NURS 3134 In-Class Foundation of Nursing Health Assessment PDF

QUIZ time!  Please download and install the Slido app on all computers you use What are you most nervous about? ⓘ Start presenting to display the poll results on this slide. Foundation of Nursing Health Assessment...

QUIZ time!  Please download and install the Slido app on all computers you use What are you most nervous about? ⓘ Start presenting to display the poll results on this slide. Foundation of Nursing Health Assessment Shaylene Chatham, MSN, RN NURS 3134 Health Assessment and Promotion How to use your resources in 3134 Textbook- READ paying close attention to Safety Alerts Clinical Significance boxes, Tables, and Clinical Judgment sections. Make quizzes or flashcards Use your Subjective cues (RATIONALE) and Objective cues (ABNORMAL FINDINGS) sections in your text for Lab Watch your Lecturio videos! COME TO CLASS AND LAB Do your vSim each week and read the feedback! Colman, H. (2022 Jan 7). Learning Retention: How to Make Information Stick. ELearning Blog. https://www.ispringsolutions.com/blog/lea rning-retention Colman, H. (2022 Jan 7). Learning Retention: How to Make Information Stick. ELearning Blog. https://www.ispringsolutions.com/blog/learni ng-retention Colman, H. (2022 Jan 7). Learning Retention: How to Make Information Stick. ELearning Blog. https://www.ispringsolutions.com/blog/le arning-retention How to “Make it Stick” Effortful retrieval makes for stronger learning and retention Repeated retrieval produces knowledge that can be retrieved faster, in varied settings, and applied to a wider variety of problems Quizzes and tests are a type of retrieval practice, and gains increase as the frequency of classroom testing increases (same applies to lab and clinical). Students who take practice tests have a better grasp of their progress and can spot gaps in learning Brown, P.C., Roediger III, H.L., McDaniel, M.A. (2014). Make it Stick: The Science of Successful Learning. Belknap Press: An Imprint of Harvard University Press.  Roles of the Professional Nurse  To promote health  To prevent illness  To treat human responses to health or illness  To advocate for individuals, families, communities, and populations Why do we start with assessment? GATHER DATA- Subjective and Objective ANALYZE and SYNTHESIZE the data Assessment: A health history (subjective) and a NOT ALL DATA IS THE SAME! physical Nurses make judgments about assessment the nursing interventions based on the findings (objective) EVALUATE patient care outcomes based on interventions chosen!  Clinical Judgment Model Types of nursing assessments  EMERGENCY ASSESSMENT  ABCDE  You preform assessments and critical interventions simultaneously  COMPREHENSIVE ASSESSMENT  A complete health history and physical assessment. All body systems in a head-to- toe format  FOCUSED ASSESSMENT  Occurs in all settings; Involves one or two body systems and is smaller in scope than the comprehensive assessment but is more in depth on the specific issue(s)  SUBJECTIVE CUES-CLIENT EXPERIENCES AND PERCEPTIONS  The primary source for subjective data collection Gathering Data- is the patient Assessment  Client describes feelings, sensations, and expectations; "put in quotes"  Health history and interview process OBJECTIVE CUES- THE PHYSICAL ASSESSMENT  Observations and measurable data  Include the most important screening assessments for each system  Observe and documents client's general appearance, vital signs, auscultation of heart, lungs, and abdomen, assess peripheral circulation and skin. Priority Setting Systemic before local Acute before chronic Actual before potential problems Medication timing Unexpected vs expected  Please download and install the Slido app on all computers you use Why did you choose RSU? ⓘ Start presenting to display the poll results on this slide.  Priority Setting Frameworks Maslow's hierarchy of needs Urgent and Acute vs Chronic ABCDE Safety/Risk reduction Nursing process- ASSESS Survival potential (disaster triage) Least restrictive interventions when client is stable  Please download and install the Slido app on all computers you use What do you think will be your biggest challenge in nursing school? ⓘ Start presenting to display the poll results on this slide.  The Communication Process 1)Write 2 yes/no questions and 2 open-ended questions 2)Be ready to share Therapeutic communication  Focuses on the patient and their concerns  Caring  Empathy  Nonverbal/verbal communication skills  Avoid nontherapeutic responses Culturally competent communication  Patients with limited English skills  Working with an interpreter  Gender bias Providing false Giving assurance Using unwanted or authority advice reassuran ce Using Engaging Using avoidance in profession Ten Traps of language distancing al jargon Interviewing *Discuss specific situations or Using circumstances where it would be easy to fall into leading or Talking Interrupti interviewing traps. biased too much ng *Be ready to share. questions Using Don't “why” ASSUME questions Copyright © 2020 by Elsevier Inc. All rights reserved.   Subjective Data Demographic Data Reason for seeking care HPI Past health history Components Medications/Allergies of the Family history Health Functional health History assessment/Growth and development Review of systems  Objective Data Physical Assessment  Psychosocial and Lifestyle factors  Cultural considerations (Chapter 10)  Mental health assessment (Chapter 9)  Abuse and violence (Chapter 9)  Sexual history (Chapter 23, 24)  Lifespan considerations (pediatrics and med/surg courses) Question #2: Higher-level thinking question A nurse is caring for a client who has been diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take to adhere to contact precautions?  When should hand hygiene be implemented for maximum effectiveness? When should gloves be used? Give When should gloves be changed? Examples Where should we discard PPE? Inspection, Palpation, Percussion, Auscultation  Inspection  The FIRST technique used  Gain an overall impression  Observe for cues  Expose body parts  Adequate lighting  Remove devices or clothing  Label and document findings  Do your findings match subjective report  Palpation  Use of touch to assess:  Texture  Temperature  Moisture Ask for permission first  Size  Shape  Location  Position  Vibration  Crepitus  Pain  Edema Light Palpation- 1 cm Deep Palpation- 2 cm  Percussion  Produce sound or elicit tenderness  Dense tissue- flat or quiet tones  Air- louder tones (tympany)  Direct percussion- directly on skin  Indirect percussion- use your hand as a barrier  Usually, an advanced practice but is being phased out due to imaging  Auscultation  Listen with a stethoscope to transport normally unheard sounds  Diaphragm- larger side used for most sounds  Bell- smaller side used for murmurs, small clients  Use proper technique  Purpose of a medical record LEGAL COMMUNICATION QUALITY FINANCIAL EDUCATION DOCUMENT AND CARE ASSURANCE REIMBURSEMENT PLANNING RESEARCH Principles governing documentation  Confidentiality  Accuracy and completeness  Organization  Timeliness  Conciseness  Compare documentation formats Narrative SOAP(IE) PIE Charting DAR by exception Communicating with other health care professionals