General Survey
The goal of general survey
What is Overall impression
This is comprised of Data gathering through observation, interviews, and physical assessment.
What is Assessment
A visual examination of body, including movements and posture.
What is inspection?
A standard way to report/communicate medical info to improve accuracy and cuts down on errors.
What is SBAR?
Non-specific or more vague/overarching characteristic.
Age, race, gender, ethnicity
What is physical appearance?
Uses Analyzing, validating, and clustering related symptoms
What is diagnosis?
Use of hands to feel texture, size shape, consistency, location of painful or tender areas.
What is palpation?
When you introduce the patient, name, room, age and report the problem or reason for call
What is situation?
The association that adopted the broad variety of nursing diagnoses.
What is NANDA?
Height, weight, nutritional status
What is body structure?
Prioritizing the nursing diagnoses and identifying short and long-term goals that are realistic, measurable, and patient focused.
What is planning?
The technique used to evaluate size, borders, and consistency of internal organs, detect tenderness, and determine the extent of fluid in a body cavity.
What is percussion?
Contains admission diagnosis with date, pertinent medical history, and a brief synopsis of current hospitalization.
What is background?
identification of existing problems or concerns of a patient.
What is Actual nursing diagnosis?
Gait, Range of Motion, Assistive device
What is assessment of mobility?
When the nurse initiates specific nursing interventions and treatments to help achieve established goals or outcomes.
What is implementation?
Listening to sounds within the body; using stethoscope
What is auscultation?
Most recent vitals, mental status, pain, neuro changes, skin color, and rhythm changes.
What is Assessment?
Applies when there is an increased potential or vulnerability for a patient to develop a problem or complication.
What is a Risk diagnosis?
Facial expression, eye contact, mood, speech, dress, hygiene
What is behavioral assessment?
When the nurse determines whether the goals are met.
What is evaluation?
Looking at all aspects of the patient from the start of time you see the patient.
What is general survey?
Examples : Suggesting transfer, change in treatment, request at bedside, talk to family and patient, ask for consult, suggest labs, x-ray, EKG, timeline for certain treatment.
What is Recommendation?
Used in situations which patients express interest in improving their health status through a positive change in behavior.
What is health promotion nursing diagnosis?