History
The founder of Modern Nursing.
What is Florence Nightingale?
Obtaining uninterpreted material, facts, or clinical info about a patient. (Ex: Vital Signs, personal habits, medications used, heart and lung sounds.)
What is Data Collection?
Interview, physical examination, and review of records.
What is Data Collection Methods?
The FIRST and FOUNDATIONAL step of the nursing process.
What is assessment?
Data that the patient or SO tell the examiner. Subjective information. Ex: Itching, abdominal pain, 9 on scale of 1-10.
What is Symptoms?
Modern Nursing stresses the importance of
What is Nursing observation and reporting?
What is Emergency Assessment?
Data told TO the nurse by the patient and others. Referred to as the Health history (Hx): Chief Complaint (CC) and Review of Symptoms. This is the patient's description of symptoms, personal opinions, values, or social relationships.
What is Subjective Data?
This is a step in the assessment process that provides an opportunity to establish a positive, therapeutic relationship (Rapport, trust) between the nurse and the patient.
What is The health assessment interview?
Data that are observed, felt, heard, or measured. This includes objective information or findings collected by the examiner. Examples: Fever, rash, enlarged lymph nodes, BP 198/100, urine output 250ml over last 24 hours.
What is Signs?
Relies on the ability of the nurse to measure, record, and interpret data (aka data collection skills), Interview the patient to obtain pertinent information and assesses the environment and living conditions of the patients.
What is Modern Nursing?
A written display of findings/observations used as the basis for clinical judgments and diagnosis. A Method to make data accessible to other providers via the medical record contributing to continuity of care. A legal record of events and findings, may be used to justify the provision of services.
What is Documentation?
What is Objective data?
A detailed chronologic description of the presenting illness (CC)
What is History of Present Illness (HPI)?
Techniques of Physical Examination
What is Inspection, Palpation, Percussion, Auscultation?
Physicians use the medical model for their assessment framework with the goal of collecting data r/t symptoms, body systems findings, medical hx, Family history to intervene with medial treatment whereas nurses also collect info but in addition they must collect information for holistic aspects of care such as developmental, psychosocial, spiritual, etc.) to determine is nursing can intervene with independent nursing interventions.
What is Nursing vs Medical Assessment?
What is Focused/Problem-Oriented assessment?
Challenges that include language barriers, health beliefs, health practices, religious influences, role of individual in the family, folk remedies etc.
What are Ethnic and Cultural Challenges.
The variables of the HPI that make up the acronym "OLD CARTS".
Onset, Location, Duration, Character, Aggravating factors, Relieving Factors, Temporal factors, Severity
What is Percussion?
Are we going to pass this exam?
What is YES?
The ability to think critically about the assessment process/findings and to make appropriate clinical judgments.
What is Diagnostic Reasoning?
Variations of interview technique that depend on the type of patient you are interviewing. Ex: Children, adolescents, adult, elderly or the condition of the patient (Ex: pregnancy).
What is age and condition related variations?
The goal of this is to gather subjective data from the patient on each of the major body systems.
What is Review of Systems (ROS)?
technique that involves listening to sounds produced within the body using a stethoscope.
What is Auscultation?