Critical Elements/Ouch!
Three things to verify on client wristband.
What are the client's name, date of birth, and MRN?
Four examples of objective data.
What are vital signs, laboratory data, diagnostic tests, signs, etc.
The categories of the mental status assessment represented by A-B-C-T.
What are appearance, behavior, cognition, and thought processes?
The differences between acute and chronic pain.
What is acute pain resolves when the injury heals, usually less than 3 months? What is chronic pain lasts longer than the healing period, usually over 6 months?
Qualifiers related to client allergies.
What are allergies to food, medicine, and/or the environment?
Things to look for in the external auditory canal.
What are inflammation, cerumen, discharge, foreign bodies, or hearing devices?
Five parts of the health history.
•Date, Time, Source
•Biographic data
•Reason for seeking care (Chief Complaint)
•History of present illness (HPI)
What are past medical history, medication reconciliation, family history, review of system, and functional assessment (includes ADLs), etc.
Quesions about level of consciousness or orientation
What are person, place, time, and event?
What are using a sign language interpreter, written guidelines, face the patient when talking (do not exaggerate lip movements), and use good lighting to assist communication.
Questions assessing the client's level of consciousness (A&O x 4).
What are oriented to person, place, time, and situation?
What is pulling the pinna up and back for adults and down for children under 3 yo?
How empathy differs from sympathy.
What is acceptance of the other person's feelings without criticism, or the ability to step into someone else's shoes?
Considerations for interviewing an aging adult.
Isolation, depression, no decline in intelligence, slower response time, long-term recall easier, age related perception changes
Things to consider when interviewing clients under the influence.
The things you are looking for in the client's chart before entering the room.
What are the provider orders, as well as any lab/diagnostic results, vital signs, MAR, and nurses' notes?
Pupil assessment represented by the acronym PERRLA.
What is the Pupils are Equal, Round, Reactive to Light, and Accommodation? Also assess size of pupil.
External factors (physical setting) that should be considered when interviewing a client.
What are privacy, interruptions, lighting, temperature, distracting objects, etc?
What are eye opening, verbal response, and motor response?
The difference between signs and symptoms.
What are subjective (symptoms) and objective (signs) data?
Represented by the acronym SOCRATES.
In relation to pain, what are site, onset, character, radiation, associated symptoms, time/duration, exacerbates/ameliorates (makes worse or better), and severity (0-10)?
The seven lymph nodes that you will assess.
What are the preauricular, posterior auricular, occipital, posterior cervical, submental, submandibular, and supraclavicular lymph nodes?
What is, "Tell me how I can help you?", "What brings you to the hospital?", or "Tell me more about..."?
The order of physical assessment techniques, and when does it change?
What are inspection, palpation, percussion, and auscultation, and it changes with abdominal assessment (inspection, auscultation, palpation, and percussion)?
Medication reconciliation and how often should it be done?
What is a comparison of a list of current medications to a previous list, and it should be done every hospitalization and every clinic visit?