spiritual) that guide health-related choices Subjective Data… Investigation of Patient Reported Symptoms P – Provoke Q - Quality R – Region/Radiation
S - Severity T - Timely U - Understanding Pain Scales Physical Examination: Objective Data General survey Physical examination
- Techniques (in this order) 1. Inspection 2. Palpation 3. Percussion 4. Auscultation - Abdomen (exception) 1. Inspection 2. Auscultation 3. Percussion 4. Palpation Physical Examination: Objective Data Palpation - Light, Deep - What is this used for? Percussion - Tapping on a finger
c. determine the extent of the patient’s identification with a cultural group. d. engage the patient in general, nonthreatening conversation when performing auscultation. Question The nurse takes a health history and performs a physical examination on a patient admitted to the hospital. The nurse would be most concerned if what occurs? a. The patient reports intermittent abdominal pain. b. The patient requests the presence of a family member. c. The patient suddenly develops severe shortness of breath. d. The patient is unable to provide a list of current medications. Question Which of the following are subjective data that the nurse collects in the course of an assessment? Select all that apply a. Nausea b. Shortness of breath c. Malaise d. Abdominal pain Question Which of the following requires the nurse to perform an emergency assessment? a. The patient with a respiratory rate of 60, nasal flaring, and supraclavicular retractions. b. The patient's family reports that the patient has not had a bowel movement in 4 days c. The patient with new onset of abdominal pain, rated 5 on 0-10 pain scale. d. The patient with a blood pressure 156/ Question During the course of a comprehensive assessment completed by the nurse, the patient complains of abdominal pain. What is the nurse's next step? a. Document the findings
b. Continue with the next system to be assessed c. Stop the assessment d. Investigate the symptom using PQRST Short term goal – within an hour Long term goal – by the end of shift, write as evidenced by SMART goal for both S – specific M – Measurable A – Achievable R – Realistic T – Timely Administer prophylactic 30 minutes before incision for preoperative checklist If the patient refuses, nurse must inform or educate about the benefits of surgery.
