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health assessment exam 1 , week 2
Terms in this set (33)
Provide 9 reasons why we document
1. To form a foundation for that client's care while in healthcare facility
2. Ensures that information about the client and family is easily accessible to members of the health care team
3. Provides a vehicle for communication
4. Prevents fragmentation, repetition, and delays in carrying out the plan of care.
5. Provides a chronologic source of client assessment data and a progressive record of assessment findings that outline the client's course of care.
6. Communication between health care providers
7. Meeting legislative requirements
8. Quality improvement
Describe 5 Reporting Formats
1. Change of Shift Report - end of shift, one RN gives to another RN, transferring responsibility of the client. Now done at the bedside in order to include the patient (patient centered care)
2. Telephone Reports - used when contacting provider or other team member; Have all data collected prior to contacting, be professional, use exact, relevant and accurate information and document the name of the person who made the call and to whom the information was given, time; content of the message and instructions given (ISBAR format)
3. Telephone or verbal prescriptions -Best to AVOID; used during emergencies; have 2nd RN listen, always repeat back and verify (RBAV); questions anything inappropriate; Provider has to sign within 24 hours
4. Transfer (hand-off) reports - These occur when transferring into or out of a health care facility and from one unit to another.
5. Incident reports - reports made b/c of an accident of an unusual event like a medication error, fall, needlestick; Never refer to the incident in a client's medical record and always document facts without judgment or opinion.
Provide 5 guidelines on how to document
1. Keep all information confidential (HIPAA)
2. Document legibly or print neatly in nonerasable ink (Errors in documentation are corrected by drawing a line thru the entry and writing "error" and initialing the entry.
3. Use correct grammar and spelling
4. Use phrases instead of sentences to record data
5. Record the findings, not how they were obtained
6. Write entries objectively without making premature judgements
7. Document clear & concise information
8. Follow hospital policy: frequency of documentation
9. Be objective
10. Document in a timely manner
11. Be clear and concise
12. Always document refusals
13. Manner to identify self
· Melissa Downs, RN, GGC Faculty
· Sally Cabbage Patch, SN, GGC
Provide 5 examples of What to Avoid/DO NOT DO when documenting
1. If an error is made, never obliterate the error with white paint or tape or erase anything (medical record is a legal document)
2. Avoid recording the word "normal" for normal findings.
3. Do not enter a chart of a patient you are not caring for.
4. Never use patient's name when preparing written or oral reports as a student
5. Do not use non-approved abbreviations
6. Do not blame someone in your documentation
7. Avoid subjectivity in your documentation (stick to the facts, do not add opinions)
Describe 5 different documentation formats (include advantages and disadvantages of EHRs
1. Flow Charts: shows trends in Vital signs, BG, pain levels and other frequent assessments.
2. Narrative documentation: records information as a sequence of events in a story-like manner.
3. Charting by exception: uses standardized forms that identify norms and allows selective documentation of deviations from those norms.
4. Problem-oriented medical records: are organized by problem or diagnosis and consists of a database, problem list, care plan and progress notes Examples include SOAP, PIE and DAR.
5. Electronic Health Records (EHR): are used by a variety of health care providers; focuses on total health of the client; designed to reach out beyond the health organization that originally obtains the information.
· Advantages: Provides ease of maintaining ongoing health records and easy access for multiple users, can share data amongst PCP- specialists, health care providers; provides standardization for documentation, improves accuracy of documentation, Elimination of redundant data collection, with computer security in place can help keep documentation confidential.
· Challenges: learning the system, knowing how to correct errors, maintaining security.
Describe the purposes of validating assessment data.
-Validation of the data collected during assessment of the client is the CRUCIAL first step of the nursing process!
-Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate
- Is Data reliable and accurate?
-Deciding whether data requires validation
Does the data require validation?
Determine ways to validate data.
Identify areas in which data is missing.
U wanna analyze the data you want to make sure that data is correct or accurate
- Provide a chronological source of client assessment data and a progressive record of assessment findings that outline the client's course of care.
- Ensure that information about the client and the family is easily accessible to members of the health care team; provides a vehicle of communication, and prevents fragmentation, repetition, and delays in carrying out the plan of care.
- Establishes a basis for screening or validating proposed diagnoses.
-Acts as a source of information to help diagnose new problems.
-Offers a basis for determining educational needs of the client, family and significant others.
-Provides a basis for determining eligibility for care & reimbursement.
-Constitutes a permanent legal record of the care that was given or was not given to the client. Forms a component of client acuity system or client classification system.
-Provides access to significant epidemiologic data.
-Promotes compliance with legal, accreditation, reimbursement and professional standard requirements.
making sure that our data is accurate and reliable.
Describe the general guidelines for documenting data.
- Keep confidential and documented information in the client record. (HIPAA)
- Document legibly or print neatly in nonerasable ink; Errors in documentation are usually corrected by drawing one line through the entry and writing "error" and initialing the entry.
- Use correct grammar and spelling. (Only use abbreviations that are acceptable and approved by the institution.)
- Avoid wordiness that creates redundancy.
- Use phrases instead of sentences to record data.
- Record data findings, not how they were obtained.
- Write entries objectively without making premature judgements or diagnoses.
- Record the client's understanding and perceptions of the problems.
- Avoid using the word "normal" or "good", "fair", "poor"
- Record complete information and details for all client symptoms or experiences.
- Include additional assessment content when applicable.
- Support objective data with specific observations obtained during the physical examination.
Document assessment findings
two key elements need to be included in every documentation: nursing history and physical assessment (Also known as subjective(info gathered in interview) and objective (info gathered during physical assessment. )
only document what the client tells you and what you observed
not what you interpret or infirm from data
use ISBAR method to verbally report client data to another health care provider.
S- Situation (mary lorno, 18 yro, is experiencing a sudden onset of periumbilical pain)
B- Background (describe the events lead up to the current situation)
A- Assessment (state obj n sub. sbj: client rate pain 7-8 on scale to 10, denies headache; obj: client is alert, bp 123/89)
R - recommendation (suggest what you believe needs to be done)
Describe the purpose of the general survey.
The general survey consists of a patient's age, weight, height, build, posture, gait and hygiene
Provides the nurse with a first general impression of the patient
Using keen (acute) observation, the nurse can gather important information about the patient before focusing on the health assessment.
Can help the nurse to better understand the patient and the patient's situation.
Can provide clues about the patient.
Abnormal findings can be indicators of physical or mental health concerns
General survey data collection really starts the minute you set eyes on your patient as the nur
list the elements of a general survey
A general survey is a comprehensive view of the patient.
An observation of physical characteristics and behaviors.
The first look at the patient.
Includes: Physical appearance ,Body structure, Mobility, Behavior, and Vital signs and pulse oximetry
list the elements of a mental status exam
Client's level of consciousness
Behaviors and Affect
- Orientation ,Concentration, Recent and remote memory, Abstract reasoning , Judgment, Visual perception, Constructional ability.
Analyze strategies the nurse should employ to obtain accurate data during the general survey and mental status exam.
-Recheck: Recheckyour own data through a repeat assessment
a client that haven't had a fever of a hundred and four and if it was inconsistent or did not did not drive or correlate with the other findings want to repeat it take the temperature again either use a different thermometer a different method or different area on the body like axillary versus oral
- Clarify: clarify data with the client by asking additional questions
you can verify data with another Healthcare professional ask someone else to come in and see if you're hearing when did you think you were hearing
- Verify: verify data with another health care professional
- Compare: compare your objective findings with your subjective findings to uncover discrepancies
- Want to compare your objective findings with your subjective findings. so if the client states that he never goes on sun but there is tan marks they have obviously sunspots then you wanna validate the data
Assess for the presence of pain as a fifth vital sign using the COLDSPA technique
C= character - "Can you describe your pain? Is it stabbing, deep, dull?"
O = Onset - "When did the pain begin?"
L = Location - "Where is the pain located?"
D = Duration - "How long does it last?"
S = Severity - "How bad is it? On a scale of 0-10; 0 is no pain, and 10 is worst pain ever; can you rate it?" 5 is moderate pain.
P = Pattern - "What makes the pain better? What makes it worse?"
A = Associated factors/How it affects the client - "What other symptoms occur with it? How does it affect you?"
Differentiate between the different types of pain assessment tools.
wihout cognitive impairment
-Visual Analog Scale (VAS)
-Numeric Rating Scale (NRS) /Numeric Pain Intensity Scale (NPI)
-Categorical rating scale using words as - None (0), Mild (1), Moderate (2), Severe (3)
-Faces Pain Scale Revised
physical Report abnormal findings
-Appearing older than stated age: Potential chronic illness or chronic substance overuse
-Facial grimacing: Indicative of pain
-Facial droop: Indicative of possible stroke
-Shortness of breath or increased work of breathing: Indicative of respiratory distress
body structure Report abnormal findings
Excessively over normal weight range: Obesity which can negatively impact health.
Excessively under normal weight range: Cachexia which can indicate physical or mental health concerns.
Slumped posture, deflated appearance: May indicate depression
mobility Report abnormal findings
Limping: May indicate injury
Shuffling gait, dragging leg: May indicate neurologic issue/previous stroke or chronic illness condition. Typical aging sometimes you'll have the older adult who shuffles with their gait because they're afraid of falling
Limited range of motion (ROM): May indicate past injury or potential arthritis
Behavior: Some Abnormal findings
Abnormal facial expressions and/or speech: May reflect physical or mental concerns
Clothing too large or too small: May indicate large change in weight (either loss or gain)
Change in personal hygiene: May indicate mental or physical illness
Reporting abnormal findings
Communicating finding to the med-ical term
change of shift report
transfer handoff report
problem oriented medical record: SOAP, PIE, DAR
SOAP - Subjective, Objective, Assessment, Plan.
- Problem, intervention & evaluation
focus charting - Data - Action - Response
Vital Signs: older adults consideration:
temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F.
the respiratory rate may range from 15 to 22.
Systolic pressure over 140 with diastolic pressure under 90 is called isolated systolic hypertension.
(96.8º to 100.4ºF); with an average
Axilla : usually 0.9ºF lower than oral temperature readings
Rectal: usually 0.9ºF higher than oral temperature readings
Temporal: usually 0.9ºF higher than oral temperature readings
Tympanic: usually 1.4ºF higher than
Pain that arises from damage to or inflammation of tissues
Usually described as throbbing, aching and localized
Types of nociceptive pain include:
Somatic - in bones, joints, muscles, skin or connective tissue
Visceral - in internal organs (like stomach or intestines)- can cause referred pain (if patients had internal organ surgery) (example: abnomal surgeries pain in shoulder)
Cutaneous - in the skin or subcutaneous tissue
Pain that arises from abnormal or damaged pain nerves , nerve inflammation
Usually described as shooting, burning or "pins and needles"
Type of neuropathic pain - Phantom pain (like pain below a level of spinal cord injury and diabetic neuropathy) ( oftentimes patients who have had an amputation will have pain still in that Leg , that has the area where the leg has been amputated )
Physiologic responses to pain
Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide.
Focus on pain, reports of pain, cries and moans, frowns and facial grimaces.
Decrease in cognitive function, mental confusion, altered temperate, high somatization and dilated pupils.
Increased heart rate (Tachycardia), Increased blood pressure (Hypertension).
Increased respiratory rate (Tachypnea)
Muscle spasm, resulting in i
7 Pain Dimensions
Physical Dimension: "What surgeries or medical procedures have you had?"
Sensory Dimension: "Where is the pain?"; "How would you rate the pain on a scale of 0 to 10?"
Behavioral Dimension: "I notice you are holding your side, are you having pain?"
Sociocultural Dimension: "Do you have any special cultural or social practices that may influence you?"
Cognitive Dimension: "What do you think is causing your pain?"
Affective Dimension: "How does the pain affect your daily life and activities, your mood?"
Spiritual Dimension: "What religious or spiritual beliefs may impact your health car decision?" ( we want to make sure that we are paying attention to any type of religious or spiritual beliefs that may impact the client's health )
is a BP that decreases when a client changes position from lying to sitting or standing A drop of 20 mmHg or greater
is the Difference between systolic and diastolic pressure
The Hierarchy of Pain assessment techniques
Self-report (such as cognitively impaired clients Elders with the unconscious clients, clients that are intubated or have a breathing tube in infants or pre-verbal toddlers; these are all examples of clients that are unable to self-report pain)
Search for potential causes of pain
Observe client behaviors
Attempt an analgesic trial
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