NR 302: Health Assessment Exam 1 CAS SESSION

NR 302: Health Assessment Exam 1 CAS SESSION HIPAA: When could the information about the patient be given out? • Patient consent • Health care proxy – if it is documented If a patient says they want to kill another patient or you or “I want to kill nurse Devin” • Can you relay that information? YES YOU DO! SUBJECTIVE DATA– what the patient tells you OBJECTIVE DATA – what you observe or lab results NURSING PROCESS: ASSESSMENT  • Collect data • General assessment/exam • Physical exam • Neurological Exam • Musculoskeletal Exam • Very important to document what on this FIRST ASSESSMENT? 1. Allergies  Most important; can be life or death 2. Medications 3. History of diseases ** REMEMBER  You’re doing the nursing care plan on what they are admitted for – not what they had in the past unless it correlates Patient comes in and you’re doing an assessment patient says to you: • Patient: “I can’t remember at times where I put my keys, wallet, or can’t remember how to get home sometimes”