fundamentals- chapter 5 Flashcards
who initiates the plan of care?
the RN
- LPNs may collect data to contribute to the assessment
approaches to assessment
- functional health patterns assessment (Mary Gordon)
- focused assessment (focuses on a specific problem)
- basic needs assessment based on Maslow’s hierarchy
Gordon’s 11 health patterns
- health perception - health management pattern
- nutritional-metabolic pattern
- elimination pattern
- activity-exercise pattern
- cognitive-perceptual pattern
- sleep-rest pattern
- self-perception-self-concept pattern
- role-relationship pattern
- sexuality-reproductive pattern
- coping-stress tolerance pattern
- value-belief pattern
for each pattern, the following are assessed:
functional:
- present function
- personal habits
- lifestyle and cultural factors
- age-related factors
dysfunctional:
- history of dysfunction
- diagnostic test abnormalities
- risk factors related to medical treatment plan
the interview
- based on gathering data
- not a social interaction
- find out patient’s major complaints, perform a physical exam, and determine the patient’s overall health
- good communication essential (verbal and nonverbal)
- your posture, facial expressions, attitude, and movement are important
interview stages
- the opening: rapport is established with the patient
- the body: necessary questions are presented
- the closing: information is summarized
medical records (chart) review
should include:
- face sheet and physician’s orders
- nurses notes (at least past 24 hours)
- physician’s progress notes, history, physical exam
- medication administration record
- Surgery operative report and pathology report
- Diagnostic tests
- Nursing admission history and assessment
- Fall risk assessment and skin assessment
- Nursing care plan or problem list
physical assessment
- use techniques of inspection, auscultation, palpation, and percussion
- head-to-toe assessment
- Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem
physical assessment
- use techniques of inspection, auscultation, palpation, and percussion
- head-to-toe assessment
- Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem
head-to-toe assessment
initial observation:
- breathing
- how the patient is feeling
- general appearance
- skin color
- affect (expression)
head-to-toe assessment pt. 2
head:
- level of consciousness (awake, alert, and oriented)
- ability to communicate (language spoken, any communication deficits)
- mentation status (able to comprehend, form thoughts)
- appearance of the eyes (pupil size, light reaction)
obtunded
stuporous
head-to-toe assessment pt. 3
vital signs:
1. temperature
2. pulse rate (rhythm, strength, apical, radial)
3. respirations (rate, pattern, depth; oxygen saturation)
Blood pressure
• Within normal limits
• Compare with
previous readings
5. pain
head-to-toe pt. 4
adventitious
head-to-toe pt. 5
head-to-toe pt. 6
assessment in long-term care
- Extensive initial assessment performed when patient enters long-term care facility
- Reassessment at fixed intervals and as the patient’s condition changes
- Physical assessment, health history, medication history, and a functional assessment performed
- skilled facilities may require different charting
- “medicare charting”
assessment in home health care
- initial patient assessment in the home is usually performed by the RN
- the LPN/LVN will need to perform daily assessments and maintain necessary documentation
- changes found on assessment should be reported to the RN supervisor or physician
analysis
nursing diagnosis/ problem identification
indicates the patient’s actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms)
etiologic factors
- causes of the problem
- signs are abnormalities that can be verified by repeat examination (objective data)
- symptoms are data the patient has said are occurring that cannot be verified by examination (subjective data)
defining characteristics
- characteristics (signs and symptoms) that must be present for a particular problem statement to be appropriate for that patient
- supply the evidence that the problem statement is valid
prioritization of problems
- problems ranked according to their importance
- physiological needs for basic survival take precedence (airway, circulation, etc)
- after physiological needs are met, safety problems take priority
- every nurse must look at the patient holistically, keeping psychosocial needs in mind
problem statements in long-term and home health care
planning: expected outcomes
interventions (nursing orders)
documentation
