module 1: assessing Flashcards
primary source of information
the patient
initial/comprehensive assessment
performed shortly after admittance to health care facility; establishes a complete database for problem identification and care planning; in depth, ask specific and open ended questions
focused assessment
focuses on a specific problem; can be during an initial assessment or on its own as ongoing data collection
quick priority assessment (QPA)
short, focused, prioritized assessments completed to gain the most important information first; look for red flags and identify if pt. needs to be in isolation or on percautions
emergency assessment
performed when a physiologic or psychological crisis presents; identify life threatening problems
time lapsed/ongoing assessment
compare pt. current status to baseline data; rehab pt. to make necessary revisions in care plan; not done in response to a complaint
triage assessment
screening assessment to determine the extent and severity of pt. problems and recommend appropriate follow up; general surveillance questions to determine the pts. next actions; done in person or over the phone
objective data
observable and measurable data; can be verified by another person
subjective data
information perceived only by the affected person; ex. pain, HA, dizziness
nursing history
general information that is used to identify strengths, weaknesses, and potential health risks/problems; includes the patient interview
inspection
observation using senses; begins before even touching patient, ongoing throughout health history and physical exam
cardinal rules of palpation
warm hands, palpate light-deep, rough area that hurts last
light palpation
1 cm (0.5in)
deep palpation
2 cm (1 in)
moderate palpation
1-2 cm (0.5-0.75 in)
diaphragm of stethoscope is best for
high pitched sounds
bell of stethoscope is best for
low pitched sounds (murmurs, bruits)
general survey
provides clues to overall health; first impressions; use observation; includes vitals, height and weight
verbal order policy
can be given in emergency situation; cannot be over the phone; record order in pt. medical record (note it is VO), read order back; after practitioner that gave the order must sign VO within a time frame
SOAP notes
subjective, objective, assessment, plan of action
PIE chart
problem, intervention, evaluation
medicare requirements for home health care
pt. must be homebound and still need skilled nursing care; rehabilitation potential is good, or pt. is dying; pt. status is not stabilized but progress is being made
ISBARR
identify/introduction; situation; background; assessment; recommendation; read back
