Assessment of the Whole Person Flashcards
Order of operation for nursing decision making
airway, breathing, circulation
What are the 5 parts of the nursing process
assessment, diagnosing, planning, implementation, evaluation
Nonmaleficence
do no harm
beneficence
do good
autonomy
respecting a patient and families decision making
justice
fair treatment
confidentiality
respecting patient rights and privacy (HIPAA)
HIPAA
Health insurance portability and accountability act of 1996
CIWA
Clinical institute withdrawal assessment scale
subjective data
patients discretion
ex: pain level
Objective info
fact
ex: pregnant or not
Open ended question
tell me about yourself, or how is it going today
closed (direct question)
where are we? do you smoke?
Sign
objective abnormality assessed on physical exam or via diagnostic testing or in lab reports
symptom
subjective report of sensation by a patient
Pain PQRSTU
p: provocative/palliative - what brings about your pain?
Q: quality/quantity - how intense if your pain?
R: region/radiation - where is it located? does it spread anywhere? localized?
S: severity - how bad is the pain?
T: timing - onset, duration, frequency
U: understand patients perception - what do you think your pain indicates?
Purpose of ROS health history
evaluate past and current health of each body system, verify all data captured and no omissions, and evaluate health promotion activities of the patient
Mini mental state exam (MMSE)
concentrates only on cognitive functioning
11 questions 5-10 mins to complete
Montreal cognitive assessment MoCA
examines more cognitive domains, more sensitive to mild cognitive impairment
10 mins to complete
