Wk 3 - Assessment/Documentation Flashcards
Nursing Process
A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
A in ADPIE
Assessment
Assessment involves
discovery, decision making, critical thinking skills, and data collection
- supplement, confirm, or refute data obtained from history
- confirm or identify nursing diagnosis
- make judgments about health status and management
- evaluate outcomes
Assessment involves C__________
communication
- look at pt.s history and determine if things make sense through assessment
- is our pt. doing ok?
First step of Assessment
Preparation
How do we prepare?
- Point of care risk assessment?
- Looking at Kardex
- Looking at their charts
– Meditech
– Loot at other nurse’s explanations w/in charts - Conversations w/ pt.s/residents
- Nursing documentation (24hr sheet)
What to look for when Gathering Data?
Who is the client?
- Hx.
- family hx.
- living situation (effects on their health)
– are they living alone or w/ friends/fam
– how is mental health going home?
– will they be able to go back to the same lifestyle they had before they received care?
- family friend supports
- ADLs
- Cultural & Context
– values/beliefs, cultural aspects that effect their care
– learning to care w/in their values/beliefs
During Assessment, what is main concern?
Why is Pt. here?
Are they in care for one or multiple reasons?
When does it matter to know about health hist.?
- When accessing concerns
- Previous concerns
- Something related to comorbidity or not?
- Is a problem a concern for something else or comorbidity?
- Past injuries can be irrelevant if it hasn’t affected mobility or anything else.
- Addiction/substance abuse may be important whether or not it is relevant to the context
– Will this cause stressors that may lead them back to their addiction?
– Maybe narcotics was what lead them into addiction and now here we are giving them narcotics back - to determine which sys. it may impact
Indep Vs. Dep
- Can they be left unsupervised
- Patient positioning
- Will I need to adjust my assessment
You walk in on a pt. who is on the floor in the bathroom. What type of assessment should be completed?
Parts of Point of Care Risk Assessment
- no need to go back to look at chars when pt. is already on floor
ABCDEs
Primary Assessment
Documentation
Types of Assessment
- Interview
- Emergency/Primary Assess.
- Focused Assess.
- Head-to-Toe Assess.
Interview Assessment
- Health hist.
- assessment to see what supports pt. needs
Emergency/Primary Assessment
- pt. falls on floor
- emergency situations
Focused Assessment
- lvl of injury
- could be part of primary
- what is main concern for pt.
– if trouble breathing, focus on resp. sys.
Head to Toe Assessment
assess all symtems by moving through a set guideline of questions and pieces to note
Pt. found on the floor in the bathroom: Relevant Focused Assessment (what to note)
Muscle/Skeletal Injuries
- MSKL
- Did individual break hip?
Neuro Problems
- head injury w/ fall or caused fall
Causes
- were meds the problem
Cardiovasc. changes
- fainting
Witness vs unwitnessed fall
- did she hit her head or not
Subjective Vs. Objecting
Feelings, Perceptions, Self-Report
OR
Observations, Measurements, Verifiable Facts
Which is priority? Subjective or Objective
Objective
Data Sources
Primary
- client
Secondary
- family
- physician
- allied health (PT/OT)
- chart
Tertiary
- nurse experience
- literature
Primary Data Source(s)
Client
Secondary Data Source(s)
- family
- physician
- allied health (PT/OT)
- chart
Tertiary Data Source(s)
- nurse experience
- literature
