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Questions and Answers
What is the proper order of assessment for a patient?
What is the proper order of assessment for a patient?
While taking a patient's vital signs, you notice their heart rate is significantly elevated. What should you do first?
While taking a patient's vital signs, you notice their heart rate is significantly elevated. What should you do first?
Which of these factors could potentially influence a patient's subjective pain report?
Which of these factors could potentially influence a patient's subjective pain report?
Which of these is an example of objective data?
Which of these is an example of objective data?
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What are the four phases of a patient interview?
What are the four phases of a patient interview?
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What is a key component of assessing suicidal ideation in a patient?
What is a key component of assessing suicidal ideation in a patient?
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When preparing to conduct a physical assessment, which of these steps should be taken first?
When preparing to conduct a physical assessment, which of these steps should be taken first?
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What is the primary goal of health promotion?
What is the primary goal of health promotion?
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A patient reports experiencing a sharp pain in their right knee. What should the nurse do first?
A patient reports experiencing a sharp pain in their right knee. What should the nurse do first?
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Which of the following is an example of an open-ended question used to assess a patient's pain?
Which of the following is an example of an open-ended question used to assess a patient's pain?
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Which of the following is the most important step to ensure a patient understands their discharge instructions?
Which of the following is the most important step to ensure a patient understands their discharge instructions?
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Which of the following resources can help a nurse understand the difference between objective and subjective data?
Which of the following resources can help a nurse understand the difference between objective and subjective data?
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Which of the following resources can be used to learn about the different parts of a stethoscope and their proper use?
Which of the following resources can be used to learn about the different parts of a stethoscope and their proper use?
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Which of the following topics is NOT covered in the provided video resources?
Which of the following topics is NOT covered in the provided video resources?
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Which of the following YouTube videos provides information about practical strategies for managing suicidal ideation?
Which of the following YouTube videos provides information about practical strategies for managing suicidal ideation?
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Which of the following resources provides information about the Health Promotion Model?
Which of the following resources provides information about the Health Promotion Model?
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Flashcards
PQRSTU method
PQRSTU method
A method for assessing pain characteristics including Provocation, Quality, Region, Severity, Timing, and Understanding.
Open-ended question
Open-ended question
A question that allows for a detailed, narrative response rather than a simple yes or no.
Teach-back method
Teach-back method
A communication technique to confirm patient understanding by asking them to repeat instructions in their own words.
Subjective data
Subjective data
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Objective data
Objective data
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Stethoscope parts
Stethoscope parts
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Health Promotion Model
Health Promotion Model
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Elder abuse
Elder abuse
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Stethoscope Uses
Stethoscope Uses
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First-Level Priority Patients
First-Level Priority Patients
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Vital Signs Abnormalities
Vital Signs Abnormalities
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Pain Assessment
Pain Assessment
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Skin Cancer Identification
Skin Cancer Identification
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Study Notes
Objective vs. Subjective Data
- Subjective data is what the patient describes or feels.
- Objective data is what the healthcare professional observes and measures.
- Examples of subjective data include pain level, symptoms, and past medical history.
- Examples of objective data include vital signs, physical exam findings, and lab results.
Stethoscope: Uses and Parts
- A stethoscope is used for auscultation, which is listening to sounds produced by the body.
- It has two main parts:
- Diaphragm: best for high-pitched sounds like normal heart sounds, breath and bowel sounds. Apply firmly to the skin.
- Bell: best for low-pitched sounds like extra heart sounds or murmurs. Apply lightly to the skin to create a seal.
- Stethoscopes should be cleaned using alcohol wipes before and after each patient to prevent infection.
Cultural and Religious Assessments
- Cultural assessments are vital for a complete patient profile.
- Key domains include heritage, health practices, communication patterns, family roles, nutrition, pregnancy/child-rearing, spirituality/religion, death, and health providers.
- Do not assume anything about a patient’s culture; ask directly about their beliefs.
- The FICA tool is a helpful resource for assessing a patient's religious or spiritual beliefs:
- F - "Do you consider yourself spiritual or religious?"
- I - "What importance does your faith or belief have in your life?"
- C - "Are you part of a spiritual or religious community?"
- A - "How should I address these issues in your healthcare?"
- Be mindful of how cultural beliefs can impact healthcare decisions and may influence use of traditional or alternative therapies.
First-Level Priority Patients
- First-level priority concerns are emergent, life-threatening, and immediate needs, such as airway, breathing, and circulation.
- These conditions require immediate action to prevent further deterioration.
Proper Order of Assessment
- The typical assessment order involves:
- Inspection: Detailed visual assessment of the patient's overall and body system.
- Palpation: Using touch for assessing factors like texture, temperature, moisture, and organ location (swelling).
- Percussion: Tapping the skin to feel underlying structures.
- Auscultation: Using a stethoscope to listen to body sounds.
Suicidal Ideation
- Mental health assessment for suicidal ideation is essential for all patients.
- The HEEADSSS method can be used for adolescents to identify risk factors.
At-Risk Patients: Drugs and Alcohol
- When assessing persons under the influence of alcohol or other substances, use simple, direct questions to assess for safety.
- Identify the time of last use, amounts consumed, and types of substances used.
Elder Abuse and Elder Neglect
- Explicit information regarding elder abuse or neglect isn't provided in the given context.
Intimate Partner Violence
- No details of intimate partner violence are specifically provided in the text.
- However, the assessment should address this issue during the functional assessment, given other details in the document.
Phases and Portions of the Patient Interview
- The patient interview process involves collecting data.
- It should include:
- Introduction – explain purpose of interview.
- Working phase – employ open-ended questions and note verbal responses.
- Closing – summarize key findings and thank the patient.
- Key components: Biographical data Reason for visit Present health/history of present illness (h/o p.i.) Past medical history Family history Medication reconciliation Review of systems Functional assessment
Vital Signs: Abnormalities and Causes
- Vital signs include temperature, pulse, respiratory rate, and blood pressure.
- Older adults may have reduced vital capacity and decreased responsiveness.
- Temperature - take into account variations in taking temp depending on site (oral, rectal, tympanic, temporal)
- Pulse – normal range but can be irregular in older adults.
- Respiration – may be shallower in older adults.
- Blood pressure – systolic pressure tends to increase with age, causing widened pulse pressure. Consider orthostatic hypotension when positioning changes.
Pain Assessment
- Subjective pain reports are the gold standard in pain assessment.
- Tools like numerical scales, verbal descriptor scales and visual analog scales can quantify pain during the assessment.
- The PQRSTU mnemonic (Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing, Understanding) can help clinicians to assess pain.
Skin Cancers, Decubitus Ulcers (Pressure Injuries), and Lesions
- Skin cancers have distinguishable patterns described by a simple ABCDE rule for screening:
- Asymmetry (not symmetrical shape)
- Border (irregular borders or margins)
- Color (varied colors)
- Diameter (larger than 6mm)
- Evolving changes.
- Decubitus ulcers/pressure injuries from impaired circulation. Risk factors include immobility, thin skin, decreased sensation, altered consciousness, moisture, shearing injury, poor nutrition, and infection.
- Lesions are assessed for shape, size, location, and surrounding skin characteristics.
Medication Reconciliation
- Medication reconciliation involves comparing current and previous medication lists to reduce errors.
- This is important for patient safety and to help reduce medical errors.
SBAR Communication Tool
- SBAR is a communication tool used for clear and accurate information exchange between healthcare professionals.
- It supports providing information accurately and reducing ambiguity.
- Each letter of SBAR represents an element of the tool (Situation, Background, Assessment, Recommendation)
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Description
Test your knowledge on the key components of patient assessment, including vital signs, pain evaluation, and conducting effective interviews. This quiz covers essential nursing practices that ensure a thorough understanding of patient needs and health promotion. Perfect for nursing students and professionals alike!
